Oftentimes the thin septum bulges considerably into the anal depression and is dark in color, owing to the meconium which is within.

This condition is readily relieved by a small incision which provides an exit for the retained discharges. At first only a small opening should be made which after the lapse of a few days should be supplemented by a cross slit making a crucial incision. (+)

This operative procedure should be followed by digital dilatation, which is made by anointing the finger in oil and inserting it daily. This should be persisted in for a number of weeks, when longer intervals may be permitted. The patient should not be lost sight of, for a stricture of the rectum is liable to supervene.

2d. When the anal pouch is well formed but the anal dimple is absent, there will be more or less bulging of the parts upon straining. The dark color of the meconium may show through the integument, conclusively demonstrating that the anal pouch is near at hand.

This condition differs from the preceding in that the anal dimple being absent there is no definite landmark for the incision. Yet it should be made at the point of greatest bulging as nearly as possible to the normal location of the anus, and the treatment thereafter should be exactly as in the preceding condition.

3d. When the rectal pouch ends at a point some distance from the anus, we have a very much more serious state of affairs. There will probably be no bulging of the perineum when the child cries or strains, or discoloration from the meconial accumulations. There may be an anal dimple or it may be absent altogether.

An incision should be made and the dissection carried upward until the rectal pouch presents. This will be recognized by its dark color and even contour. By pressing upon the abdomen bulging will now occur. The pouch should be freed as much as possible from the peri-rectal fat and connective tissue, the end seized with tenaculum forceps and brought down as much as possible. Where it presents at the external orifice it should be opened and the meconium expressed. The

incised edges should then be sutured to the anal integument with silkworm gut sutures. Further treatment consists in inserting a rubber drainage tube within the rectum until healing occurs, when digital dilatation should be commenced and persisted in until the tendency to stricture is overcome.

When the rectal pouch is located high in the pelvis it will be impossible to reach it by dissection and there remains but one course, viz., to make a colostomy. This operation is never attempted until extensive dissections have first been made in the perineum in search of the rectal pouch. This work is attendant with some loss of blood, considerable time has been expended, and in a child only a few hours old the shock will be considerable. Nevertheless if anything is to be done for the child's relief it must be immediately undertaken, and a median laparotomy is advised. The descending colon must then be found and brought out through the incision and immediately opened. This procedure if successful leaves the child in such a deplorable condition that it is something of a question whether it should be undertaken. Very rarely would it result in the saving of life. A child a few days old is not very tolerant of operation, and in the course here laid out the operative procedures are formidable and few survive. Should a child live he would have an artificial anus at the site of the colostomy which it is possible might be relieved by making a subsequent operation, yet the chances for a satisfactory result are few.

4th. When the rectal end terminates in the bladder, urethra, or vagina, the resultant conditions are difficult to treat surgically. In the two former conditions a septic systitis and pyelitis will usually end the patient's life.

When the gut terminates in the vagina a bent probe may be passed into the fistulous opening, its direction backward may be felt through the anal dimple or perineum, where an incision should be made. The opening thus established should be kept dilated and the fistulous connection with the vagina disregarded until the child is grown up, when it may be treated by the ordinary operation for recto-vaginal fistula.

CASE. Baby, thirteen; aged two days. Entered the Massachusetts Homeopathic Hospital, November 10, 1899, suffering

from imperforate anus. Examination revealed an anal dimple, well formed. The upper part of the depression was snipped with scissors, and apparently entered the rectal pouch, but no meconium could be found. On introducing a sound an obstruction was soon discovered. Anus dilated and highest por

tion of depression snipped and apparently opened into rectum. No meconium escaped nor could be forced out. Second obstruction found to exist somewhere in rectum. Opening in left linea semilunares two inches long. Large intestine brought up with great difficulty and sutured into wound with silkworm gut. Intestine opened and gas and fæces escaped. Dressed with gauze. Ten P M., fed 1 oz. of 1-3 milk and 2-3 water. Seemed hungry. Wound and anus bled slightly. Bandaged with gauze. Died quietly soon afterwards.

Discussion.

J. Herbert Moore, M. D.: A point I wish to emphasize is that, notwithstanding this great infrequencyof the malformation occurring only once in every seven thousand cases, the duty of

the obstetrician is certainly not fulfilled until he has thoroughly examined the patient and made sure that the outlet of the intestinal tract, as well as the outlet of the urinary tract, is in a normal condition.

The varieties into which Dr. Briggs has divided this subject and his concise symptomatology of the same should so simplify the diagnosis as to make a failure on the part of anyone, and especially on the part of one who has heard his paper, to appreciate the trouble, before his attention has been called to it by the nurse or attendant, an unpardonable oversight or mistake.

H. E. Spalding, M. D.: I had a case of imperforate anus, and I remember it now, although it dates back a quarter of a century. There was a dimple marking where the anus should be. I inserted my lancet a little way, and did not get anything. Finally I took a small trochar, and I touched that and drew up my cannoa, and meconium flowed. I depended upon that as a guide, and enlarged the opening until I got a good escape of meconium. I could introduce my finger very well, and I thought I had done pretty good work. I did not know quite as much about surgery as I know now, and I did not know that it was absolutely necessary to bring down the gut over the one and one-half inches. I recognize it is a mistake. However, the child lived two days, and then died. The parents very kindly allowed me to make a post-mortem, and I then found what I called a sphincter tertius in that case, magnified. Up just below the sigmoid I found a constriction of the gut, an opening not much larger, as I remember it, than a lead pencil; so that the child really died from obstruction, because there was not a free passage. There was evidently this pouch below that held the meconium, but nothing could get through the stricture from above to allow the child perfect relief and a possible recovery.

THREE UNFORTUNATE CASES.

BY GEORGE D. GRANT, M. D.

My experience for ten years up to 1901 had been a very comfortable one in obstetrical cases, and I had begun to think that any dread of such cases was over, and that I could accept engagements and not be fearful of results. Just at this time, however, I began to have difficult cases, and in the next two years at least twelve were of the sort that leaves me dreading the time when I shall be called.

The first case I shall recount, occurred December 1, 1901, a Mrs. H., in her second pregnancy. The first four years before, had been a forceps delivery, owing to inability to help herself, the pains lacking force. I saw her early, and found complete dilatation and a face presentation. The frontal prominences were wedged against the pelvic bone, the chin against the sacrum, and severe pains held it there firmly. I made every effort to change the position but was unable, and calling assistance, my diagnosis was confirmed. Both then tried to change the presentation but were still unable to alter conditions in the least, and this, too, under complete anæsthesia.

We decided to use forceps and force. My forceps were easily placed, and on traction slipped, and would slip every time I used traction. Finally, I used a pair brought by Dr. Gotwald and these succeeded in keeping on. I had used considerable force at different times in my life before this, but never had I known what is sometimes necessary for a forceps delivery. After nearly one hour's fruitless traction, with three persons holding against me, and braced by one foot against the bed, I was able to move the head, and finally had the satisfaction of seeing the head fill out the perineum. I then removed my forceps, delivered without force, and saved the perineum. The child was alive, but I found every bone in the head movable, showing that the slipping of the forceps had been fatal, and death ensued two hours later. I watched my patient very carefully for twelve days. Her temperature never went above