its natural size.
" Just where the rectum commences, the coats of the in-
testine were suddenly expanded, forming a great oval pouch,
or bag, sufficiently large to contain three pints of fluid. The
structure of this bag was more dense and strong than that of
tlie intestine in its natural state.
" The contents of this bag were a very large quantity of fruit
stones, with bits of stick, straws and dirt ; together with a
large collected mass of fluid, dark fgecal matter, M-ith which
the whole of the colon was more or less filled, as well as the
large sac that contained the stones.
" The enlargement of the rectum had extended itself quite
down to the anus, so that to remove the tumor entire, it be-
came necessary to dissect out part of the integuments which
formed the artitical anus. The latter opening was found to be
so confined, that it was with difficulty a bougie of middle
size could be pushed through it. This opening consequently
could give passage only to the thinnest kind of faacal matter."
{Practical Ohservations in Surgery and Morhicl Anatomr/. p.
317. London: 1816.)
Second Case. — " A medical friend, Dr. Samuel Merriman,"
says Mr. Howship, "to whom I mentioned the above case,
acquainted me, that he had seen an instance, which he be-
lieved to be of a very similar nature with the'preceeding one.
A child was born with imperforate anus, and an enlarged
abdomen. The integuments were punctured with a trocar,
S4 THE SECOND SPECrES OF IVfALFDEl^rATION'.
the meconium first appeared, and ftjecal matter subseqnentljr„
It was intended in this instance, to have formed an enhirged-
and adequate orifice by the nse of bougies, or such other
means as might liave been necessary ; bat the mother, botb
ignorant and obstinate, was not to be prevailed upon to allow
any thing more being done on tlie child's behalf- The infant
went ott tolerably well for about six months, althouigh the-
enlargement of the abdonaen continued to increase. He sub-
sequently became poorly, and died. The body was not ex-^
amined." {Loe. cit. ;p. 320.)
Cases XX. — XXI. — M, Di^areque records two cases-
of this species of malformation upon which he operated.
The first case was that of a child which had not passed
meconium for thirty-six hours after birth. M. Bnpareque
having acertained that there was imperforation of the anus,,
opened it with great success. {Bevvoe Medicale de Paris.
J/cn', 1835. jt?. 284.)
M. Dupareque's second- case was a child to which he was-
called in consultation, and wliich for thirty hours after Birtli
had ])assed no meconium. M. Duparque having acertained
that there was imperforation of the anus, succesfully per-
formed the operation with a strait and narrow bistoury, A
gum-elastie canula was placed in the rectum. Twelve or
fifteen hours afterwards, all the signs of eflfu'sion of the ab-
domen manifested themselves, and the child succumbed. At
the autopsy the rectum was found to be softened and punc-
tured at the point of union with the- sigmoid flexure of the
colon. This accident was produced by the gmu-elastic canula,
which from carelessness by the nurse had been too far ad-
vanced, and kept too long in. {Loc. dt. jp. 285.)
This case should be a warning to both surgeons and nurses-
how they use canulas and bougies. In my opinion, the canula
was by no means indicated in this instance, and should not
have been used. Soft tents with the occasional use of the
little finger were all that were i-equired to keep the passage
patulous. Several cases in which similar accidents have occur-
red from the careless manner of usiug canulas and bougies will
be found recorded elsewhere in this work.
Case XXIL — M. Petit reports, with several otliers, the
case of a cliild presenting an imperforate anus, in which no
sign of such an organ was visible. On the third day the
THE SECOND SPECIES OF MALFORMATION, 85
mcinbrano elosini:; the anns, wliieli was both thick and firm,
was incised by iiiin with a hanoet. The inecoiiium passed, but
the child died in coiividsions. {Memoir-e deV AeademieJivyal/G
U Clvirunjie de Paria. tome II. ]). 237. 1781.)
Cask XXIII. — M. Petit m\ another occasion witnessed a
new-born child which was destitute of an anus, or any sign
of one- lie first attempted to incise the membrane which
covered tlie anus, with a hmcet, but failed. He then empk)yed
a trocar, when the meconium passed out freely ; nevertheless,
the infant died on the ft^llowing day. {pj>. cit.)
Cask XXIY.' — M. Saviard, Mdio was, at the time, chief
•surgeon of the Hospital Hotel Dieu, in Paris, relates a case
of simple occlusion of the annal orifice.
" On the 16th of Kovember, 1693, an infant four days old
was brought to tlie Hotel Dieu, whose anus was closed. Sa-
viard examined the place where the natural aperture ought
to have been, and perceived a membrane extended across" it,
through which he could distinguish the meconium by its dark
fiolor. He incised this membrane with a strait sharp-pointed
bistoury, which afforded a passage to the contents of the
bowels. After this he dressed the wound three days with a
tent dipped in digestive to prevent its reunion, and the child
was cured." {Nouveau Reoueil d^ Observations Chirurgicales.
Ols.iri Park: 1702.)
Case XXY. — The following account of a case of mon-
strosity, having a closure of both ears, an imperforate anus,
and a double fissure of the palate, was received from W, Otis
Johnson, M. D., of Cambridge, Mass., and read to the Boston
Society for Medical ImprovemeM, July 12th, 1858, by Jeffries
Wyman, M. D., who also showed easts of the ears.
" On the 16th of June, 185S, I was called early in the after-
noon to Mrs. F., an intelligent woman, wife of a respectable
zVmerican mechanic. In half an hour she was easily delivered
of her third child. The first is living and is an unusually hand-
some girl of about five years; the second died before the
family came to Cambridge. Mrs, F, had previously told me
that she had continued to nurse her second child three montlis
;after her last conception, which of course, there is reason to
4oubt, She considered her ' time ' as at hand.
" The ' monster' gave no signs of life for more than a minute
•f'cfter birth, and was what is professionally called hlue. The
.coi'd was about the neck. In about tifteeu minutes after
S6 THE SECOND SPECIES OF MALFORMATION.
birth, having in the mean time made but a few faint cries, he
gave out some half a dozen of the most unearthly shrieks for
an infant I ever heard. These were repeated some eighteen
hours afterwards.
-' I found the ears closed and undeveloped^ as your casts
will show ; a double fissure of the palate, and an imperforate
anus. The ensemble of the features was idiotic ; the remain-
ing development was perfect, and seemed to be that of a six
months' or six and a half months' foetus.
''Thirty-six hours after birth, a fihn, of apparently mucous-
membrane protruded from the anal fissure, and,, after reaching
the size of about half an inch in diameter, burst, and meco-
nium escaped.
" The child continued to show an increasing vitality till
about the thirtieth hour after birth, from which; time it began
to sink, and died easily, forty -live hours after birth." {Records
of the Boston Society for Medical Improvement, Vol. III.
p. 214. Boston : 1859.)
Case XXVI. — Ruysch saw a child whose anus was closed
by a membrane. On the fifth day after its birth there was a
spontaneous rupture of the occluding membrane and death
soon followed. {Adversaria Anatomica, decad. II. Cajy. 10,
p. 13.)
Case XXYII. — Von Ammon reports the case of a male
eliild in whom there existed an imperforation of the anus by
a simple membrane which, he at once incised. In this
instance there was quite a depression at tlie natural situation
of the anus, and what was remarkable, the penis was in a
constant state of priapism which continued until after the
operation of incising the occluding membrane, and the
complete evacuation of the rectum.
This child was well formed in other respects and lived four
months after the operation, the anus and the rectum perform-
ing their functions admirably, the sphiuctores ani being-
present and well formed. The child died of a scrofulous-
diarrhoea. {D-le Angehorenen Ckirurgischen, KranTcTieiten
Des Menschen, S. 4A. Berlin, 1S4:±) [Vide Plate. III.]
The following authors have also seen and described cases
of this peculiar species of malformation.
Fabricius of Hildanus. {Ohsei^atiomtm Chirurrjicarum
Genturia.. Cent. 1. Ohser. 73, p. 51. Basil^ 160G. Folia.)/
Fabricius ab Aquapendente. {0^. cit^-
TUE SECOND SPECIES OF MALFOliMATIOX. 87
Villi Meeckrcn. [Olservationes Medico-Chirurgka. cap.
XXIV. p. 114. Amstelod, 1G82. 8w.)
Littre. {ITistoire de V Academic Royale des Sciences, annee
1710,^.47.)
"Wagner. {Commer, Utierar. Xorimherg, p. 3G1, annee
1735.)
Motais. {Mernoires de V Academic des Sciences., annee 1771,
p. 5T9.)
CT3:-A.P»TEIl IV.
THE THIRD SPECIES OF MALFORMATIOIS.
SECTION I.
DESCRIPTION.
Atresia Ani et Intestini Recti. In this si^ecies of arrested
development the rectum does not descend as low in the pelvis
as it should, but terminates abruptly in some form of cul-de-
sac, at a variable distance above its natural outlet, and either
hangs loosely in the pelvic cavity, or adheres to the anterior
surface of the sacrum, or to the bladder, or to some contig-
uous part. ISTo anus exists, and there is generally not even
the trace of an anus to be observed in situ naturali^ the
perinseal raphe being extended from the scrotum to the point
of the coccyx without interruption. [ Yide Plate lY.,, Fig. 1.]
The space which should, have been occupied by the anus and
the absent portion of the inferior extremity of the rectum, is
filled with some intermediate substance of a cellulo-fibrous
nature.
This is truly a deplorable form of congenital imperfection,
especially should a considerable portion of the inferior
extremity of the rectum be deficient ; then indeed the case
becomes most serious and embarrassing to the surgeon, as
there are no external signs by which he can ascertain posi-
tively where the end of the rectum can be found, or, indeed,
whether the organ even exists at all or not ; and to add fur-
ther to the perplexity and the difficulty, the rectum, besides
being abnormal, sometimes occupies an abnormal position.
In all these respects, it will be observed that this species dif-
TIIIO TIIIUI) SPECIES OF MALFORMATION. 89
fers most widely from the second species, in wliicli a swelling,
a fluctuating tumor, or an accompanying projection or depres-
sion in tlic natural situation of the anus, indicates the exist-
ence and the position of the rectum, and directs the surgeon
at once where to find it.
From the nunihcr of cases of this species which are re-
corded, and which I have presented, it might he inferred,
that it is much more common than the first and second
species ; but this would by no means be a rational conclusion,
inasmuch as such cases scarcely ever escape notice, and are
doubtless every one of them reported, both on account of
their formidable, as well as their peculiar character.
SECTION II.
PHYSICAL EXPLOKATION— DIAGNOSIS.
In these cases, in which there is no external indication
whatever of either an anus or a rectum, it is of the utmost
importance to success, that a minute and careful exploration
should be made as a preliminary step to the treatment.
The index finger of the right hand should be placed in the
normal position of the anus, and pushed firmly np tow\^rds
the pelvic cavity in the direction of the rectum, whilst, at the
same time, with the left hand firm pressure upon the anterior
walls of the abdomen, should be made, both inward and
downward towards the finger in perinsieo. In this manner the
ajjproach of the rectum towards the index finger, may be
detected if it exists.
Sometimes by the finger alone in the perinseum the fluctua-
tion of the distended end of the rectum can be detected,
should it not be too far distant.
After having made an incision of the ]3roper depth in the di-
90 Tin: TllliU) SPECIKS OF ^[ALFOKMATIOX.
rectiou of the rectiim, without discovering the end of it, the in-
dex finger of one hand should be introduced to the bottom of
the incision, whilst with the other hand, or the hands of an
assistant placed upon the anterior walls of the abdomen, the
intestines should be pressed down into the pelvic cavity. In
this manner, if the rectum exists, it might be detected by
the fino;er in the wound.
. In these cases auscultation and percussion may also be used,
in order to discover the presence or absence of the rectum.
The stethoscope should be applied to the perinseum, and at
the same time percussion should be made upon the walls of
the abdomen. By these means the presence of the rectal
exti*emity filled with gas and fsecal matter may be dis-
covered.
In arriving at a correct diagnosis in these obscure cases, con-
siderable aid will be afi'orded by the introduction of the sound
into the bladder, if possible, or into the vagina. Tlirough
these media much may be discovered in relation to the exist-
ence and the exact locality of the blind sac of the rectum.
Mr. A. Copeland Hutchison recommends in these cases,
gentle titillation of the skin with the finger, over the natural
situation of the anus, which, he says, invariably causes the
child to strain, or make efibrts to evacuate its bowels, and
thereby produces a protrusion of this part, if the rectum is
distended with meconium, which will be conspicuous, or felt
in proportion to the contiguity of the intestine to the external
surface ; unless indeed the rectum terminates quite high up,
then there will be no protrusion whatever, and no fluctuation
felt. {Oj>. cit, p. 269.)
In some of the cases of congenital imperfection of the anus
and the rectum, especially in the peculiar species under con-
sideration, there is sometimes found a small excrescence or
elevation of the skin in the form of a button, or of a crest, as
will be observed in several of the cases I have reported.
These excrescences, from their peculiar conformation, might at
THE THIRD SPECIES OF MALFORMATIOX. 91
first sight, be regarded by a superficial observer as indicative
of an anus, and also lead to the supposition that the rectum
would be found in their immediate vicinity ; but sucli would
not be the case, as they are altogether cutaneous in their
structure, and liave no connection or communication wliatever
with the blind end of the rectum which in these instances is
generally quite remote from them.
Sometimes a small dejjression or a pit, or a fissure or fissures
of the skin exist at the place of the absent anus. Some exam-
ples of this kind will also be found reported.
SECTIOK III.
PROGNOSIS.
It has been a source of much regret that the treatment
heretofore, of those cases, in which there is an absence of
from one and a half, to two and a half inches of the inferior
extremity of the rectum, has not been crowned with more suc-
cess. "When, however, the serious and sometimes almost des-
perate character of such cases is taken into consideration, as
well as the many difliculties attending the old and imperfect
methods of operating, the numerous failures heretofore, have
nothing in them to cause surprise. One can well imagine the
gravity of such an operation, and how difficult a thing it
would be, even after having found and opened the end of the
rectum, to establish permanently a canal in so soft and porous
or spongy a substance as the peculiar tissue which in these
cases fills the wliole space which the intestine itself should
naturally occupy, and through which the artificial canal
would necessarily have to pass, and how very inadequate
such tissue would be as a substitute for the muscular rectum.
The dilficultieSj therefore, enumerated by Bell, Yelpeau and
92 THE THIRD SPECIES OF MALFORMATION.
others, of keejjing such a canal patulous, are by no means
exaggerated or imaginary. These various considerations have
induced many surgeons to look upon all such cases as entirely
hopeless, considering the operation for their relief to be too
grave and uncertain, and more hazardous and injurious than
beneficial — hence they repudiate it altogether. Dr. J. H.
Bigelow, Professor of Surgery in the Massachusetts Medical
College of Harvard University, says that — " Judging from
results, I do not consider the operation for imperforate rec-
tum, or even for imperforate anus, a desirable one. I believe
that in the present state of the art, it is better that a child
born with either of these imperfections, should die without this
operation ; although it must occasionally be performed in
deference to established opinion." [Boston Medical and Sur-
gical Journal, Vol. Z VII., p. 24:0. Boston: 1858.)
I am surprised that so able a surgeon as Dr. Bigelow should
have given this as his deliberate judgment ; that such doc-
trine, so directly contrary to the genius of this age of real
progress should have emanated from so high a source as the
chair of surgery in the Medical Department of Old Harvard
University. Should the sentiments of Dr. Bigelow be strictly
and universally adopted, when, I ask him, would the " present
*
state of the art " arrive at that degree of j^erfection which would
justify the operation ? Such views, if carried out to their le-
gitimate consequences, would for ever close all the avenues to
future improvement in the art, and be the burial ground of
all further progress. Admit for the sake of argument, that
the operation heretofore has utterly failed in every instance ;
what then ? Are we on this account to abandon all such
cases to their fate, in future ? Are we to sit down, fold our
hands, quietly look on, and not make another earnest and in-
telligent effort to save such ? Dr. Bigelow, however, says
that this operation must occasionally be performed in defer-
ence to established oj>inion. Can it be possible that Dr. Bige-
low, through mere regard fjr established opinion would,
Till': Tllliif) SI'ECIKS ()!•' MAi;i'"OKMATIUN. 93
imclor any circumstance, perfonii oi- :i(l\is(,' an ()})cratiou in
which he had no conlidence whatever, and wliich he believed
woiikl confer nothing, at best, but a lingering miserable deatli
on the unfortunate little j^atient ?
I admit that the results of the operation heretofore, have, in
a majority of instances been unfortunate, but a much lai-ger
number of cases have been saved by it, than is generally sup-
posed ; and many of the fears of surgeons with regard to it,
are ill founded and greatly exaggerated, as well as are their
denunciations of it, unjust. Notwithstanding this proscription
of the operation by several eminent surgeons, it is nevertheless
sufficiently justified, even admitting the uncertainty and the
danger attending it, by the success of a number of cases of a
most desperate character, which wdll be found recorded in
full in this chapter. The highly encouraging results in these
cases, authorise and warrant an attempt at relief by some op-
eration. An operation may not be followed by the desired re-
sult, still an attempt should be made, unless there should be
other complications or conditions of the system that would
contra-indicate it. A very favorable issue, however, of the
success of the operation in any of these cases must not be too
confidently prognosticated.
Some surgeons denounce the operation as being a cruel, a
most barbarous proceeding, and on this account decline alto-
gether to perform it. I would most respectfully refer all such
to the reports of several cases given in this chapter, in which
the little dying patients were so astonishingly relieved by the
operation, that they immediately after nursed vigorously, slept
most tranquilly, and ultimately recovered.
The disrepute into which the treatment of such cases hereto-
fore has fallen, may be in a great measure justly attributable
to ignorance of the anatomical and pathological conditions
and relations that pertain to these cases ; to the w^ant of skill
in the operator ; to an imperfect method of operation ; to the
operation being contra-indicated, &c.
94 THE TriTKD SPECIES OF MALFOR:\IATIO^*.
Tlie treatment laid down and recommended in tliis chapter,
if perse veringly carried out witli judgment, caution and tact,
will, in my opinion, in the majority of cases, if not in all, not
only preserve the life of the child, but also j)revent those sad
consequences which so often unfortunately attended the treat-
ment heretofore pursued.
The celebrated French surgeons, MM. Amussat. Eoux de
Brignoles and Goyraud, in their various publications on this
subject, during the years 1834 and 1835, declared that pre-
vious to that time, such cases as we are now considering, were
never successfully treated, if treated at all, but were suflPered
to perish, because, as they imagined, their predecessors had
not sufficient skill and courage to make free incisions in the
perinasum, in order to search for, and to find the blind end of
the rectum, when it laid deep. Tliey claimed great merit to
themselves for introducing as something entirely new in such
cases, free incisions with a scalpel guided by the finger, instead
of the old method of punctures with the lancet or the trocar.
Although these gentlemen deserved great credit for calling
public attention to this entirely neglected, but most important
subject, at that time, and for introducing several valuable im-
provements in the mode of operating, they nevertheless were
egregiously mistaken in supposing that no bad cases of this
kind were ever previously treated with success, and that
they had the honor of first suggesting and putting into prac-
tice the method by dissection with a scalpel guided by the
finger. The evidence that will be adduced in this chapter
will place this matter beyond all controversy. It will estab-
lish the fact that such cases, even of the most desperate char-
acter, Avere sometimes successfully treated both by dissection
as well as by puncture, for years previous to the promulgation
of the views of these gentlemen, and that they were by no
means the originators of the method by dissection.
Benjamin Bell more than half a century previous, not only
taught, but successfully performed dissection in just such
THE THIRD SPECIES OF MALFORMATK i.V. 95
cases. His directions for the performance of this operation,
I will give in his own language. — " In such cases," says lie,
" when the gut is found to lie deep, on the child heiug ])roperly
secured, an incision of an inch in length should Itc made di-
rectly on the spot where the anus ought to be ; and this
should be continued by gradual and repeated strokes of the
scalpel, in the direction the rectum is usually known to take ;
not in a direct course through the axis of the pelvis ; for in
that direction the vagina or bladder or perhaps both might be
brought to sufter; but backwards and along the coccyx,
wdiere there is no risk of w^ounding any part of importance.
The best director in every case of this kind, is the finger of
the operator. The fore finger of one hand being pushed in
towards the coccyx, the surgeon with the scalpel in the other,
should dissect gradually in this direction, either till he meets
with fffices, or till the scalpel has reached at least the full
length of his finger ; and if after all the feeces are not ' evacu-
ated, as death must undoubtedly ensue if something further
be not attempted, a long trocar should be pushed forward
upon the finger in such a direction as the operator thinks will
most probably meet with the gut." — (^1 System of Surgery.
Vol. II. Ckaj). XIX. I). Ta. Edlnhurgh: 1787.)
These were the graphic instructions of Mr. Bell, and he
'himself put them into successful execution in two formidable
cases. [ Vide Cases XXX. — XXXI^
Tliis operation too was successfully performed in the year
1822, by the late and distinguished Mr. A. Copeland Hutchi-
son, of England, whom I have already favorably noticed.
The case upon wdiicli he operated w^as one among the worst
on record, and the operation did not difter essentially from
that recommended by Mr. Bell. I have reported the case in
full. â– [ Vide Case XXXVI.^
A formidable case was successfully treated in the year 1800,
now sixty years ago, in our own country, and in the then
wilds of my owai adopted State — ^Iventucky. I feel proud to
96 THE THIRD SPECIES OF MALFORMATION.
inform those distinguislied French snrgeons, that even at that