of a large calculus in , the rectum. The anus Avas so much
contracted that it would hardly admit a goose quill. —
Dr. Miller enlarged it sufficiently to introduce his finger, and
he found the concretion was large enough to fill the hollow of
the sacrum. The hardness of this calculus made him think it
only possible to extract it in fragments. For this reason he
constructed a drill, by the aid of which he could easily make
a hole five-eighths of an inch in diameter. To hold the stone
during the drilling, he introduced forceps in separate parts,
and afterwards united them when in proper jjosition. The
amis was then enlarged in the antero-posterior direction to a
sufficient extent, and the drill was worked until the stone was
completely traversed. Into this opening a strong pair of poly-
pus forceps was placed, and forcibly separating the blades
the stone was broken into several pieces, each of which was
also in its turn, drilled, broken and extracted. The operation
lasted two hours and three-quarters. All the fragments being
removed, the patient was put to bed. At the end of ten days
he was able to rise and the anus had returned to its normal
dimensions. The calculus was of the size of a very large tur-
key Qrfi:!;, quite hard, and very rough on the outside, and
seemed formed of earihy matter.
Dr. Miller, having left the country for several years, lost
sight of his patient, but hearing mention made of two cases
of malformation of the anus, (one of which presented an anus
opening into the bladder,) and upon which no operation was
]>erformed, being considered useless, he caused inquiry to be
made to learn what had become of his patient. He was still
alive, and Dr. Miller had an interview with him. He was hi
good health, and had never complained since the stone was
removed, and is to day a strong and active farmer. At the
age of twelve years, a second soft stone, the size of a chesnut,
THE SIXTH SPECIES OF MALFORMATION. 248
passed M-itliout pain, but he had h»st it. The functions ftf iho
bladder and tlie rectum were performed with perfect re^uhir-
ity." {Edlnbur(jh Medical and Surgical Journal. No.
XCVIII, p. r.i 1S29. Also— Gazette des Uopitaux de
Paris. No. VL, 10 Septemhre, 1857.)
Case CXXXVIII. — M. Cavenne, a physician of Laon
(Aisne,) reports the following case of a male child who pre-
sented an imperforation of the anus and rectum, the latter
terminating in the bladder by means of an abnormal cana-l
and orifice.
" Celine Plainou, 38 years of age, wife of Pierre Cordevan,
of the Commune of Brie, Department of C'Aisne, gave birth,
on the 22nd January, 1824, at eleven o'clock, A. M. to a male
child, seemingly healthy and well formed ; for up to the 24th
January, the second day after its birth, the parents had not
discovered the infirmity with which it was afflicted. The
cliild sucked well, and hitherto the urine passed, was
unmixed with any foreign matter.
"Soon the abdomen became swollen, the child cried out,
and appeared to suffer much ; it also vomited meconium sev-
ei'al times. The health officer of the place being consulted,
prescribed a bath into which the child M'as placed for some
minutes. The same symptoms continued, and as it had had
no evacuation of the bowels, it was resolved to administer an
enema ; but they were not a little surprised to discover no
trace of an opening at the normal place of the anus, nor even
in its vicinity. On leaving the bath a little urine was passed,
mixed for the first time with meconium. The passage of this
foreign substance through the urethra caused swelling of the
entire penis, which was temporarily remedied by emollient
applications.
"I was called in on the mornino-of the 25tli to examine the
cliild and employ suitable means to remedy the malformation.
The abdomen was distended, slightly tinged with green and
sensitive to pressure. In the perinseum I discovered only a
line of depression extending from the end of the coccyx to
tlie point where the skin of the scrotum unites with that of
the penis, so that the scrotum instead of affording a single
envelope to the testicles, formed two very distinct ones ; tlie
prepuce adhered also to the lower half of the gland. I
caused the child to lie on its abdomen so that the pressure
caused by this position might render the place ordinarily
occupied by the extremity of the intestine more prominent,
if it was not too far distant. I discovered no sign of its exist-
ence. During this manoeuvre the child vomited meconium,
24: i THE SIXTH SPECIES OF MALFORMATION.
whicli also passed by the penis mingled witli tlie uriiie, tiiitr-
iiig the diapers a dee]j green since its exit from the bath.
" Presuming then that there was a communication between
the intestine and the bladder, forced to act promptly, since
the abdomen was rapidly swelling, while the meconium was
passed by vomiting, it became necessary to choose a method
and to put it into execution. To establish an artificial anus
after the advice of M. Dumas would only j^artially remedy
the malformation, at least on the supposition of the oblitera-
tion of that portion of intestine below the new amis, for want
of which a part of the meconium must continue to pass into
the bladder. I therefore gave the preference to the process
recommended by M. Martin, Junior, a surgeon at Lyons.
" To perform the operation the little patient was placed on
the border of a sufficiently elevated table, furnished with a
cushion, and a cloth folded several times ; a very small staff
was introduced into the bladder by the urethra ; the thighs
were flexed upon the abdomen a little apart, the scrotum was
raised with the left hand, and the perineum rendered promin-
ent by pressure exerted by the assistant to whom the staff was
confided. A longitudinal incision in the perinasum, about an
inch long, allowed me to pass the point of a long straight bis-
toury over the finger nail of the fore-finger of the lefc hand,
into the groove of the staff" which I raised towards the pubis,
whose direction I followed in order to penetrate the bladder
and incise its neck by the withcb-awal of my bistoury.
Instead of the great quantity of meconium which I ex])ected
to see gush out, there only flowed a little urine mixed with
blood. I introduced a female catheter by the opening just
made, to make sure of having penetrated the bladder ; it pen-
etrated in fact to a greater depth than the blade of my bis-
toury had done, and passed around the cavity of the organ
very freely, always arrested by the resistance of its walls. A
silver canula, two inches and a half in length, surrounded
with fine linen, well greased, was introduced into the opening
for the purpose of dilatation and to arrest the hemorrhage ;
nothing passed the canula and the child died at six o'clock,
P. M., on the 25th of January.
" Upon opening the abdomen there flowed out several ounces
of serous fluid of a greenish color, apparently caused by the
great quantity of meconium which distended the large intes-
tines, as well as the greater part of the small intestines.
'â– ' The end of the colon cut longitudinally brought to view the
cavity of the rectum very short, terminating in a cul-de-sac,
from which there issued a narrow canal, about a half inch
THE SIXTH SPECIES OF MALKOUMATION. 245
long coininuiiic!itin<i; witli tlie bladder, Ix'liiiid tlic iiccl< of that
organ by an opening of very small diameter.
riirough an opening made in the anterior j)art ol" tlu' \\;dl
of tlie bladder uliieli contained no ilnid, was seen the incision
of the neck, abont tlwee lines in length, and at the right of
this, the vesical oju'iiing of the canal commnnicating between
the intestine and the bladder, surrounded with a slight border
which seemed to perform the ottice of a Sj)hincter. I conld
only ]>enetrate tlie (bict from the cavity of the intestine to that
of the bladder, by the aid of a blunt stvlet a little larirer than
those used for sounding the lachrymal ducts. {An'hicefi Gen-
erales de Medecine de Paris, Annee 1824. tome Y. p. 63.)
Case CXXXIX. — The late Dr. John 11. Steel, of the Sara-
toi:;a Sprinf>;s, New Yoi'k, reported the following case.
^"On the 13th of April, 1833, Mrs. C, a strong, healthy
woman, was delivered of her tenth child, a fine, fat boy, who
weighed between eight and nine pounds. He was dressed,
and placed in bed with his mother, and nothing unusual was
observed about him until the succeeding day, when he
became restless and exceedingly fretful, and although he was
nursed freely, his attention to the breast was frequently
interrupted by fretful stai-ts, accompanied at times by pierc-
ing shrieks and noisy crying. His diapers were observed to
be frequently wet, and when removed were found to contain
portions of feculent matter, of a natural appearance, and in
about the usual quantity; liis restlessness however continued
to increase, and his crj-ing became more constant and
alarm in o;.
'' On the second or third day after birth, it was discovered
by the nurse that the usual aperture for the evacuation of
the contents of the bowels was entirely wanting, and that
the feculent matter which had appeared, was voided through
the urethra along with the urine. It was at this period that
I Hrst became acquainted with the case.
" On removing the diaper, about a spoonful of faeces and
urine, of the consistence of thick gruel was voided at once,
apparently with some effort, troni the extremity of tlie
urethra; the glans penis was considerably inflamed, and the
child cried as if in great agony. Several other and stronger
eflforts were evidently made, wdien smaller portions of fffices
of the same appearance and consistence as the first were
excl'ided and the little sufferer then became more quiet.
" The parts behind the scrotum were perfectly natural in
every respect, except the want of an anus, of wdiich there
was not the slightest vestige, the spot where it should have
2J:6 THE SIXTH SPECIES OF MALFORMATION.
been was smooth, and of a uniform color with the adjacent
parts, the sphincter muscle was evidentl>^ wanting, and there
was nothing to indicate an accumulation of fseces in the
vicinity.
''The examination resulted in the conviction that the
intestine did not extend to the perinseum, but probably ter-
minated in the bladder or some of its a])pendages ; under
this view of the case any attempt to form an artificial anus
would have been useless, if not absolutely injurious. The
parents, therefore, were instructed to keep the parts clean,
to use a little sweet oil about the glans penis, and by all
means to keep the bowels loose should any tendency to con-
stipation occur.
" For the first three or four weeks the child continued
fretful, and evidentlfy to decline in vigor and growth ; but
from tliat period to a short time before its decease it suffered
but little apparently, nor did its growth or strength seem to
be at all impeded. The only peculiarity observable was the
appearance of two large front teeth in the upper maxilla,
which at the age of seven months were as large and fully
grown as those of an adult ; they, however, in the course of
two or three months became loose, and finally dropped out.
In the latter part of the month of March ensuing its birth its
bowels became obstinately obstructed, the scrotum enlarged,
and became extremely tender, and on the 30th of the same
month its sufferings were terminated in death.
" At the antopsy, on removing the integuments from around
the body of the penis, which were considerably swollen, two
ap2?le seeds of a large size, which had passed through the
intestines, together "with a portion of the capsule or hull
which surrounds the seed in the core of the fruit were found
lodged in the urethra about three-fourths of an inch from its
termination ; they were so situated as to completely obstruct
the passage, and a small opening had been formed immedi-
ately behind them in the urethra through which some of the
contents of the bladder had been infused into the cellular tis-
sue, and extended to the scrotum. Inflammation and conse-
quent gangrene was the result, and to this may undoubtedly
be imputed the immediate cause of the child's death.
" Tlie contents of the abdomen appeared perfectly natural,
excepting that portion of the intestinal canal termed the colon
sinistrum or descending colon, which was found to be entirely
destitute of the sigmoid flexure ; the gut passed along the
left lumbar, and through the iliac regions in nearly a straight
line to the neck of the bladder, into which, after an abrupt
but imperfect curve, and being suddenly contracted in its
THE SIXTH SPECIKS OF MALFOUMATION. 247
(iiiiU'iisions, it was inscrtoil just hi'liind the hasc of tlicyy/vAv-
tate {/land. The ajK'rture wiiicli iinit,i.'(l the gut and hhuhler
of urine into (»ni' conmion receptacle for their respective con-
tents, was of suiliciont (•aj)a('ity to a(hnit a iarti:;e si/.i'd gonse-
(|uill ; throug'li tliis a[)erture the urine found a rea<ly egi-ess
into the intestine, where becoming united with the contents
of that receptacle it was forced back to the bhidder, and
finally expelle<l through the urethra. About half a pint of
urine and l\eces of the consistency of that whicli was usually
voided, was found to occupy the cavity of these two organs,
and was readily excluded by means of a slight pressure on the
parts. The space between the ])erinaHim and the termination
of the intestine was occupied by a sofr, fatty substance, but
there was not the slightest vestige of a gut." [ Vide
Plate X, Figure 2.] (Atnerieafi Journal of tJie
Medical Sciences. No. XXX. p. 40-4, Philadelphia ., l^elru-
ary, 1835.)
Case CXL. — M. Cruvielhier gives a very interesting in-
stance of a fully matured male ftetus, in which was presented
an imperforation of the anus, with the rectum terminating in
the bladder by a very small canal, at the posterior extremity
of the vesical uvula. In this case, besides the malformation
already mentioned, there existed a very remarkable deformity
of the pelvis with congenital luxation of the femur, club-foot,
&c. The perinasum was enormous in its antero-posterior
diameter. There was not the slightest trace of an anns and
no median raphe, but all was smooth in the ano-perinteal re-
irion. At the extremity of the coccyx a small depression
coidd be observed, resulting from adhesion of the skin to that
point. The genitals were well formed but were pressed to
the front, and the scrotum was destitute of testicles. [ Vide
Plate Xi, Figures 1, 2, 3.] {Anatomic Pathologique du
Corpes Humain. Tome I. Livraison, II. Planche, II.
Figs. 1, 5, 6. Bruxelles : 1833, 1834.)
Case CXLL — Baillie saw a child in which at birth, the rec-
tum opened into the bladder. The deformity was of such a
character, he observes, as neither to admit of a remedy by
art, nor to allow of life being continued. {Morbid Anatomy^
p. 165. London: 1833; hj Wardrop.)
Case CXLII.— Dr. Dorsey remarks, that a very interest-
ino- case of imperforate anns in a male child, is related by
his friend Dr. J. A. Smith, in the second volume of tlie
"- Xcw Yorl: Medical anl Philosophical Journal?' In fjiis
case the rectum terminated in the urethr;i, through which
248 THE SIXTH SPECIES OF MALFORMATION.
canal its contents were evacuated. An unsuccessful oi)era-
tion was performed tor tlie relief of the patient; the wound
healed, but M'ithin a month the child expired. No dissection
was |)ermitted, consequently tlie mode and place of commn-
nication between the rectum and the urethra or bladder
remained uidvnown. {Elements of Surgery. Vol. 11. Chap.
LXIV. J), ttfjy, Zrd Edition, Pfiiludelphia : 1823.)
Case CXLIIL— The following case was communicated to
the " Boston Medical and Sargioal Journal,^'' by Dr. L. W.
Houghton, of Waterford, Maine, in a letter dated July 8tli,
1847.
"I was called on the 20th of last month to see an infant
child, who, the messenger said, 'seemed to have no passage
from the bowels.' The child was some eight or ten liours
old, the mother having been attended during lier confine-
ment by a midwife, there being no physician within some
eight miles of her residence. With the following exceptions
the appearance's of the child were healthful. ' The lower
extremities were not well developed, and the cuticle M'as
wanting in considerably large portions, while in other parts
it appeared dry and horny. Tlie spine also terminated from
t\yo to four inches higher up than natural ; the sacral portion
of it, if no more, being wanting. The rajyhe along the perin-
aeinn extended only a short distance back of the scrotum, and
there was no appearance of the anus. I came to the conclu-
sion, that from the external appearance of the child, there
was malformation of the pelvic viscera, or that some portions
were wanting, and did not therefore attempt the operation
for artificial anus. A few hours after I left, the child com-
menced voiding meconium ]>er urethra, and continued to do
so till death, which occurred forty-eight hours from its birth.
" Post-mortem Examination. — I found, on examination, a
termination of the rectum into the neck of the bladder, by a
very small opening, barely sufficient to admit an ordinary-
sized probe. The rectum, besides the opening already de-
scribed, terminated against the lower lumbar vertebra." —
{Boston Medical and Surgical Journal. Vol. XXXVI.,
p. 520. Boston : 1847.)
Cask CXLIV. — M. Amussat reports the following case of
imperforation of the anus and rectum in a new-born infant
of the male sex, in which the rectum opened into the
bladder :
" On the seventh of May, 1842, MM. les docteurs Miquel
and Devilliers sent a child to me, about forty-eight hours old.
THE SIXTH SPECIES OF MALFORMATION. 249
We were intonucd tlioro was no unus, that tlic cliild |>assc(i
mecouiiiiu with the uriiu', and that on account of tli is cii-ciiin-
Btance, the diapers Leui<^ stained yeUo\v, they had onlv jii-t
discovered tlie nialt'orniatidii.
''1 examined the chihl in tlie ])resencc of ^1^[. L. lioyci,
Fillios, Grabowski, Kontsoscki, Silvestrc Dii Perrt)n and I.e
Vail hint.
*' No anal oj^enino; existed ; the raphe, stroni;-ly niarki-d,
extended beyond the coccyx, and tlie perliueal reg-iun was
everywhere uniformly developed. Tlie abdomen was n^xuch
distended, and the lower part tilled with seroslty. The urine
was of a yellowish hue, thick, and coIojxhI the linen. Press-
in<;' Urmiy on the abdomen with the lingers placed on the
])erinix.'uui, it was impossible to discover any kind of fluctua-
tion. Although the conviction existed that the rectum termi-
nated in the bladder, there was reason to suppose that the end
of the intestine descended to the lower part of the pelvis,
either directly opening into the fundus of the bladder, or by
dilatation approaching the floor of the perina3um and coccyx.
lleasoning from this supposition, we should operate from
below, and endeavor to establish the anus in the region of
tlie coccyx, before attempting to make an artificial opening
in the left lumbar region by incising the descending colon.
" An incision was first made in the median raphe, of suffi-
cient depth, extending about a half an inch from before
backward. No fluid escaped. Searching under the coccyx
nothing was found. To aid the exploration, we amputated
the cartilaginous extremity of the coccyx and explored with
the index finger introduced into the wound. In the u^jper
part of the pelvis, a protuberance was seen wdiich seemed to
us to be the end of the large intestine. We now hoped to
reach the end of all our eftbrts ; but this protuberance having
been incised, furnished no liquid, and yet a sort of mucous
membrane was seen, and a stilette could be inserted into its
cavity. It was really a cavity, as it seemed, but a cavity con-
taining neither gas nor fluid. Finally, after many useless
endeavors to recognize the fluctuation which should be sensi-
ble, if the intestine had been in the upper portion of the
wound, as we had hoped at first, the operation was abandoned,
by reason especially of the feebleness of the child, and from
the same cause we deemed it advisable to operate in the left
lumbar region by opening the descending colon.
"The cluinces of life in this child were very small, even
before the operation ; lor there w^as an infiltration of the
lower part of tlie abdomen, an Infilrratlon announcing already
existing disorders of that region, and perhaps of the respira-
250 THE SIXTH SPECIES OF MALFORMATION.
tion. Its condition became still more disturbed after so lonij
and fruitless an operation. A gleam of hope jet remained
frum the idea that the end of the intestine might become
c'liiraored in the wound by the cries and efforts of the child,
and that then we might open it and tix it to tlie edges ot
the wound. But we were disappointed even in this hope,
and the child died thirty-six hours afterwards without our
perceiving through the opening which we had kept open
with a tent of charpie, any species of fluctuation indicating
that the rectum terminated in the pelvis.
" At the autopsy, performed in the presence of MM.
Piett, Filhos, L. Boyer and Le Vaillant, the following was
observed.
"The large intestine was distended by meconium and gas.
It jn-eserved its ordinary relations and it was demonstrated
that the left lumbar colon was fixed to the posterior abdom-
inal M'all and that the peritonseum did not come at least one
third of its extent. The rectum, M'liich was very much dis-
tended, formed a voluminous sac, terminated by a conical
extremity opening into the bladder between the two ureters
hy h narrow strait half tlie size of the opening of the neck
of the bladder.
" By the perinseal incision which was made in order to
reach the end of the lai'ge intestine, we arrived within a very
short distance of the rectum. Had we persisted in this effort,
it is })robable that Ave should have reached it." {Troiseme
Memoire sur la Possibilite d''etablir une ouverture aitifciSUe
sar la Colon lomhaire gauche sans oavrier le Peritome, chez
les Enfans imperfores. Paris : Annee 18^2. Also L'Ex-
aminateur Medical de Paris^ Annee 1843, tome^ III. p.
215.)
Case CXLY.— C, E. Buckingham, M.D., of Boston, Mass.,
communicated the following case to the " Boston Medical
and Surgical Journal ;"
" William, the son of William Lund, was born on the 6th
of December, 1851, and on the morning of the following day
the nurse reported that there was an obstructed anus. On
examination, the cleft of the nates was found sufficiently
imirked, but there w^as no evidence of an anus, either by pro-
trusion or discoloration. During the night there had been
r>ccasionally bilious vomiting, and latterly straining, as if to
eviicuate the bowels. There had been no discharge of urine.
Ilad taken no food of consequence, but had tried to nurse,
'the countenance looked badly, and there was lividity about
TIIIC SIXTH SPECIES OF MALFORMATION. 251
the inoutli and ejos. Was somewluit stuj.i.l ; did noi cry, Init
was constantly nioaniiiiij.
"O])oration tliirty-two and a half lioiirs after l)irt]i, with the
assistance of Dr. IJenry Osgood Stone. Tiie child was licld
upon the lap of the nurse, its nates resting over the right
knee, and the knees raised as for lithotomy. I made an
incision in the centre; of the cleft of the nates from the scro-
tum to the coccyx, and crossed this with another, at right an-
gles, from the tuberosity of one ischium to the other. The
dissection was carried on with a sharp-pointed, straight
bistoury, backward and a little to the left, for two inches.
No evidence of the neighborhood of the rectum being
obtained with the linger, I passed a hydrocele trocar into the
wound, in the same direction, a half inch further. On with-
drawing it, meconium was found upon it. The wound was
then enlarged with the knife, and a female catheter M'as intro-
duced, through which an enema of warm water was adminis-
tered. There was immediately a fair discharge of meconium,
and a slight discharge of urine.
" The child cried but little, and the whole loss of blood was
not much more than two drachms. A few spoonfuls of milk
and water were given, and it was dressed in the usual manner,
no application being made to the wound. Half an hour later,
the moaning had ceased, the child looked brighter, and there
was a profuse dejection.
"5, P.M. — Has had two full evacuations, but has not vomited
nor passed urine. At 5, P.M., on the 8th, I introduced a
sponge tent two and a half inches, with some little difticulty.