wards she was delivered by this new passage. The inform-
ation which was gained from her husband led to a more care-
ful examination of the rectum, and an orifice was found within
the anus, wliich would only admit a siixall probe. This orifice
communicated Math the artificial canal which had been made
by the surgeon, and was no doubt the channel by which
impregnation had been efl:ected.
The reflections which were suggested to M. Rossi upon
considering this case, are not devoid of interest. Such was the
malformation of the parts, that the os uteri had no other
external communication but by the small hole within the
anus. This aperture was so small that it would not have been
seen, had the parts not been very carefully examined. It did
not pass in the direction of the opening of the cervix uteri,
but formed an angle with that part. It is difficult, therefore,
to conceive that the male semen could possibly have pene-
trated the uterus. He therefore imagines that " m quodam
spiritu, quddam. aura, exGiijus 'prcBsentla organorwm genita-
lium imilierum vis peculiaris modo ahsoj'hens excttaUirT
{Hlstoire de la Societe de Medicine de Montjpellier, tome I^jj.
39.)
Cases CCXIX — CCXX. — A case of absence of the vulva,
with the vagina terminating in the rectum, is recorded in the
" Meinoires de Berlin^'' for the year 1774. A similar case in
every respect is found recorded in the " Journal des Savants^^
for the year 1777.
(3.) Case in which the Uterus Terminated in the Rectum.
Case CCXXI. — ^Yallesnieri dissected a female in wliom
were found two uteri ; the orifice of one opened into the va-
gina, whilst that of the other into the rectum. M. Fournier
says, in relation to this case, that there is no doubt but that
coitus per ajium would liave been followed by conception.
He founds this opinion upon the case related by M, Louis.
{Dictionnaire des Sciences Medicates de Paris, tome IV.)
CHAPTER IX.
THE EIGHTH SPECIES OF MALFORMATION.
SECTION I.
DESCRIPTION.
This species of congenital malformation is characterized by
the entire absence of the rectum, or by the comj)lete oblitera-
tion of its whole cavity, and constitutes one of the most seri-
ous vices of conformation, pertaining to these parts, infallibly
leading to death in a few days unless the patient is relieved
by surgery. In these instances the colon generally ends in a
cul-de-sac, and either floats unattached in the abdominal cav-
ity, is suspended in the pelvic cavity, or fastened down to the
top of the sacrum. The absent rectum, in case of complete
obliteration, which occasionally though rarely occurs, is re-
presented by a fibro-ligamentous cord attached to the blind
end of the colon, and sometimes passing down along the sac-
rum and becoming blended with the cellular tissue behind
the prostate gland and the neck of the bladder. The pelvis
in these cases is sometimes abnormally small and contracted,
and there is generally no sign whatever of a normal aims pre-
sent, yet occasionally a preternatural anus does exist.
This is comparatively a very rare deformity, being by no
means as common as that in which a portion only of the rec-
tum is wanting. Some authors, however, confound these
cases ; they arrange under the head, ahsence of the rectum,
cases in which there is only a partial absence of the rectum,
(283)
284 THE EIGHTH SPECIES OF MALFOEMATION.
thus making no distinction whether the rectum is partially or
wholly wanting.
This species of malformation is usually attended by some
other deformity, especially by a contraction of the pelvis.
MM. Martin, L'Eveille, and Meckel report such cases.
[Vide Cases CCXXXY1I^-CCXXXYIII—CCXXXIX:\
These authors have made the important observation, that
in cases in which the rectum is wholly wanting, the pelvis is
usually very narrow, and that the nates approximate closely
to each other. This is doubtless the result of an early arrest
of development of the pelvis in its evolution.
As there is no positive or pathognomonic sign by which the
absence of the rectum may certainly be known, we can only
establish our diagnosis in the usual manner, by a thorough
exploration, as advised in the fourth chapter, and by search-
ing for, and endeavoring to reach the rectum through the
perinaeum with the knife. Should we fail thus to find it, we
conclude that it does not exist. Some surgeons in these cases,
recommend making an exploratory puncture over the normal
position of the anus ; when the rectum or some portion of it is
present, there will be a flow of meconium follow the with-
drawal of the instrument ; when the rectum is absent, no issue
of meconium will follow the puncture. This proceeding,
however, is too hazardous and too uncertain, and should never
be adopted.
SECTIONII.
THE TREATMENT.
The only treatment that holds out any prospect of success
in cases in which the rectum is wholly absent, is the creation
of an abdominal artificial anus. [ Vide Chapter on Abdom-
inal Artificial anus.'}
THK I.IGIITII SrECIEb OF MALFORMATION. 2S5
M. Amnssat, I tlihik it is, wlio asks tlie question — SliouM
the suri^eon, in searching tor tlie rectum through the perin-
a3uni, l';ii! to find it, hut find tlie end of the colon or some
other intestine, should he bring this down in the perinatal
region and form an artificial anus there, in preference to one
in the abdomen ? I would answer 3'es — provided the intes-
tine met with, was long enough, had no adhesions, and could
be brought down easily without violence being used.
SECTION III.
CASES AND REMARKS.
Case CCXXII. — Binninger saw a child who presented no
trace of an anus, and the attempt to reach the rectum
through the perinseum failed. The child died ten days after
birth.
At the autopsy it was found that the colon terminated in a
cul-de-sac, and was further on, changed into a slender cord.
The rectum was completely absent. {Ohsero. et Curat, M<i(J.
ccntur. II. Olserv. ^l,p. 222, Ilontbdg : 1673. Also, Dlctlon-
naire des Sciences Medicates, tome XXIV. jp. 129.)
Case CCXXIII.— Bonet records the case of a child in
whom no rectum existed. {Sepulcretum Anatomicum. Sect.
XVII)
Case OCXXIV. — Morgagni records the case of a child in
whom the entire rectum was " solid like a ropeJ^ {Ojym
citatmn, lih. Ill Epist. XXXII. Art 3. et 5.)
Cases CCXXV — CCXXVI. — Ruysch mentions having
seen two new-born children, in whom there was no trace
whatever either of an anus or a rectum. No operation was
performed and death was the result. {Adversaria Anatorii-
ica, decad. 11. c. 10. p. 43.)
Case CCXXVII. — Beauregard relates the case of a child
in whom the colon terminated in a cul-de-sac and the rectum
was wanting. {Backer Journal de Medicine, Janvier, 1786.
p. 90.)
286 THE EIGHTH SPECIES OF MALFOEAIATION,
^ Cases CCXXYIII— CCXXIX.— Meiy relates the curious
circumstance of two male infants {twins) whom he saw, and
who were destitute of the anus and rectum ; and in both of
whom the colon terminated at the umbilicus in a nipple-like
projection, in the centre of which was an opening a line
and a half in diameter, through which the faeces passed.
Both cases terminated fatallj^ no operation having been per-
formed. {Historu de VAcacUjnie Royale des Sciences, Aiinee
1700.^. 40.)
Case CCXXX. — Henkel relates a case in which no rectum
existed. {Mem. Med. Clvirug. Amnerkungen, 11. 17T2.)
Case CCXXXI. — Estero mentions a case in which the rec-
tum was absent. {Listit. Chirurg. tome 11. Sec. V. cap. 163.
m. 1.)
Case CCXXXII. — Bonn reports an instance in which
there was a complete absence of the rectum. (Papendorf.
OjMs citatum.)
Case CCXXXIII. — Ludov^icus gives an instance of a child
in whom no rectum existed. {Miscellanea curiosa sive
ephem. acad natur curiosor. ami. III. decur. I. ohserv. 257.)
Case CCXXXI V. — Huber reports a case in which the
rectum was wanting. — {Acta Physco-Medica. tome VII,
Ohserv. 24:. _p. 64:.)
Case CCXXXY. — Matani cites the case ot a child in
whom the rectum was wanting. {Orteshi Giornal di Medi-
cini. tome III. p. 250. Padoue.)
Case CCXXXVI. — Mr. Jamieson, surgeon in Kelso, relates
the following interesting case of imperforate anus, and ab-
sence of the rectum.
"Some years ago, Mrs. Hannah, midwife in this town, was
called to one Mrs. Stevenson, in Plowland, five miles distant
from this place, whom she delivered of twins, the one female,
the other male ; and discovering in the latter no appearance
of an anus, came home, and sent me to see the child, whom 1
found otherwise sprightly, and seemingly in perfect health,
but not the least vestige of an anus to be seen or felt, but
equally firm and solid from the coccyx to the scrotum : where-
upon I told the grandmother, who only was acquainted there-
with by the midwife, that it was preternatural, and that,
THE EIGHTH SPECIES OF MALEORMATION. 287
though I liad twice seen the anus covered by a membraiie,
which was easily cured, I conhl not projiose to do the like in
this ; but, if she pleased, I should try to reach the gut by in-
cision, which she, with the mother's consent, fondly agreed
to: whereupon I made an incision pretty deep in the most
reasonable })art, then introduced my little linger into the
wound, to tind the gut, but in vain.
" 1 afterwards tried the trocar, which penetrated, but nothing
followed but some gutts of blood ; so was obliged to leave the
patient without |)rospect of further help from me, only desired,
that when he died, I might be allowed to open the body,
which 1 did next day.
'• Upon opening the child, I saw the rectum entirely wanting,
and the colon was a perfect intestinam caecum^ suspended
loosely in the abdomen, and full of meconium ; all the other
parts being in a natural state." {Edinburgh 31edical Essays
and Ohseroations, Vol IV., Art. XXXIII,]^. 354, 1771.)
Case CCXXXYII. — Martin de Lyon saw a case in which
the rectum was entirely wanting. In this instance the tuber-
osities of the ischia approached so near each other, that the
pelvis was almost closed. {Meriioires de la Societe de Sante
de Lyon, tome I, p. 185.)
Case CCXXXVIII. — Meckel reports a case in Mhich tlie
rectum was absent, and the pelvis quite small and contracted.
{MeiVs Archivfur die Physiologic, Band IX., Heft I.)
Case CCXXXIX. — M. Leveille reports the case of a child
in whom the rectum was entirely wanting, and the pelvis so
small and contracted that it presented quite a deformity.
{y)Ki^-A\\\\, Journal de Chirurgie, tome IV., sur V imperfora'
tlon d\mus.)
Case CCXL. — Giering mentions an instance of a child in
whom no rectum existed. {8el Med. Francqf. tome IV.,
p. 137.)
Case CCXLI. — Fitteau reports the case of an infant in
whom the rectum was entirely absent. (Sedillot, liecueil
Periodiqiie. tome II., p. 101.)
• Case CCXLII. — Carvenon cites the case of a child in whom
the rectum was w^auting. (Sedillot, Eeoaeil Periodique. tome
II., p. 36.)
288 THE EIGHTH SPECIES OF MALFORMATION.
Case CCXLIII. — Oosterdyke reports the case of an infant
ill wliom no rectum existed. (Papeudorf. Opus citattiin.)
Case CCXLIY. — Fleisclimann reports tlie case of a male
child in whom both the anus and the rectum were wanting,
and the colon terminated in a cul-de-sac and hun^ looselj in
the abdominal cavity. [ Vide Plate XIII, Figure l.J
(2>« Vitiis Congenitis Circa Thoracem et Abdomen. Tab.
IV. ErdargcB 1810. Uo>,
Case CCXLV. — Otto cites the case of an infant in whom
the rectum was absent. {PatJiologische Anatomie. Bres-
lau: 1813.)
Case CCXLYI. — Dr. Palmer dissected the body of a child
in whom the colon, after reaching the vicinity of the left kid-
ney, began, as it descended, to form a sigmoid flexure, but
previously to its arrival at the concavity of the left ilium,
made a sudden turn to the right, and crossing the psoas mus-
cle, reached the projection of the sacrum, where it terminated
without at all entering the ])elvis. With this malformation
was combined an imperforate meatus urinarius and other con-
siderable deviations of the genital organs from their natural
structure. [Medico- Vhirurgical Journal. Vol. I. London :
1816.)
The case of Dr. Palmer was that of a female child who
lived four days, and upon whom the operation for imperforate
anus had been performed without success.
Case CCXLYII. — M. Jacquemin witnessed the following
case of this species of malformation :
" Several years since, an intant was brought to the consult-
ation of M. Dupuytren, at the Hotel Dieu, who had not yet
passed meconium. A bistoury was introduced about an inch
without giving issue to any faecal matter. The parents
refusing permission to make any further attempt, the child
shortly died. At the autopsy it was discovered that there
was an entire absence of the rectum." {Revue Medicals de
Paris. Mai, 1835. p. 286.)
Case CCXLYIIL— Mr. AYcst says that Mr. Arnott commu-
nicated a case to him in Avliich the child lived seven weeks
and three days, the rectum being entirely absent and the
colon terminating in a blind sac, and floating loosely in the
TIIK KIOIITII SPKCIES OF MALFOKMATIOX. 28^
abdominal cavity. {Lectures on the Diseases of Infancy and
Childhood, p. 376. Philadelphia : 1854.)
The following case belongs to this the eighth species, aiul
should be so classed. Its history and description will be
given in the chapter on Abdomitial Artifoial Anus:
Case CCLXXIL
19
THE NINTH SPECIES OF MALFOKMATION.
SECTION I.
DESCRIPTION.
In this species of malformation the rectum and the colon
are both absent, and generally some other portion of the
intestinal canal terminates externally in a preternatural anus,
at some extraordinary part of the body — such as at the
umbilicus, left iliac fossa, the lower part of the abdomen just
above the symphysis pubis, below the scapula, and at the
side of the face, as it has been known to have occupied each
of these situations. No normal anus ever exists.
Writers generally in describing these cases remark that it
is the rectum which terminates externally in an abnormal
anus, at these distant and unusual situations of the body.
This is, however, a great mistake, for in these instances th«
rectum and the colon are absent ; indeed, the rectum when
present has never been known to have terminated at any of
these extraordinary points of the body. I have already
shown, in the sixth chapter, the various abnormal situations
at which the rectum has been known to have terminated
externally in a preternatural anus.
This species of malformation is but seldom met with, and is
usually attended by other aberrations of structure. Tlie preter-
natural anus or faical fistula which generally attends it, is a most
disgusting infirmity, and unfortunately one, which in the ma-
jority of cases, can be but little, if any, benefited by a surgical
operation. It does not, however, always necessarily at once
(290)
THE NINTH SPECIES OF MALFORMATION. 291
prove mortal, as would be the case if no opening at all
existed, but on the contrary the miserable patients have been
known to have lived for months and for years. Happily such
cases are not common.
Sometimes this malformation is not accompanied by an
abnormal anus, and then it is truly formidable, there being
no rectum, no colon, and no outlet whatever for the passage
of the excrementitious matters.
By a proper exploration, the existence or non-existence of
the colon, can be very easily ascertained, and the diagnosis
established accordingly.
SECTION II.
THE TREATMENT.
"When the absence of the rectum and the colon is not
accompanied by a preternatural anus, the case, as before
observed, is desperate, and demands immediate treatment.
Nothing but the formation of an abdominal artificial anus,
either in the caecum, or in the ileum, holds out any hope of
saving the life of the patient.
M. Yoisin, in a case in which the rectum and colon were
absent, but which was accompanied by an abnormal antis
situated in the hypogastrium, established an artificial anus in
the abdomen, according to the method of Littre. Instead,
however, of opening the colon as he thought, which in this
case was absent, he opened the ileum. [ Vide Case CCLX.']
Should the abnormal anus which usually attends this mal-
formation, or this absence of the rectum and colon, be of sirffi-
cient size to admit of an adequate discharge of fseces, it ought
not to be interfered with. Should it not be large enough,
eflforts should be made to enlarge it, either by dilatation or
incision. The inconvenience of the infirmity, however, shoul d
292 THE NINTH SPECIES OF MALFORMATION.
always be preferred to an uncertain operation wliich might
be attended with more or less danger, and should only be
j^erformed in case of the most urgent necessity. As 1
remarked before, in a large number of these cases, surgery
can afford no aid, so far as the preternatural anus is concerned.
In all such cases, therefore, as do not admit of a surgical
operation, the efforts of the surgeon should be directed to the
use of palliative measures for the alleviation of the suffer-
ings of the patient, and for rendering him less offensive to
himself and others. This may often be accomplished by
various mechanical contrivances.
SECTION III.
CASES AND REMARKS.
Case CCXLIX. — 'M. Littre records the case of a child in
whom both the rectum and the colon were absent. In this
instance the ileum opened into a fleshy pocket the size of a
hen's egg. From the inferior extremity of this pocket was
a canal three lines long and tw'o thick, wliich terminated in a
circular opening a line and a half in diameter, situated just
above the symphysis pubis. This abnormal opening served
the child as an anus. Tliis case resulted in death, no opera-
tion having been performed. {Meinoire de V Academie Royale
des Sciences de Paris. Annee 1709. p. 9.)
Case CCL. — M. Petit reported to the Academy of Science,
the history, in the case of a child who had neither a rectum
nor a colon, and only a portion of the cfficum. In this case
the extremity of the ileum terminated at the left side of the
has-ventre in an abnormal anus. {Memoire de V Academie
Royale des Sciences de Paris. Annee 1716. p. 89.)
Case CCLI. — An extraordinary case is related by Bils, in
w^hich the intestine ascended from the pelvis, througli tlie
chest, into the neck, and opened on the face by a very small
orifice. {Specimina Anatomica et Varia Opuscula, p. 10.
Roterod: 1661. 4^o.)
TIIK NIMH SrKCIES OF MALFORMATION. 293
Cask CCLII. — Dr. l)Uslio suj^s tliat Dinmorc rnoitions a
remarkable instance of jiu iiifjuit iu Avliom the inferior i)or-
tion of the abdomen was badly (leveh.)i)ed. In this case some
portion of the intestinal canal tnrncMl upward and opened
niider the border of the right scapula, (^Malformations^
Injuries and Diseases of the Itectuin and Anus, p. 46.
JVew York : 1837.)
Case CCLIII. — Professor Samuel D. Gross, of the Jefferson
Medical College, dissected a fostus in which both the rectum
and the colon were wanting ; the ileum terminating iu a capa-
cious cul-de-sac two inches and a half in length, and floating
loosely in the abdominal cavitv. {Pathological Anatomy, ]).
628. Pliiladel])hia : 1845.)
Case CCLIY. — The following case of imperforate anus,
M-itli absence of the rectum and colon, is given by Dr. Loh-
mann :
" The author was called to a child who had been born five
days, and who up to that time had passed nothing from its
bowels. It was a boy of mature but weak development. From
the account of the mother, vomiting of a thickish green fluid
had occurred several times. The raphe of the scrotum was con-
tinued to the point of the os coccygis, and in its centre, in the
place where the anal opening is usuallj' found, were two
strong folds of skin united together. The abdomen was dis-
tended, and hard, like a drum, and the windings of the small
intestines were visible below the skin. A puncture an inch
deep was made between the folds with a lance, and kept open
with charpie ; the following day a trocar was introduced, to
the depth of two inches. It seemed, by the sensation commu-
nicated, that the instrument had been pushed into an empty
space. No fa3ces came away, and the child died on the day
after, the seventh from birth.
On opening the body, the small intestines were found dis-
tended with gas, and in many places filled with meconium, and
with yellowish- colored fseces. The colon and rectum were
altogether absent. The ileum went to the place where tlie
colon should have comhienced, and there terminated in a
blind sac, distended with meconium. There was no commu-
nication between the sac and the neck of the bladder. The
puncture had perforated the cavity of the abdomen, without
reaching the blind sac described. {Medicinisohe Vercins
Ziitung. Berlin : 1845. iVo, 8.)
The following case belongs to this, the ninth species, and
294
THE NINTH SPECIES OF MALFORMATION.
should be so classed. Its history and description will be
given in the chapter on Ahdo7ninal Artificial Anus :
Case CCLX.
SECTION IV.
RECAPITULATION.
The following table will exhibit at one view the whole
number of cases of congenital malformation of the rectum
and anus, collected from various sources which are reported
in this work. It will give the number of each species ; the
number treated or operated on, and the result ; the number
not operated on, and the result ; and the number of those cases
in which neither the treatment nor the result are reported.
It will be seen that it comprises by far the largest number of
cases ever before published in a single work.
TABLE.
RESULT.
o
KESCLT.
O
Q
is
U
r,
o
<l
SPECIES.
i
H
O
«
H
tK
0.
O
^S
n
o
o
U
!5
H
ta
D
n
n
>
O
o
O
d
1.)
u
s
b)
&
H
Id
O
T?
10
8
S
1
a.
1
z
1
12
First Species,
Second Species,
16
5«
14
49
8
23
6
26
2
1
....
2
1
":V
16
53
Third Species,
Fourth Species,
45
25
36
14
20
43
16
1
8
1
"i
8
1
in
45
25
Fifth Species,
Sixth Species,
85
17
27
15
12
22
11
11
36
17
85
17
Seventh Species,
Eighth Species,
?«
5
ft
6
6
17
28
Ninth Species,
6
1
1
1
1
4
6
287
156
87
69
42
12
30
89
287
CHAPTER XI.
ABDOMINAL AllTIFICIAL ANUS.
SECTION I.
GENERAL REMARKS.
The term aTtificial anus^ from having been indiscriminately
extended or applied to the preternatuial^ the accidental^ or
abnormal anus, has occasioned more or less confusion among
surgical authors. This term is strictly applicable only to such
an anus, as is designedly established by the surgeon.
The first, or rude idea of the formation of an artificial anus,
was doubtless the result of suggestions occasioned by having
witnessed and contemplated the accidental or preternatural
anus ; the difiference, however, between the two, compared
as an affliction, is very considerable, the latter being a mere
faecal fistula, located in the small intestine, is a most disgust-
ing and revolting infirmity, whereas the former, approaching
so much nearer the normal anus in character, is far less often-
sive, and consequently quite easy to tolerate.
Two operations have been devised and proposed by sur-
geons for establishing an abdominal artificial anus, for the
relief of insurmountable obstruction of the inferior extremity
of the intestinal canal. The principles upon which these
operations are conducted vary considerably, according to the
difterent localities in which they are practised. It is there-
fore necessary to consider them separately and distinctly, as
performed either in the iliac or the lumbar region, which I will
presently do. [ Vide Plate XV. Figs. 1, 2.]
(295)
296 ABDOMINAL ARTIFICIAL ANUS.
Tlie operation for abdominal artificial anus should by no
means be undertaken until the surgeon shall have first failed
to recognize the end of the rectum through the perineum,
and after having exhausted all the measures for disco verino-
it which are recommended for this purpose. Then, and not
till then, should he consider the propriety and the necessity
of forming an abdominal artificial anus, which at best, is a
poor substitute for a jDcrinseal artificial one.
Some very able and distinguished surgeons, however, have