CHAPTER XIX. MALFORMATIONS OF THE RECTUM AND ANUS. MALFORMATIONS and congenital deficiencies of the intestinal canal and its terminal aperture, occasioning entire obstruction or admitting of but a very partial evacuation of its contents, demand the especial attention of the surgeon, from the necessity of prompt interference, and the certainty of a fatal issue unless the defect is remedied, by establishing a free outlet for the meconium and excrementitious matter of the alimentary organs. The accomplishment of this object is thought by many who have not had to treat such cases a very easy and simple matter; but to the practical surgeon various difficulties present themselves. The diagnosis, when the case is not one of occlusion of the anus by merely a thin membrane, is attended with doubt, as the symptoms and physical signs do not in the majority of cases afford a definite clue as to how much of the intestine is deficient, or as to the relative position of its termination to the external surface; consequently an attempt to reach it by cutting instruments is attended with much uncertainty. Moreover, supposing an operation to have been performed, and an opening into the bowel made, this is only the beginning of the surgeon's anxiety and trouble, for the proneness to contraction in the artificial aperture is so great, that it is only by the most constant attention for weeks, months, or even years, that it can be maintained. In many of the recorded cases, an operation has been performed several times, in order to re-establish the opening a short time since, I was requested to operate on a child fifteen weeks old, that had been operated on twice previously; the case will be again referred to under the proper section of this chapter. The result of the majority of published cases is by no means encouraging; and if the history of others were known, there is reason to believe the view presented would be still less so, and that little hope exists of an infant thus born ever attaining a mature age: still, as it must inevitably perish unless relieved by art, it behooves the surgeon to make an effort to preserve the life of the child, if the nature of the case can be so far made out as to offer a probability of success. CONTRACTION AND OCCLUSION OF THE ANUS. The anal aperture is sometimes preternaturally small, either in consequence of a contraction in the extremity of the rectum, or from the skin extending over the border of the sphincter. The opening may be only sufficiently large to allow the more fluid part of the meconium to drain away, or the size of the orifice may be such as to cause a difficulty in passing, but not entirely preventing, the escape of excrementitious matters. When the anus is merely contracted it must be dilated by tents and bougies. If an extension of the skin beyond the margin of the sphincter abridges the anal opening, several slight notches may be made in it with a blunt-pointed knife, and afterwards it may be dilated by the pressure of bougies. Sometimes two anal apertures exist more or less distant from each other; the one may also be larger than the other, and give exit to the greater part of the contents of the bowels. If the two openings are close together, and not large, it will be advisable to divide the septum between them; but if any great thickness of tissue intervenes, it will be better to enlarge that opening which corresponds most nearly to the position of the natural outlet, and to procure the closure of the other: to accomplish the one object, it will be necessary to have recourse to dilatation by pressure and incision, and when this has been effected, the other may be brought about by the application of strong nitric acid, nitrate of silver, or the actual cautery. In other cases total occlusion of the anus exists, an anomalous condition much more common than either of the preceding forms of malformation. The structure closing the anus is not generally a continuation of the integument, but a lamina of fibro-cellular tissue. It is usually thin and transparent, permitting the meco nium to be seen through it, and forming a small roundish prominence, which is most distinct when the child cries or strains. This bulging membrane communicates to the finger a doughy feel, and sense of obscure fluctuation; by pressure it is made to recede, but it reappears immediately the finger is taken away. In some rare cases the membrane is very thick and dense, especially at the circumference; the protrusion will then be less prominent, and the meconium will not be distinctly felt or seen. This form of malformation will probably be discovered before any symptoms of obstruction arise; but if by carelessness it is overlooked, some days may elapse ere the child betrays any evidence of inconvenience or suffering: but sooner or later it will be observed to cry violently, to strain much, and although at first it may have taken the breast readily, and retained the milk, sickness sets in, and if no relief be afforded, the infant perishes with all the symptoms resembling those arising from strangulated hernia. When the membrane is thin and the nature of the case evident, no delay in making an opening should take place; but if the membrane be thick, and a doubt exist as to the continuation of the rectum, the operation may be delayed for twenty-four or fortyeight hours, no mischief being likely to occur in that time; and during this period the intestine will become distended, and the condition of the parts be more clearly revealed. The operation necessary to remedy this condition is very simple, and consists of making a crucial incision through the occluding membrane with a bistoury, removing the intervening flaps with a pair of scissors, and, if required, dilating the opening by the occasional introduction of bougies: dilatation will also most probably be required. I was called to see a child of a poor woman living in the neighborhood of University College Hospital, that had the anus imperforate. It had been born about eighteen hours; the membrane closing the anus was thin, and rendered prominent by the contents of the intestine. With a lancet two incisions were made crossing each other, and the intervening angular flaps removed: a tent was introduced at first, but no contraction ensuing, its use was very soon discontinued, and the infant progressed satisfactorily. Among the recorded cases are the following: Dr. Thomas Cochrane,1 in April, 1780, was sent for to see a child of 1 66 Edinburgh Medical Commentaries," vol. x, pp. 379-80. a soldier of the 55th regiment; it had been born eighteen hours previously, but no evacuation had taken place from the bowels. The abdomen was much distended, and a swelling, the size of a hen's egg, projected from the fundament; this being punctured, a large quantity of meconium and gas escaped. The child did well. Mr. A. Copland Hutchinson' had a male child brought to him, with imperforate anus. The child was one day old, and when it strained a bulging of the intestine was very perceptible. An incision was made through the occluding structures, and the aperture maintained by the introduction of dossils of lint dipped in oil. After three weeks no further treatment was required. IMPERFORATE RECTUM. The anus in some cases is well formed, and the bowel is continuous, but the meconium is retained by a membranous partition, which may be just within the anus, or an inch or more above it: as in imperforate anus, the membrane varies in thickness, but is usually thin: the nature of the case is made manifest by the retention of the meconium, and by digital examination, or by using a probe or a small elastic catheter or bougie. Dr. Bushe2 mentions having seen in the dissecting-room, a child in whom two partitions across the rectum existed: the one was half an inch from the anus, the other three-quarters of an inch above that. In imperforate rectum the obstructing membrane must be incised by a narrow bistoury, carried up on the finger, or by a pharyngotamus, and bougies afterwards employed. When the membrane is thick, we may not be able to tell whether the intestine is continuous above till we have made the incision; but if it be thin it will bulge down upon the finger, and convey the like sensation as when the anus is closed by a membrane. After establishing an opening in the occluded gut, it is most necessary that as the child grows it should be fully dilated. The evil of neglect of this important part of the treatment has been illustrated by several cases that have come under my observation. In 1855, a 1 "Practical Observations in Surgery," Second Edition, 1826, p. 264. 2 Op. cit. p. 40. gentleman came from Australia to place himself under my care with stricture of the rectum from congenital malformation. When he applied to me the opening in the bowel was only sufficiently large to admit number eleven urethral bougie. He was born with imperforate rectum, which had been punctured with a trocar: after he was eleven years old the opening had been sufficiently dilated to admit number four rectum bougie. For some time before coming to England he had neglected to keep the bowel free; contraction ensued with all its attendant miseries. After being under my care some time he was able to pass number twelve bougie, and experiencing none of his former suffering and inconvenience, he returned to Australia. In 1857, Dr. Hall, of Brighton, requested me to go down and see a child he was attending: she was about nine years old, and suffered from some contraction of the bowel. Upon examination I discovered two inches from the anus a dense membrane, in which a triangular opening existed barely large enough to admit a goosequill. I incised the membrane in eight or nine points, and dilated it freely with the forefinger. Dr. Hall subsequently continued the dilatation with an instrument; and seeing him in the autumn of 1859, he informed me his patient is perfectly well, and the bowels act in every respect quite naturally. Mr. Wayte' operated on a child born 7th March, 1814, in whom the rectum was occluded by a septum. The malformation was not discovered till the child was two days old. In consequence of the closure of the opening, it was necessary to repeat the operation on the 23d of April, and again on the 27th, after which bougies were used daily. The child died of hectic when six months old: caries of the sacrum was supposed to exist. A case occurred to Mr. Jenkins2 of a male child born with imperforate rectum: the anus was perfect, and a cul-de-sac extended upward for about three-quarters of an inch. No attempt to remedy the condition of the parts was made till the eleventh day; a trocar and canula were then thrust through the rectal septum, and fæces followed the withdrawal of the trocar. At the time of the report, twenty-one days after the operation, the child was progressing favorably. 1 "Edinburgh Medical and Surgical Journal," vol. xvii, p. 378. |