rectum existed. — {Op. cit. p. 511.)
Case C. — In the case of a new-born infant which died six
days after birth, M. Littre found the rectum normal both be-
low and above an obstruction composed of a fibrous mass an
inch in length. This obstruction divided the rectum into two
portions, each terminating in a cul-de-sac.
ISTo operation had been performed in this instance. — {His-
toire de VAcademie Royale des Sciences de Paris. Annee
1710. 2>- 36.)
Tliis was the case that suggested to M. Littre the idea of
creating an abdominal artificial anus. [ Vide Chapter Xl.'\
In addition to the authors already named, the following
may be referred to, as having also witnessed cases in which
the rectum was imperforate at a greater or less distance above
a well formed anus.
Courtial. Nouvelles Ohservatlons Anatomiques sur les Os.
p. 147. Leide: 1704.
Fourcade. Revue Medlcale de Paris. Anfiee 1830. tome
IV. p. 52.
Cruvielhier. Revue Medicale de Paris. Annee 1833. to7ne
II. p. 422.
Dupuytren. Journal Hehdornadaire de Medicine de Paris.
Annee 1829. tome II. p. 421.
Colson. Journal Hehdomadaire de Medicine de Paris.
Annee 1829. tome II. p. 150.
Bonn. Papendorf. op. cit. p. 253.
Griraaud. Journal GenSrale de Medicine, tome XXIV.
p. 238.
THE FOURTH SPECIES OF MALFOltMATION. 199
Tlic following cases all belong to this the tV)urth species,
and should be so classed. Their history and description, for
obvious reasons, will be given in the chapter on Ahdombial
Artificial Anus. [ Vide Chapter XI.'\
Casks — CCLXIII— CCLXVn— CCLXVIII -CCLXXVII
— CCLXXXIV— CCLXXXY— CCL XXXVII.
THE FIFTH SPECIES OF MALFORMATIOK
S E C T I O X I .
DESCRIPTION.
1. In this species, the anus being generally either absent,
occluded by a membrane, or existing only in a rudimentary
state, the rectum near its interior extremity, sends off ajnpe-
lihe prolongation which terminates externally in a preter-
natural orifice at some point in the perinseum, or at various
points beneath the urethra, as far up as the frsenum prceputii ;
at the labia pudendi, or at some point in the sacral region.
2. The rectum sometimes terminates in two extremities in
the perinaeal region, each one by an abnormal anus, both per-
forming the functions peculiar to the natural anus, and situa-
ted more or less distant from each other. The one niay be
larger than the other, and give egress to the greater portion
of the contents of the bowels. Dr. Bushe has mentioned such
a case. [ Vide Case CXIII7\ Dr. Green also relates a sin-
gular instance of the same kind. [ Vide Case CXIV.^
3. These adventitious canals of the rectum differ from the
ordinary fistulous passages only by being more perfectly
organized ajid being entirely free from induration. They
remind me verv much of the fistulous sinus which the rectum,
in order to relieve itself sometimes sends off from beyond a
permanent stricture of that intestine, when the contraction
exists a few inclies above the anus. Tliey may be regarded
in the character of supplementarv conduits, and cannot be
(200)
TIIK Firm SPECIES OF MALFOKMATIOX. 201
considered Jis either lui arrest of development, nor a-; an
excess of development, but as a purely i>atliolo<^ical tV.ruia-
tion.
4. In some of these instances tlie conjjenital eloniration of
the rectum in the form of a fistulous sinus is covered merely
1)}' the thin skin of the perinreum^ so that the meconium can
be seen throuirh it, and the course of the canal traced to its
termination. The celebrated M. Cruveilliier reports a very
interesting case which 1 have presented in fnll translated
from the original. [Vide Case CV.']
5. A few instances are recorded in which the sacrum was
found to be so congenitally malformed, so very deficient as to
permit the extremity of the rectum to perforate it, and open
externally in an abnormal anus. M M. De La Faye and
Lacoste mention cases of this character. [ Vide Cases CX- —
cxi—Gxn:\
6. Papendorf, as well as others, has classed all such cases,
I am here considering, with those of his species which he
denominates — " Atresia Ani Vesicalis — UrethraUs — Vagi7i-
alis,''^ but as the rectum in these cases terminates externally,
and has no communication whatever with the genito-urin-
ary jiassages, they cannot therefore be so classed with propri-
ety. I will, however, have occasion again to refer to these
accidental canals of the rectum in the next chapter, in whicli
I will show, that they, instead of opening externally, by an
abnormal anus as in these cases, do sometimes open internally
into the genito-urinary passages by an abnormal anus.
7. The prognosis in these cases is generally favorable.
Should the accidental canal be tolerably large with a corres-
ponding orifice, the little patient may live for some time in
comparative comfort, if the other requisites of life are pres-
ent, but as soon as the diet of the child is changed, and the
stools become more consistent or hard, and are voided with
greater difficulty, the troubles commence which, unless
relieved by an operation, must sooner or later end in death.
202 THE FIFTH SPECIES OF MALFORMATION.
8. Ill those cases whicli the anus is occluded by a simple
membrane only, the operation almost always succeeds. On
the contrary wlien this membrane is very thick, or when
there is no trace of an anus, and a considerable portion of the
inferior extremity of the rectum deficient, the operation of
course is much more difficult, and the result more uncertain.
SECTION II.
THE TREATMENT.
The indication to be observed in the treatment of those
cases of this species which occur in the male subject, is to
isolate completely the accidental canal from the end of the
rectum, and to establish the artificial anus in the perinseum
at the normal site of the anus. The jyijpe-like passage being
separated from the rectum should now be treated as an ordin-
ary anal fistula, by inserting into it a fine silk ligature and grad-
ually destroying its wall ; or by incising it with a small nar-
row sharp-pointed bistoury, guided by a flexible, grooved
director.
I will now give the method which Professor Dieffenbach
proposes for the treatment of those cases which occur in the
male subject.
The Process of Dieffenhach. At the place of the normal
anus a small oval flap of integument is incised, being held
wnth the bull-dog forceps, the skin is dissected away with a
small sharp scalpel. After its removal, the wall of the rec-
tum becomes visible, whicli must not be incised. One quar-
ter of an inch in front of this longitudinal wound and towards
the commencement of the scrotum, a vertical incision is made
in the raphe by means of a fold, about one-quarter of an inch
long and deep enough to reach the prolonged rectum at this
point. The cellular tissue is now separated from each side of
THE FIFl'n SPECIES OF MALFOUMATFOX. 203
the rectiun, or a large probe is introduced beneath the rectal
prolongation, and mIiIcIi is completely divided \\i\]\ scissors
in a direction vertical to its axis. Then by the crucial wound,
the free end of the rectum is seized with the bull-dog forceps
and is drawn into the oval wound designed for the Jiiud open-
ing ; after having completely separated it IVom its cellular
adhesions, the end is brought througli the opening, and by
means of six points of suture the edges of the intestine are
united with the cutaueous edges of the oval wound. Tlie
fsecal matter having been expelled, there is passed into the
isolated and now abandoned end of the intestine, by means of
a large eyed probe, a coarse cotton thread, the ends of which
are tied with a knot, and the wound is then covered with lint.
The formation of the anus is now perfect, and is soon followed
by healthy cicatrization of the wounds. The useless anterior
extremity causes indeed some trouble by means of its mucous
lining, but it requires little attention until the effects of the
first operation are overcome. A caustic crayon may be passed
througli the canal, or a large meche of lint covered with some
irritating ointment may be introduced, and after remaining in
some time, it may be removed and perfect compression estab-
lished, by means of lint and strips of adhesive plaster. If
after all this the obliteration of the canal is not effected, it
may be incised, and in this way the object attained. {Opera-
tive Chh'urgle. Band. I. S. 675. Lipzig : 1845.)
Dieffenbach successfully executed this operation upon two
male children. [ Vide Cases CIII^CIVJ]
Dr. Friedberg has also projDOsed a method of operating in
such cases, which differs somewhat from that of his illustrious
coimtryman Dieffenbach. This operation he successfully exe-
cuted in the highly interesting case of the child Albert M .
As this case fully illustrates Dr. Friedberg's method of
operating, I have given it entire, translated from the French,
being, as I remarked before, unable to obtain a German copy
of his valuable essay. [Vide Case CJlVII.]
20 i THE FIFTH SPECIES OF MALFORMATION.
Witli regard to tlie operation of Dieifenbacli, Dr. Friedberg
says:
" In the case of Albert M , I thought best to adopt a
method somewhat diflt'erent from that of Dieffenbach, and
which attains the end w'ith greater simplicity, and may be
employed in cases of union of the rectum to the bladder, ure-
thra and vagina ; but as the method of Dieffenbach is distin-
guished by the tiict that when the skin and cellular tissue are
removed, the rectal wall is visible, it w^ould not answer in
cases such as that of Albert M , in which the closed
extremity of the rectum is very high up, and since this fact
cannot always be determined before the operation, it is 23refer-
able to perform it in such a manner as will be adapted to any
possible condition. AVhen the rectum, interrupted in the
cavity of the pelvis, sends oiF a canal-like prolongation open-
ing into the bladder, or the vagina, or is prolonged tOM^ards
the exterior, passing above the position of the normal anus,
and opens near the scrotum, (as in the case of Albert M )
or in the penis, I should perform the operation as I have
already stated above in ordinary cases of anal imperforation.
I shouhl cut the canal as I did in Albert M , if it were
found in the viciuity of the perinseum ; in a contrary case I
should not trouble myself about the formation of the anus, but
rather atteud to the obliteration of the canal, which object we
may hope to effect by diverting from it the passage of faecal
matter. The obliteration may be rapidly effected from the
point of departure from the rectum, as the post-mortem of
Albert M clearly showed, but if it should be attended
with considerable delay, I should attempt cauterization by
means of a "wire heated to a red heat by electricit3^" iOp. cit.)
Ill the formation of the artificial anus in those cases in which
the rectum terminates by an abnormal orifice at the labia
pudendi, the vulva, &c., tlie short accidental passage should,
if possible, be obliterated without dividing the septum sepa-
rating the artificial from the abnormal anus, as the division
of the circular fibres of the sphincter going to the vagina,
and perhaps the incontinence of the fseces consequent upon
the section of the canal, might be of serious consequence ever
after. Friedberg, however, does not at all fear any evil con-
se(piences to follow the complete incision of the canal. He
says that if it is cut and projjerly treated, it will granulate and
TiriC FIKTII Sl'KCIKS OK MALFOItMATK >\, 205
ciciilrizc, and this will the more ivadilv Im11..w if th(; knees of
tlie chikl lire honnd together; and if the divided halves of
tlie external spliincter tini muscle are united l)y a Jiealthy
cicatrix, tliere is no cause for fear as to the functions of that
muscle. 1 confess, however, that I should have fears, ant I
would decidedly prefer to ohliterate tlie canal hj the " Gal-
vano-Causiiti''' method of Middeldorpfi*, of Breslau. This would
be attended with no danger, and would most certainly succeed.
Dr. Friedberg himself recommends this method in otlier
cases, in which, in my opinion, it is not as applicable as in
these.
In cases of this character some surgeons recommend tlie
practice of M. Yicq d'Azyr in the instances in which the rec-
tum opens into the vagina. His operation is certainly vei-y
simple and easy of execution, but is liable to the objection 1
have already stated.
The Process of Vicq D^Azyr. A straight bistoury guided
by a grooved sound introduced through the fistulous opening
and passage into the rectum, and directed from before back-
ward, or from the peringeum to the coccyx, or from above
downward, would divide all the tissues which had caused the
deviation. A canula fixed in the rectum near the posterior
angle of the wound, would enable the solution of continuity
in front to cicatrize, and the matters to re-acquire their nor-
mal direction. {MoWs Velpeau. Vol. III. p. 1087. New
York: 1817.)
In those cases in which the rectum terminates by two
abnormal apertures in the peringeum at the same time, differ-
ing in size, and more or less separated from each other, Mr.
Asliton, of London, says — " Surgical interference will not be
required if either opening be of suflicient size for the free dis-
charge of the fseces ; but if both be so small that the process
of defecation cannot be properly performed, the septum
between them must be divided, or that which corresponds
206 THE FIFTH SPECIES OF MALFOKMATION.
most clearly to tlie natural position of tlie anus must be
dilated by pressure, and by incision if necessary. (A Trea-
tise on the Diseases, I)ijuries, and Malforinations of the Rec-
tum and Ames. Chapter XIX. p. 337. London : 1854.)
In tliose cases in wbicli the rectum terminates by an abnor-
mal anus in the sacral region, I am not aware that any treat-
ment has ever been proposed.
SECTION III.
CASES AND REMARKS.
Case CI. — Fabricius of Ilildanus mentions the case of a
child which had an abnormal anus situated at the root of the
penis, the orifice of which was about the size of a pea, and
from which meconium and gas escaped. In this instance there
was no trace of an anus, a thick, strong, and hard membrane
covering the place it should have occupied, and extending
itself forward to the abnormal opening at the root of the penis.
The operation of incising this membrane, was performed on
the sixth day, and the result was a cure. — {Ohservationum et
Curationum Chirurgicarum. Centuria. Centur. I. Ohserv.
76. J). 54. Basil : 1606. JPolia.)
Case CII. — Dr. George Tobie Durr, a physician of Augs-
burg, relates the case of a male child having an imperforate
anus, in which the membrane that closed the anus was pro-
longed forward to the anterior part of the perinoeum, in which
was a small opening through which the meconium drained ofi".
Two months after the birth of the child, Durr performed the
operation of incising this membrane up to the natural place
of the anus. The faeces were voided in abundance and the
cure was ultimately completed. — {Miscellanea curiosa, sire
ephem.. acad. natur eurlosor. decur. II. ami. VI. ohserv. 62.
p. 3. 1668.)
Cases CIII. — CIV. — Dieifenbach mentions the two follow-
ing cases of imperforation of the anus attended with a prolong-
ation of the rectum opening in the perinreum.
He observed this elongation of the rectum in two male
THE FIFTH SPECIES OF MALFOUMATIOX. 207
cluldren, one a few weeks, and tlic otlier two munilis old.
In the first, the somewhat siiiull unal orifice was lui'iucd in
the posterior part of the scrotum, lii tlie second it opened on
the anterior face of the scrotum. In tliis last case tlie (■lonji:-
ated portion of tlie rectum, conti"actin<^ t(.»wards the anterior
part, was nevertheless hirge enou<2;h to admit an elastic cathe-
ter of medium size. In both children the tVbces were voided
throug-h the fistulous canal and ahnornuil anus with ]>ut little
dilliculty, and in each case iJieffenbach operated with com-
plete success. — {Operative Chirurgie. Band. I. S. 676.
Ze/j)2i(/: 1845.)
Diefi'enhach was the first surgeon who proposed '■[Anap-
lasty " by lengthening the rectum in the male subject.
Case CY. — Tlie celebrated M. Cruvielhier gives the details
of a highly interesting case of a male infant who presented a
congenital imperforate anus, with a prolongation of the rectum
in the shape of a narrow fistulous passage formed in the very
substance of the raphe scroti, and terminating in an abnormal
oj)ening immediately below the meatus urinarius.
" A woman twenty -nine years of age, who was pregnant
the second time, and who w^as an invalid and considerably
a3dematous during the second montli of her pregnancy, was
delivered on the sixth day of July, 1828, at the Lying-in
ilospital, of a male child at full time — living and presenting
the following peculiarities. The child was poorly developed,
and afflicted with marasmus ; it was besides reduced to a
purely vegetative life ; its body was cold ; its skin discolored ;
its limbs contracted ; it uttered nothing but dull groans, and
with the exception of some slight spasmodic contractions, it
was nearly motionless.
" There was no anus, but at the situation which the normal
anus should occupy, there was an elevation of the skin caused by
an accumulation of the meconium. Tlie raphe was prominent
and knotty, and it was easily observed that a narrow canal
penetrated it, as it was distended with meconium which could
be seen through the thin skin which covered it. This canal
ultimately terminated under the glans penis in an abnormal
opening which gave issue to meconium.
" An incision was made into the raised portion of skin cor-
responding to the anus ; a great quantity of meconium es-
caped ; nevertheless the child remained in the same condi-
tion ; cold, motionless, discolored, and voiding by the nose,
the milk and sweetened water which were introduced by the
mouth. It was momentarily expected to die, and yet its life
208 THE FIFTH SPECIES OF MALFORMATION.
^vas prolonged to the fii\eentli of Julj, nine days after its
birth.
" Autopsy. It was found that the rectum terminatecl in a
cul-de-sac, that it was distended by meconium and gas, and
of sufficient size to admit the index finger. Near its termin-
ation it gave off an accidental canal, very narrow and lined
with a mucous coat. This canal at first directed its course
from behind forward, and from above downward across the
fatty tissues of the perinaium, rea<?hed the posterior extremity
of the raphe through the body of which it continued, and
finally opened under the glans penis. This opening readily ad-
mitted a slender probe, allowing it to pass the whole length of
the canal. There was no communication between the rectum
and the bladder, between the rectum and the urethra, nor be-
tween the rectum and vagina. [ Vide PlateVIII. Figs. 1,2,3,]
'•■The extraordinary symptoms that presented themselves in
this case could not properly be attributed to the malformation
just noticed. Tliere must have been a remarkable deformity
of the organs of circulation and respiration. There was a per-
ceptible defect in the formation of the blood, but it was diffi-
cult to define exactly what it was. An injection made by the
left carotid artery filled the whole circulatory system, arteries
and veins, and returned through the mouth and the nostrils."
— {Anritomie Pathologique du Corps Ilumain. tome I.
Livraison I. Planche VI. Figs. 6, 7, 8. Bruxelles :
1833, 1831.)
Case CVI. — Mr. J. F, South, one of the surgeons to St,
Tliomas' Hospital, London, reports the following case :
" I had under my care, very many years ago, a case of im-
perforate anus similar to that mentioned by M. Cruvielhier.
{Anat. Pathol. Uvr. I. pi. V.fig. 6.) At the time of birth
there was not any opening, but a slight puckering marked
the place of the anus, and this was protruded each time tlie
child cried. In front of the scrotum, and in the track of the
raphe, as it passed on to the prepuce, was a small aperture,
just large enough to admit the entrance of a probe, and from
it, when the child cried, a small quantity of meconium passed,
I cut upon the puckered skin, but it was full an inch before
the rectum could be reached, and I then opened it sufficiently
to admit a large urethral bougie, and the meconium readily
escaped. A probe introduced at the opening before the
scrotum, passed along a canal, beneath the urethra, through
the }>eriuaeum, becoming larger and larger as it approached
the rectum, in which it terminated. No bougie, or au}^ thing
else, was left in, as I thouglit keeping the bowels loose, would
THE FIKTII 8PKCIES OF MALKOUMATIOX. 2<)0
have l)oen snffici(Mit to ])rov(Mit union ; Iiowcnht, in tlu; courBe
of a fortiiig'lit the wound had closed, and no motion was
passed except hy tlie aperture in front of the scrotum. 1
therefore luid to cut into tlie rectum a<i;ain, and a ])ioc^^ of
l)oui;-ie was then introduced, to he woi-n consfantiv, l)Ut
removed three or four times a (hiy, for emptjiiii; the l)owels.
This went on very well for a short time, hut proha])ly from
iiei;li2;ence, the scar contracted, and at tlie end of three
nutntlis, the anal openin<>; wonhl not a(hnit, even the end of a
prohe. The scar was therefore again di\ick'd, and a hirger
bougie introduced and worn for a fortnight ; after which
a sliort pew^ter pipe, about the thickness of the little ^nger,
with a circular sliouldei" to pi-event it slipping entirely into
the gut, was introduced, so that the motions might pass con-
tinually by it, and the opening be established. Two months
after, the pipe having slippecl out, and been neglected, the
opening had again closed, and again required enlarging with
the kiufe to re-admit the tube. The parent's negligence again
compelled the dilatation of the aperture with the knife, and a
large bougie was directed to be passed frecpiently. I did not
again see liim nntil he was seven years old, wdien he was a
well-grown boy, but with an enormously distended belly.
The anus continued open, though not very sufiiciently, and
the oiiiice before the scrotum was still open, and occasionally
motion passed by it. I was desirous of removing this unnatu-
ral canal, but the mother was averse to it, and the child's
unhealthy appearance did not lead me to expect that he would
live very long. I had entirely forgotten him, when eleven
years after, he being then eighteen years old, I was surprised
on seeing him a line healthy young man, who said he was
the" person on whom I had previously operated. The appear-
ance of the anus could be compared to nothing else than a
bullet-hole in a board ; he said he had no difficulty in passing
or retaining his motions ; but it was quite evident from his
linen, that there was a continued oozing. The opening in
front, instead of being near the frcenum prmputii, was now
close to the scrotum, and a small quantity of stool occasionally
escaped from it. On examining more closely, I found the
anal orifice completely tilled with a protruded portion of the
lining of the rectum ; it, however, offered no obstruction to
the linger, which readily passed up as far as the knuckle, and
was received into the large cavity full of feculent matter, and
running forward along the perinseum, beneath the membranous
part aiid bulb of the penis, to the back of the scrotum where
the canal narrowed, and w<:)uld only admit the linger ; wdth
this the opening before the scrotum communicated. It was
14
210 THE FIFTH SPECIES OF MALFORMATION.
curious, in this case that, although there was an entire absence
of tlie sphincter muscle, the stools did not pass involuntarily ;
the protruded fold of the internal membrane seemed to form
a valve which prevented ordinarily the escape of the stool,
and compensated the deficiency of the sphincter. I proposed
to him the removal of the continuation of the bowel into the
perinffium, but he would not submit to any operation. I have
not seen him for the last eleven years." {Saint Thomas'
Jlosjoital Bejyorts^ p. 121. London: 1836. Also English
Translation of CJieliiCs System of Surgery^ Amer. Ed.^ Vol.
IILp. 39. 'Philadelphia: 1847.)
Case CVII. — M. Monad gives an instance of a male child
having an imperforate anus, the rectum being prolonged in
the form of a fistulous canal to within a short distance of the
glans penis, where it terminated in an abnormal anus.
{JVouvelle Bibliotheqice Medicale. tome II. 2>- 4-17. Paris :
ls29.)
Cases CVIII — CIX. — M. Fristo mentions the cases of two