rectitis during foetal life. In such a case the inflammation
within the rectum causes, in process of time, a coalescence of
its parietes, and thus produces the malformation in question.
The same may ultimately result froin permanent contractions
of the anus and the rectum.

Peritonitis may occur during intra-uterine life, giving rise
to adhesions between the intestines, aud to effusion of lymph
and serum into the abdominal cavity, and thus occasion mal-
formations, if not the death of the foetus.

M. Desormeaux records the case of a child whom at birth
displayed all the evidences of violent enteritis, but afterwards
recovered. He is of opinion that the congenital contractions
and obliterations of hollow canals — such as the oesophagus,
intestinal canal, anus and urethra, &c. ought to be referred to
the influence of previous inflammation. {Dlctionnaire de
Medicine de Paris, tome XY. j). 403.)

Dnges relates the case of a new^-born child, in whom the
abdominal viscera were found agglutinated by a yellow col-
ored and firm lymph. There were false membranes on the
liver, the spleen, the bladder, &c. The epiploon was adher-
ent to the intestines, which were agglutinated into a lump,
were yellow, hard and thick. {ReoherGhes sur les Maladies



46 iNTRODUCriOKi

les plus importantes et les moins connites des enfans noit-
veaux — lies. Paris. 1821.)

Otlier instances, of the eflfects of former inflcanimation in the
intestines of new born children, are related by the following au-
thors — M. Billard. {Traite des Maladies des Enfans nmtveaux
— iicset d la Mamelle, p. 441. Paris. 1828.) Cams. {Lehrhuch
der Gynah>lag.i^. Band. 11. S. 251. Leipzig. 1820.) M. Cruveil-
hier. {Anatomie PatJiologiqae dii Carps Ilamain. Livraison.
XV. PI. XI. p>. 2. ols. 2. Bruxelles : 1833.)

It is not easy to determine to what cause these diseases of
intra-uterine life should be attributed, at a time when the
foetus in utero is so completely protected from all those influ-
ences from without which may induce inflammation after
birth.

Sex has been supposed by some to exercise great influence
in the production of defective congenital develojjments. It is
most certainly true that malformations are most common
among males ; but why it should be so seems to me not easy
of explanation.



SECTION lY.

ANATOMICAL AND PATHOLOGICAL CHARACTERS.

The congenital malformations of the anus and the rectum
present a great variety of forms, from the most simple to the
most complicated, so that it is by no means an easy task to
enumerate and to describe them, M. Guersant says that he
has â–  operated on more than thirty cases, and that each and
every case was dissimilar. {Gazette des Ilopltaux. No.
LXX. p. 280. Paris : 1857.)

I will now consider the anatomical and the pathological
conditions which constitute the most common of these vices
of structure.



INTRODUurloN. 47

1. The anus may be more or less prctcmaturally naiTowed
at its margin and sometimes for a short distance above. This
congcnite coarctation, in such cases, is most always organic or
structural, yet sometimes, though not often, it is purely spas-
modic.

2. The marginal integuments of the anus may sometimes
extend over the border of the sphincter ani, thereby inducing
both deformity and contraction.

3. The anus and the rectum may be normal, but the simple
thin and delicate membranous septum of foetal life may still
exist, and thus produce a complete occlusion of the anal ori-
fice. The anal aperture too, is sometimes completely closed
by a very thick and hard membrane, or a substance analagous
to it.

4. The anus may be entirely absent, no sign whatever indi-
cating where it should be ; the scrotal raphe being continued
without interruption back to the coccyx. In such a case the
rectum may also be partially or entirely absent, and the
sphinctores ani, may or may not be present.

5. In the absence of the natural anus there may be a pre-
ternatural one, performing the functions of an anus, and
occupying some extraordinary situation. In these instances
the rectum may be partially or totally absent, and the colon
also may be wanting.

6. The rectum at some point in the pelvis more or less
distant above its natural outlet, may terminate in a cul-de-sac,
and either hang loosely or be attached to some of the sur-
rounding parts, there being no indication wdiatever of an
anus.

7. Tlie rectum may be interrupted at a variable distance
above a naturally formed anus, by a thin or thick annular
membranous septum like a diaphragm. Sometimes it is com-
pletely closed at several points by such membranous septa, its
diameter, however, at those points remaining undiminished,



48 INTRODUCTIO?r.

and the canal, with the exception of these j)artitions being
entirely natural.

8. The anus being normal, the rectum for a greater or less
distance above it, may degenerate into a solid mass resem-
bling a cord, or be entirely wanting ; or this degeneration may
be confined only to its superior portion, and reassume its
cylindi'ical shape again as it approaches the anus, forming, as
it were a pouch at its inferior extremity.

9. The rectum may be completely obliterated throughout
its whole extent, by a thickening of its coats, its walls approx-
imating and firmly adhering as though glued together; or
this obliteration may take place at one or two points only in
the course of the rectum, the canal at these places appearing
as if tied with a tape ; the anus and intervening spaces being
natural.

10. The rectum may be present and present its cylindrical
form, whilst its cavity may be completely blocked up with a
substance of a cellulo-fibrous character; no anus being
present.

11. Tlie rectum may terminate in the bladder or the ure-
thra ; or in the vagina, or the uterus ; or in a cloaca in the
perinsEum, with the urethra and the vagina. In these in-
stances there is generally no sign of a normal anus ; yet some-
times, though rarely, it does exist, and permits the introduc-
tion of the end of the probe for a few lines.

12. Tlie rectum may terminate in the sacral region by an
abnormal anus ; it may be prolonged in the form of a fistulous
sinus, and terminate by an abnormal opening at difterent
points in the perinaeum ; at the glans penis, labia pudendi,
&c. In these cases the normal anus is generally absent.

13. The rectum may be entirely wanting and its place sup-
plied by a fatty cellular tissue. In these instances the colon
ends in a cul-de-sac, with or without a ligamentous appendage
in continuation, and is either ^dherent,or floats loosely in the



INTKODUCTION. 49

pelvic, or abdoniiiuiml cavity. No iionnul {iims exists, but
sometimes an abnormal one does.

14. The rectmn and the colon may botli ])o absent. In
these instances there is no natural anus, but often a preterna-
tural one situated in some unusual or extraordinary region of
the body, communicating either with the cajcuni or some
portion of the small intestines.

15. With any of these malformations there may coexist iu
the same patient a further deformity of some of the neighbor-
ing sexual organs in a greater or less degree ; or of some
arrest of development — as fissure of the scrotum, witli the
glans penis and the meatus in the perinaeum, spina bifida,
the absence of a portion of an extremity, &c., &c.

I here consider it important, for the better understanding
of the subject, to give a short retrospective view of the history
of the development of the rectum and the anus.

These two organs, the rectum and the anus, in their evolu-
tion, like other portions of the organization, pass through
several types and degrees of development before they
attain that perfect form and arrxingement destined to
represent their permanent condition. The formative process
may be impeded at any one of these stages of development,
and cause such derangement of their evolution, as would more
or less interfere with their normal growth, and exhibit at
birth the precise character which was impressed upon them
when the liinderance first occurred.

In the early period of fcetal life the rectum and the amis
are isolated, the former is lodged in the abdominal cavity, but
it gradually descends into the pelvis to meet the latter ; tliey
both continue to progress, and to approach each other, attain-
ing their proper dimensions by successive accretions, the first
from the mucous and the second from the serous layer, and in
due time their extremities meet and coalesce, and the common
conduit is thus formed. Should arrest of development occur
at any period during this natural process, in one or the other of



50 IXTKODUCTION.

these organs, or in both of them at the same time, various
malformations peculiar to each might be produced.

The rectum during embryonic life is confounded with the
bladder, the urinary and genital canals terminating in one
common cloaca — Whence a derangement of the formative pro-
cess, at this period, in either the rectum, or in any one of the
genito-urinary organs, might cause one or all of them to be
more or less defective — resulting in either a limited or an ex-
tensive imperforation of the rectum, or in some anormal com-
munication between it and the bladder, the urethra or the



'?



vagina.



At an early period of foetal life the anus, together with the
other external openings of the body, is covered with a peculiar
skin, somewhat analogous to that which covers the surface of
the body. Tliis skin, should the evolution of the fostus go on
naturally, becomes gradually thinner, appearing ultimately
as a peculiar secreting membrane, and is finally removed from
its situation over the anal orifice by absorption. Should this
normal process of absorption be arrested, or cease to go on,
however, this skin or membrane would remain stationary over
the anal aperture and consequently form an atresia ani. It
will thus be seen that in such instances of imperforation of the
anus, that the occluding skin or membrane was, in the early
stage of foetal existence, a normal formation.



rSTUODUCTION.



51



SYNOPSIS.



The Congenital
Malformations ^
of the Anus.



1. Preternatural narrowing.

2. Occlusion by a tliin int'inl)rane.

3. Occliision by a thick hard nicmbraiic.

4. Partial or complete absence.

5. Abnormal.



Occlusioyi of
the Meet am.



Obliteration of
the Mectuniu



The Congenital
Malformations \
of the, Rectum.



Preternatwral

termination
of the Rectum.



Pretematiival

termination of

other organs %n

the Rectum,



"1. By one membranous

septum.
2. By two or more mem-
branous septa.

'1. By the agglutination
of its parietes,

2. By the j)uekering of

its parietes.

3. By the thickening and

the induration of its
parietes.

1. In a cul-de-sac.

2. In the bladder.

3. In the urethra.

4. In the vagina.

5* In a cloaca in the peri-
naeum with the vasri-
na and urethra.

6. In the ano-perinteal

region, at difierent
points.

7. In the sacral region.

1. Of the ureters.

2. Of the vagina.

3. Of the uterus.



Absence of the ( 1. Partial.



Rectum,



{I:



Complete.



52 INTRODUCTION.

SECTION V.

CLASSIFICATION.

Taxing as a basis of classification, the anatomical and tlie
pathological condition of the various congenital malforma-
tions and imperfections of the anus and the rectum, I will dis-
tinguish them all into nine species, each one of which may
comprise a greater or a less number of varieties. In this ar-
rangement I have considered convenience and usefulness ra-
ther than an appearance of scientific precision, I am well
aware that it is not perfect, but I trust it will be found sufii-
ciently plain, comprehensive and correct for all practical jjur-
poses. Tliis division corresponds somewhat to that suggested
by Papendorf many years ago, whose divisions and definitions
of the congenital malformations of the anus and the rectimi^,
although quite imperfect, yet, are, for the purposes designed,
as good as any I have observed of a later date. {Dissertatio
sistens observationes \de ano infantum imperforato. Lugd,
Batav. 1781. Uo.)

FIEST SPECIES.

This species consists of a preternatural narrowing of the
anus at its margin, and occasionally extending a short distance
above this point.

SECOND SPECIES.

In this species there is a complete occlusion of the anal
aperture by a simple membrane ; or by the common integu-
ment, or a substance analogous to it, more or less thick and
hard.

TIIIKD SPECIES.

In this species there is no anus whatever, the rectum being
partially deficient and terminating in a cul-de-sac at a greater
or less distance above its natural outlet, without any commu-
nication whatever, either externally or internally.



TNTRODUCTIOJr. 53

FOURTH SPECIES.

The anus in tliis species is normal, but the rectum at vari-
able distances above it, is either deficient, obliterated, or com-
pletely obstructed by a membranous septum.

FIFTH SFECIES.

In this species the rectum terminates externally by an ab-
normal anus, located in some unnatural situation, as at some
point in the sacral region ; or the rectum is prolonged in the
form of a fistulous sinus and terminates by an abnormal anus,
at the glans penis, the labia pudendi, or at different points in
the perinagum. The natural anus being generally absent, its
functions are performed by the abnormal one.

SIXTH SPECIES.

Tlie rectum in this species opens preternaturally into the
bladder, the urethra, or the vagina ; or into a cloaca in the
perinseum with the urethra and the vagina. In these
instances the normal anus does not generally exist.

SEVENTH SPECIES.

In this species the rectum is normal, with the exception
that either the ureters, the vagina or the uterus, open preter-
iiiiturally into it

EIGHTH SPECIES.

In this species the rectum is entirely wanting.

NINTH SPECIES.

In tbis species the rectum and the colon are both absent,
,and there is usually an abnormal anus situated in some extra
.ordinary part of the body.



'.54: INTKODUCTION.

SECTION VI,

GENERAL SYMPTOMS.

Should any of these congenital vices of structure have jm-
fortunately escaped the observation of the accoucheur or the
nurse at the time of the hirth of the child, its existence in the
majority of instances would sooner or later manifest itself by
a train of morbid phenomena simulating, strangulated hernia,,
the result of the retention of the meconium and other matter.
K no alvine dejections take place within twelve or twenty-
four hours after birth, the child gradually becomes restless,,
and by its peculiar plaintive cries manifests the suifering it
now begins to endure. These cries are generally attributed
by the nurse, to colic, and the little suiferer is treated accord-
ingly with all kinds of medicines, but generally to none but
the worst of purpose. The abdomen, especially in the hypo-
gastric region, now becomes enlarged, tense, hot, shining, and
painful upon pressure, the respiration becomes difficult and
irregular, and the pulse frequent, small and contracted. To
these symptoms, if no amendment soon takes place, vomiting
will be added, first, of all the milk and other fluids swallowed,
then of the mucous and biliary secretions, and finally, of the
meconium, or a dark brownish matter analogous to it»
Should no relief still be afforded the little sufferer, these
symptoms will become augmsented in violence ; the diaphragm
and other abdominal muscles will become excited to violent
expulsive efforts, during which respiration will sometimes
become suspended, the face will become swelled, discolored
and covered with perspiration ; the voice sooner or later will
become almost extinct ; there will be hiccup, with coldness-
and flexure of the extremities and convulsions. In the male,,
inflation of the scrotum and penis sooner or later takes place.
Should matters thus continue, death is inevitable and is soon
ushered in ; and it usually takes place between the third and
the eighth day, according, to the vigor of tlie little patient.



INTliODUCTION. 55

Before death occurs there is often a ^^encral yellowness oi' tlie
skin. When the case is protracted for a number of days the
emaciation becomes extreme, and the patient dies from the
etfects of inanition.

Strange to say, that cases of complete occlusion of the rec-
tum have occurred, in which life had been prolonged for a
number of days, and even for months witliout any evacuation
from the bowels, and before any violent symptoms had taken
place.

Wolf mentions a case of imperforation of the anus and rec-
tum in which, strange to say, the deformity was not discover-
ed and no unfavorable symptoms manifested themselves until
the evening of the twelfth day, the child during this time not
having had any motion from its bowels, when it was attacked
with vomiting, hiccup and convulsions, attended with disten-
tion and hardness of the abdomen and great prostration.
[Yide Case LIX.]

A still more remarkable case of imperforate rectum is re-
ported by Dr. A. B. Shipman of Courtlandville, in the State
of New- York. In this instance the child lived three months
without passing anything from its bowels. He says the child
was nearly as large as ordinary children of that age, and was
not afflicted with vomiting or crjang more than many are,
who are considered healthy. [Yide Case XXIX.]

Mr. West says that Mr. Arnott communicated to him a case
in which the child lived seven weeks and three days, the rec-
tum being entirely absent, and the colon terminating in a
blind sac, and floating loosely in the abdominal cavity. {Ojj.
cit.p. 376.)

De La Marre mentions an instance of a child having an anal
imperforation, which lived six months without ever having
had any evacuation from its bowels. In this case the milk
and everything else taken into the stomach were constantly
ejected by vomiting. {.Journal de Medlcme de Paris, annee.
1770. tome XXXIIL ^. 510.)



56 INTBODirCTION.

A case is reported iii tlie " Provincial Medieal and Surgi-
cal Journal " for March, 1851, in which a child having an im-
perforate anns lived one hundred and two days without hav-
ing any evacuation from its bowels, and dm-ing this time
never vomited.

Death in instances of imperforation of the anus or the rec-
tum, is usually the result of enteritis, peritonitis and intestinal
paralysis.

Sometimes previous to death in consequence of the violent
expulsive efforts to overcome the obstruction, the colon, or
some other portion of the intestinal canal bursts, and its con-
tents are poured into the peritonseal cavity, death being
ushered in by the sudden supervention of a state of collapse.
A. case of this kind is related by M. Fourcade. {RevueMedi-
cale de Paris, annee. 1830. tome VI. y. 52.)

On dissection, the intestines will be found enormously dis-
tended with gas, meconium and other matters, and highly
inilamed.

The distention or tympinitic state of the abdomen in these
cases is caused, in part, by the disorganization which, at an
early period takes place in the contents of the intestines, by
which great quantities of gas are disengaged. The intestinal
nerves become affected, hence the spasms. The blood vessels
of the lower extremities too, become compressed, and this
comj^ression induces congestion of the heart, lungs, and brain.
This phenomenon is very evident when the distended cavity
of the abdomen presses upon the thoracic viscera. The com-
pressed lungs no longer admit full respiration ; the vital
transformations of the blood are inadequately made, and at the
same time, as the excrementitious matters of the body cannot
be carried off by defecation, the composition of the blood
becomes such as no longer to afford any nourishment to the
vital organs.

Conjointly with the general signs of intestinal obstruction,
there are in each case some special indications of the peculiar



INTRODDCrriON. 57

form of niixlforination to which the obstruction is due. These
special symptoms will be fully given in the following clia})ters,
on the different species of malformation.

The pathognomonic sign is obtained by the direct inspection
of the anus and the rectum.



SECTIOi^" VII.
PROGNOSIS.

Anciently the malformations of the anus and the rectum,
together with those of the genito-urinary organs, were looked
upon as necessarily fatal, and the unfortunate victims of them
were regarded in the light of monsters, and left to perish.
Even at tlie present day this sentiment prevails to a certain
extent, and the subject is still surrounded by no inconsider-
able degree of mystery, the most insignificant deviations from
the natural standard being apt to be exaggerated and invested
with an importance which by no means legitimately belongs
to them.

When we take into consideration the fragility of the sub-
jects, the deplorable nature of some of the species of these
malformations, and the formidable character of some of the
operations 'necessary for their relief, the hope of ultimate suc-
cess does indeed appear but slight ; yet such are the great
improvements that have been, and are being made in modern
surgery, that the evil is by no means deplorable, even in some
of the w^orst cases, as will be shown hereafter. 'No case
should be abandoned in despair, although surrounded by the
most discouraging circumstances. Many of the cases may
be relieved immediately by simple and appropriate trea-tment,
and others admit of certain relief, by prompt surgical meas-
ures, which not only save, but prolong life, Tlie surgeon



58 INTRODUCTION.

must be very careful, however, not to promise the parents or
the friends of the child too much even in the most simple
case, recollecting how natural it is for them to imagine that
if the operation succeeds, all will be well, and that the child
will be left in every respect perfect. This would be a great
mistake, as every surgeon knows who has had any experience
in endeavoring to remedy defective formations. Therefore, to
prevent misconception on this point, and the evil conse-
quences of it, the surgeon must previously explain to them
that the operaition may indeed afford an outlet and immediate
relief ; but that such an artificial opening or anus, not being
formed by nature for the specific purpose, cannot be expected
to possess all the powers or to perform all the functions of
which the natural anus would have been capable.

The most favorable cases of course are those which require
the least surgical assistance — such in which there is a con-
traction of the anal orifice, and requires but simple dilatation,
or such in which the anal orifice is obstructed by a membrane
which only requires to be divided.

Tlie most formidable cases are those in which there is a
considerable deficiency, or an entire absence of the rectum,
and in which there exists no outlet whatever. In all such
cases, without an operation, death soon takes place from
necessity. Some surgeons, however, consider all such cases
necessarily fatal, and beyond the power of art to remedy :
yet, as I will hereafter show, even a number of such cases have
been relieved, by either the operation of proctoplasty or colot-
omy. In such a case even a doubtful remedy should be
2)referred and attempted in preference to the certain death of
the infant,

Tliose cases in which the rectum opens into the bladder by
an abnormal anus, or into the urethra, or the vagina ; or in
which there exists a preternatural anus on some part of the
body, are not so formidable and do not terminate in death so
quickly. Some of them may be entirely relieved, others



INTRODUCTION. 39

greatly benefitted, whilst otliera again admit of palliative
treatment only.

Some very remarkable cases are recorded of life having
been sustained and prolonged for days, months, and even
vears, in which no anus whatever existed, nor in which had
any operation been performed. In these instances there was
consid(^-able deformity too of the genito-urinary organs,

A man forty years of age was seen by Bartholin, in whom
no anus existed, but who discharged his fseces from his mouth
by means of a horn, made for the purpose, and who voided
his urine from the umbilicus. {Historia Anatomicce, cent. I.
ohserv. LXV. f, 113.)

Baux saw a girl fourteen years old who had neither an anal,
a genital, nor a urinary opening. There was not the least
appearance of these apertures, the skin being smoothly contin-
ned over the situation naturally occupied by them, as on other
parts of the body. At the end of every third day she experi-
enced considerable pain around the umbilicus, and immediately