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ON
THE CONGENITAL MALFORMATIONS
OF THE
RECTUM AND ANUS.
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Plate 1.
Vide Case CX. I;.p. ?47.
A r R A C T I C A L T II E A T 1 S E
ON THE
.ETIOLOGY, PATHOLOGY, AND TREATMENT
OF TIIH
CONGENITAL MALFORMATIONS
OF THE
RECTUM AND ANUS.
BY
WILLIAM BODENIIAMER, M. D.
" Necessitas medicinam invenit, experientia perfecit." Hippocratks.
" By .studying Nature in her Imperfections and Irregularities, we are more likely to
arrive at some Knowledge of her Laws, than if we regard her only in her Healthy con-
dition." Ramsbotham.
Illustrated by XVI Plates and Exemplified by CCLXXXVII Cases.
NEW YOEK:
SAMUEL S. & WILLIAM WOOD, 389 BROADWAY.
mdccClx.
Entered, according to Act of Congress, in the year one thousand eight hundred and sixty,
Bt WILLIAM BODENHAMER,
In the Clerk's Office of the District Court of the United States for the Southern District
of New York.
J. H.
TOBITT,
COMBIXATIOK
-TTPE PBINTEK, j
1 Franklin
Square, iV.
r.
TO
WILLIAM HUSTON BODENHAMER,
iSow A Student
At L^ Ecole-De-Medic'ine of Pakis,
THIS WO RK
IS
Most Respectfully and Affectionately
INSCRIBED
Ir
By his Father,
THE AUTHOR.
r» R E F A^ C E
Whatever, may be said with regard t:) either the merits or the
demerits of this wort, all will admit that the subject of it is of the
highest importance, and that such a production as is hero aimed at,
is decidedly a desideratum in surgical literature. The utility of
oUch a treatise is undoubted, and will not be called in question.
No complete, systematic or practical work on the congenital mal-
formations of the rectum and anus, has ever been published in this
or any other country. The literature on this subject lies buried in
undigested confusion in the various channels throughout the range
of the science — hence it can only be found in brief and detached
articles and memoirs as presented in the transactions of societius ;
in some of the special treatises on the diseases of the rectum and
anus ; in the systematic works on surgery ; in the dictionaries ; or in
the various periodicals of the day. The voluminous and the expen-
sive character of most of these works, containing articles on this
subject ; their scarcity and the difficulty of obtaining them, as well
as the largest number of them being clothed in a foreign language,
render them in a great degree inaccessible to the largest majority
of practitioners.
To remedy this serious evil and to fill this void, the author has in
the present work endeavored to collect these scattered materials
into one continuous whole, adding to them his own reflections and
experience on the subject; and thus presenting in a systematic and
coniuH-tcd fi;rni, a complete and accurate exposition of the cougeni
vi Preface.
tal malformations of the rectum and anus, their aetiology, pathology,
classification and treatment.
Notwithstanding several very able and highly valuable contribu-
tions on this subject have been made within the last half century,
nothing like a general treatise has been attempted. Of the princi-
pal contributors to this literature in later years, the names of Ben-
jamin Bell, Thomas Copeland, and A. Copeland Hutchison of Eng-
land ; MM. Amussat and Roux de Brignoles of France ; Von Ani-
mon and Friedberg of Germany ; and Dr. Bushe, Dr. Barton and
Dr. Gray of the United States, may be mentioned as the most im-
portant. " Th". Boston Society for Medical Lnprovement " has
within the last few years highly distinguished itself by investigating
this subject quite thoroughly, and Dr. Gay, already named, one of
its able members, has produced a valuable paper on it. It is, how-
ever, more especially to the genius and master pen of M. Amussat
of France that we are indebted for having drawn from oblivion as
it were, this long neglected and forgotten subject, and for restoring
it to that rank to which it is entitled.
Although these eminent surgeons have by their able productions
inaugurated a new surgical epoch with regard to the anatomy, the
physiology and the treatment of these congenital vices of conforma-
tion, yet it is surprising the little advancement which is being made
on the subject. A congenital imperforation of the anus and rectum
is still regarded by many surgeons merely as an anatomical lusus
naturcB, beyond the power of art to remedy, and is still to a great
extent the opprobrium medicum.
The investigation of these abnormal conditions of the rectum and
anus is invested with a deep interest, not only as an important pa-
thological inquiry, but above all as conducive to the adoption of
measures calculated to be highly beneficial to a class of little suffer-
ers, the most unfortunate and deplorable. The subject is a very im-
portant one, and is presented not for the benefit merely of the curious,
in anatomical pursuits, but on account of its practical relations, and
for the ultimate and permanent good of the little sufierers themselves ;
consequently it presents itself to the humane surgeon as an object
demanding his most deliberate and serious attention, for among the
PREFACE. VI 1
many forms of death which surround the cradle and which are the ob-
jects of parental care and solicitude, those which depend upon a
malformation, or an imperfect state of tlic excretory passages, an'
perhaps the most distressing in their nature and make the most pain-
ful impressions upon the minds of the parents.
In the elucidation of this subject, the author disclaims all preten-
tious to an extensive practical and personal knowledge of it ; indeed
this seldom falls to the lot of any one practitioner, however exten-
sive his practice may be.
It may be alleged that in treating this subject, the author has
been guilty of great repetition and prolixity, but as the subject is
so importaut, and has been so little discussed, he thought it might
prove benedcial to enter into it somewhat in detail.
Whether this work will prove to be valuable or not, it has been
the result of much reflection and long labour, and the author claims
for it entire originality in the general design and treatment of tho
subject. The extent of his researches will be understood when it
is known that he has consulted and cited the large number of
authorities. presented in the Bibliography at the commencement of
the Introduction. This extensive Bibliographical Index forms of itself
a complete history of these congenital vices, and will greatly facili-
tate the study of them.
In this work the practitioner will find reported nearly
three hundred cases, collected from the numerous sources,
being by far' the largest number ever presented in any one
sino-le production on the subject. The record of these cases will
show their singular variety ; they have all been carefully classed
according to their species, and most all of them have been reported
in full, and as near as could be, in the precise language of their
authors. Many of these reports have been translated from the
French, the German, and the Latin, especially for this work. The
author has made but few remarks in relation to any of them, pre-
ferring to present in full the instances themselves, as facts, from
which each practitioner might form his own opinion, and draw his
own conclusions. It will be seen that the observations of authors
and the cases, have been generally collected from the original
Vlll PREFACE.
sources, instead of, as is often the case, from the mere references
made to them by others.
It is a singular fact, and not unworthy of observation, that in
reading the French authors on these congenital deformities, one
will be strongly impressed with the idea that beyond the bound-
aries of France nothing whatever is known on the subject. The
same may be said with respect to the Germans. In their produc-
tions on these congenital vices, they scarcely ever, if at all, allude
to the French or the English ; and neither the French, the Germans,
nor the English ever refer to any American authority in relation to
them. Whether this should be attributed to ignorance of the gen-
eral literature of the subject, or to national pride or prejudice, the
author will not attempt to determine. In the following pages, how-
ever, he has brought together in one harmonious body, for the mu-
tual benefit of the whole, authorities, both English, French, Ger-
man and American.
This work will contain both the medical and the surgical treat-
ment in full from the earliest times, with all the improvements,
down to the present day. The last chapter will give a complete
exposition of the highly interesting subject of Abdominal Artificial
Anus, so far as it relates to new-born children.
The simple Classification which has been adopted, the careful
arrangement of all the cases under their appropriate heads, the
Alphabetical Index to these cases at the end of the work, and the
numerous LithograpJdc Ilhist rations, will, it is hoped, be found
highly convenient and useful.
In conclusion the author humbly submits this treatise to the pro-
fession with all its imperfections, hoping that it will supply a hiatus
in the resources of the surgical art.
854 Broadway, New York, )
September, ISGO. |
T^BLE OF COISTTENTS.
CHAPTER I.
INTRODUCTION.
SECTION I.
PAGE.
Bibliography, - ______ 17 — 3G
SECTION II.
General Remarks. — The Rectum and Anus liable to congenital
malformations and niiperl'ections — The congenital closure of the
anus noticed from the remotest antiquity by the Greek, Roman and
Arabic physicians — The tenns used to designate these vices of con-
formation — The importance of examining minutely every infant
immediately after birth— The pernicious practice of purging new-
born children, irrespective of circumstances — These malformations
considered quite uncommon by some surgeons — The author differs
from this opinion — The impossibility of arriving at satisfactory
conclusions on the subject from the very meager data furnished, 37 — 41
SECTION III.
Etiology. — Nothing satisfactory has yet been ascertained with re-
gard to the primary cause which determines these congenital im-
perfections of structure — What the science of embryology teaches
on the subject — The herculean labors and the theories of the dis-
tinguislied and celebrated organologists MM. (Saint-Hilaire,
Serres, Meckel, Tiedmann, Andral, &c., noticed — Some of these
malformations are the result of disease in intra-uterine life —
Instances given to prove this — What influence does sex exercise
in the production of defective congenital developments, - 41 — 46
SECTION IV.
Anatomical and Pathalogical Characters. — These congenital
malformations present a great variety of forms from the most sim-
ple to the most complex —The anatomical and the pathological con-
ditions which constitute these defective developments, considered
separately — The historj' of the development of the rectum and the
anus, given — The manner in which many of these malformations
occur — Synopsis of the congenital malformations of the anus and
the rectum, - ...._- 4G — 51
is.
TABLE OF CONTENTS.
SECTION V.
PACE.
Classification. — The anatomical and the patliological condition of
these congenite vices of structure, taken as the basis of classifica-
tion — They are, for practical purposes merely, distinguished into
nine species — In this arrangement, convenience is considered,
rather than a show of scientific precision— The description of each
species, ___-__ - - 52 — 5 -J
SECTION VI.
General Symptoms. — The existence of these congenital malfor-
mations manifests itself, in the majority of instances, bj' a train
of morbid phenomena, simulating strangulated hernia, the result
of the retention of meconium and other matter — If not relieved,
death generally takes place between the third and eighth day,
according to the vigor of the little patient — When protracted
beyond this period its life is purely vegetative, there is extreme
emaciation, and death results from the eifects of inanition —
Instances given in which children have lived a niunber of days,
and even months, without any passage from their bowels —
When death takes place, it is most usually the result of enteritis,
peritonitis and intestinal paralysis — The appearances after death —
The pathognomonic sign obtained by the direct inspection of the
anus and rectum, - - ____ 54 — 57
section VII.
Prognosis. — These malformations, as well as those of the genito-
urinary organs, were looked upon anciently as necessarilj^ fatal,
and the unfortunate victims of them, regarded in the light of
monsters — These sentiments, even at the present day, prevail to
a certain extent — ^lany surgeons abandon nearly all such cases,
believing them to be bej^ond the power of art to remedy — This
is a grave error, which will be shown hereafter — From the great
improvements that have been, and are being made in modern sur-
gery, the evil is by no means deplorable, even in some of the
most desperate cases, as will be shown — The most formidable
cases are those in which there is considerable deficiency, or an
entire absence of the rectum, and in which no outlet whatever
exists — Even such cases can now generally be saved, eitlier by the
operation oi Proctoplasty or Colotomy—^o case should be abandon-
ed in despair — A doubtful remedj^ even, should be preferred and
attempted in preference I0 the certain death of the child — It is an
important fact, that cliildren sustain an operation much better
immediatel}- after birth, than at a later period, - - _ 57 (jj
CHAPTER II.
THE FIRST SPECIES OF MALFORJIATIOX.
SECTION I.
Description. — This species of congenital malformation is character-
ized by an abnormal narrowing of the anal orifice — This narrow-
ing may present all the different degrees of stricture, from that
into which the point of the smallest probe cannot be introduced,
and impossible for the meconium to pass, to that which opposes
TABLE OF CONTKNTS. XI
PACK.
no obstruction to the common size probe, and but little to the
passage of the mecoiiiinii — The contraction may be organic, and
the result of previous iniliunmation, or it may be spasmodic — Tlie
situation and the form of the anus in this species— The signs by
which it maybe recognized — The syphilitic variety of this species
of congenital narrowing, and the signs by which it may be dis-
tinguished, - - 01— <j;i
SECTION II.
Till'. Treatment. — The treatment is by dilatation alone ; or, by incis-
ion and dilatation combined, according to the straightness of the
contraction — The dilatation must be ctfected by means of the wax,
gum-elastic, or metallic bougies — The wax bougie the best — The
measures to be adopted if the process of dilatation should excite
undue irritation or inflammation — The importance of early treating
even the slightest cases of this species, in order to prevent the
evil consequences which may result from such neglect, in the
after-life of the little patient — Two interesting cases are related
by M. Boyer, in which the contz-action of the anus was overlooked,
or neglected in infancy, .__ - - C3 — 08
SECTION III.
Cases AND Kemarks, - - - - G8 — /4
CHAPTER III.
THE SECOND SPECIES OF MALFORMATION.
SECTION I.
Description. — This species of congenital malformation, atresia ori-
ficii am, is characterized by. the closure of the anal orifice, by a
thin transparent membrane, somewhat resembling the hymen ; or,
b}^ a cutano-mucous lamina, sometimes quite thick and hard, and
simulating the common integument of the anal region — The signs
by which it is distinguished — It is the most simple form of
arrested development pertaining to the anus, and doubtless the
most common, - - - - - 75 — H)
section II.
The Treatment. — The treatment of this species is simple, and if
timely adopted, generally successful — It consists of a puncture
and a crucial incision — The method of operating and the after
treatment — There is in these cases but little disposition in the
newly formed anus to contract, especially if the occluding mem-
brane has been thin, and the anus well formed, as is usually the
case — The advice of Professors Hays and Pancoast, of Philadelphia
— M. Levret recommended a circular incision in these instances, 7Cj—77
SECTION III.
Cases AND Remarks, -__. - - 78 — 87
Xll TABLE OF CONTENTS.
CHAPTER IV.
THE THIRD SPECIES OF MALFORMATION.
SECTION I. PACE
Description. — The atresia ani et intestini recti, is a species of
arrested development, in which the I'cctum docs not descend as
low in the pelvis as it should do, but terminates abruptly in a
form of cul-de-sac at a variable distance above its natural outlet —
No anus exists, and there is generally not even the trace of an
anus to be observed in aitu naturali — This is truly a deplorable
form of congenital imperfection, especially should a considerable
portion of tlie inferior extremitj^ of the rectum be deficient, - 88 — 89
SECTION II.
Physical Exploration — Diagnosis. — It is of the highest import-
ance, in these cases, in which there are no external signs, to make
a careful and minute exploration — The manner of conducting this
— Auscultation and percussion — The introduction of the sound
into the bladder, or into the vagina. The small excrescences or
elevations of the skin, which are sometimes observed in these
cases at the normal situation of the anus — Their deceptive char-
acter, with regard to their having any communication with the
rectum. The place of the absent anus is sometimes the seat of a
.small depression, pit, or a fissure or fissures of the skin, - 89 — 91
SECTION III.
Prognosis. — The prognosis unfavorable, but by no means hopelessly
so — A very fixvorable issue of the success of the operation in any
of these cases must not be too confidentl}^ prognosticated — The
difficulties and the dangers of maintaining the newly formed canal
patulous, after the ordinary operation, as enumerated by Bell, Vel-
peau and others, are by no means exaggerated or imaginary — Con-
siderations which induce many surgeons to repudiate all treat-
ment in such cases — The opinion of Professor J. H. Bigelow, of
Harvard University, on this subject — The highlj' encouraging re-
sults in a number of these cases reported, authorise and warrant
an attempt at relief by some operation. MM. Amussat, Roux de
Brignales and Goyraud, of France, in 1835, were of opinion that
all such cases, previous to that time, were never successfully
treated, if treated at all — They claimed the credit of introducing
free incisions in the perinajum with the scalpel, guided by the
finger, in search of the blind end of the rectum. Benjamin Bell
and A. C. Hutchison, of England, and Dr. Campbell, of America,
are proved to have successfully operated by this method, on just
such cases, many years previous, - - - _ _ gj yg
SECTION IV.
The Treat.ment. — That treatment which holds out the greatest
prospect of success in these cases, is that which contemplates the
establishment of an artificial anus in the perina3um, Proctoplaktu —
Description of this operation — When should the operation be un-
dertaken? — Theadvico of Hutchison and Dieffenbach on the sub-
ject — The infant pelvis — Ilie admeasurements of it in two cases —
The introduction of the sound into the urethra of the male, or into
TABLE OF CONTKNTS. XI II
pa(;k.
tlie vagina of tlie fouiale — The form of incision— Tlic loiif:;itii(linaI
incision — Tlie transverse incision — The crucial incision — The T-
incision — The sphinctores ani muscles. The coniiicting opinion of
authors with regard to their invariable presence or absence in
these cases — The rectum in these instances is not only malformed,
but may occujiy an abnormal position in the pelvis — The nu;thod
of operating recommended by the author — The ordinary method
of operating — The liability of the newly made passage to coarcta-
tion — The opinions of Bell, Yelpeau, Dionis and Malyn, on the
sulijcct — The objections of jNI. Amussat to the ordinary method
of operation — Some of his objections shown to be untenable — The
method of M. Amussat — Its merits and demerits considered —
The operation of Amussat recommended and performed by others
— x\mussat abandons his beautiful operation in these cases, and
now performs colotomy instead — The operation by puncture —
'llie great danger and uncertainty, in these cases attending the
" hl'md ■plunge'''' of a piercing instrument — Perinaeal puncture, at
this day, shoidd be abandoned in these cases — The modification
of the operation by puncture, as practiced by Bell, Hutchison and
Dieflenbach — What to be done in case of the failure to form a
perina3al artificial anus, - - - - 9G — 123
SECTION V.
Oases AND Remarks, _______ 123—161
CHAPTER V.
THE FOURTH SPECIES OF MALFORMATION.
SECTION I.
Description. — In this species of congenital malformation the anus
is usually quite normal, whilst the rectum at a variable distance
above it, is either obliterated, partially or wholly absent, or oc-
cluded by a thin or a thick annular membranous septum like a
diaphragm — The ano-rectal septum sometimes thick, and the con-
sistence of horn — A well-formed anus, no evidence that the
rectum above it is normal — This species presents a form well cal-
culated to deceive the most experienced — The importance of
making a visual and tactile examination of the anal region of
every child which fails to pass meconium within the first twelve
hours after birth — The speculum ani can be used iu these cases to
great advantage — The prognosis, - - - 162 — 165
section II.
The Treatment. — The method of opei*ating in those cases — The
peculiar method of M. Amussat, - - - 165 — 167
section III.
Cases and Remarks, __ - __ 167 — 199
CHAPTER VI.
THE FIFTH SPECIES OF MALFORMATION.
SECTION I.
Description. — In this species of malformation the rectum near
its inferior extremity sends off a pipe-like prolongation, which
XIV TABLE OF CONTENTS.
PAGE.
terminates externally in a preternatural orifice at some point in
the perinajum, or at various points beneath the urethra; at the
labia pudendi, or at some point in the sacral region — These ad-
ventitious canals resemble very much the ordinar}' fistulous pas-
sages — This species has been included in that which Papendorf
denominates " Atresia Ani Vesicalis — Urethralis — Vaginalis''' —
This arrangement improper for reasons given — The prognosis is
generaUy favorable, - - 200—202
SECTION II.
The Treatment. — The indications to be observed — The treatment
in the male subject — The process of Dieffenbach — The process of
Friedberg — The treatment when the rectum terminates in an
abnormal opening at the labia pudendi, the vulva, &c. — The pro-
cess of Vicq D'Azjr, 202— 20G
section iii.
Cases and Remarks, ._____- 206 — 224
CHAPTER YII.
THE SIXTH SPECIES OF MALFORMATION.
SECTION I.
Description. — In this species the rectum terminates by an abnor-
nal anus, either in the bladder, the urethra, the vagina, the
uterus, or in a cloaca in the perinaeum with the urethra and the
vagina — Generally no normal anus exists — This preternatural
alliance of the digestive, the urinal and the generative .systems is
analogous to the normal formation of some animals — This division
of the congenital malformations of the anus and rectum is the
" Cloaca Congenita''' of Meckel, and the " Atresia Ani Vesicalis,
Urethralis and Vaginalis " of Vixpendovt — The manner in which the
rectum communicates with the genito-uriuary passages — Physical
signs and diagnosis — The prognosis in each variety of this species, 225-231
section ir.
The Treatment. — The indications in the treatment of the various
varieties of this species — The treatment when the rectal open-
ing is either vesical or urethral, in the male — The proceeding
©f Amussat in such cases — The proceeding of IMartin — The treat-
ment when the rectum opens in the vagina — Two very distinct
methods of operation proposed, with very ingenious modifications