CHAPTER XIV. SPASM OF THE SPHINCTER, NEURALGIA, WOUNDS, RECTAL ALIMENTATION. (Part 6)

constipation; nor do such contractions lead to the ordinary changes in the mucous membrane above and below the spot which are usually seen in cases of stricture of the rectum. On the other hand, when the stricture is tight it will give rise to all the usual signs of such a condition in the child — ^absence of free passage of meconium, dis- tention of the abdomen, and vomiting. The diagnosis is easily made by a digital examination should the symptoms be sufficiently marked to lead the attention of the surgeon to the rectum; for the stricture is generally near the anus and may be felt as a ring with sharp edges. The treat- ment consists either in dilatation or in nicking.' 2. Closure of the Anus ly a Membranous Diaphragm, — The mem- brane in these cases may be of greater or less firmness and thickness, and may be composed of skin or of mucous membrane,^ It is sometimes so thin as to bulge out with meconium when the child strains or coughs, and has been known to rupture spontaneously. This is the simplest of all the forms of congenital malformation of the anus, and, unfortunately, one of the rarest. It is easily diagnosti- cated by simple inspection of the parts; and the treatment consists m making a crucial incision through the membrane. The remains of the * -" Dissertatio sistens observationes de ano infaatum imperforate." Lugd. Batav., 1781, 4to. (Bodenhamer). •'* " A Practical Treatise on the Etiology, Pathology, and Treatment of the Con- genital Malformations of the Rectum and Anus," by Wm. Bodenhamer, New York. Wm. Wood & Ck>., 1860. 3 ''Traite des Maladies du rectum et de ranus,"par Daniel Molliere. Paris, 1877. * Op. cit. ^ Inaugural Thesis. Strasbourg, 1861, No. 555. •See also Gosselin, CliniqueChirurg.," 3d ed. Paris, 1879, T. iii., p. 706. Berard et Maslieurat-Lagemar, Gaz. Med.de Paris, 1839, p. 146. Demarquay, Journal de Texp^rience, t. ix., 1842, p. 273. Ashton, ** Diseases of the Rectum,' London, 1854, p. 27. Devilliers, Rev. Med. de Paris, 1835. 32 DiaSABES OF THE BEOTUIC ANU AMUB. membrane, like those of the hymea which it strongly resembles, will shrink up bo aa not to cauae trouble or deformity. 3. Entire Absence of the Anus, the Rectum ending in a Blind Pouch at a Point more or less Distant from the Perineum. In these cases there may be a slight depression at the point where the anos should be found; or there may be no trace of the anal orifice; the raphe of the perineum extending over the spot and back to the coccyx. The external sphincter muscle is also sometimes present and at others entirely wanting. The poach of the rectum in these cases may hang loose in the pelvis or abdominal cavity, or be attached to some adjacent pait; and the spaoe between it and the perinenm may be filled np with. FiQ. 7:— (HoKUre). cellular tissne, or in other cases a distinct fibrous cord may be traced from the rectal pouch to the skin, as is shown in the plate. If the pouch of the rectnm be nut at too great a distance from the skin, a sense of fluctuation may be felt by firm pressure with one finger ' over the anus and the other hand on the abdomen. In females, valuable aid in diagnosis may be obtained by the introduction of a finger into the vaffina. The use of a stethoscope over the anus, and of percussion on the abdomen, has been recommended to detect the rectal pouch filled with gas (Bodenhamer, Molli^re); and also the irritation of the skin over the anus to provoke efforts at defecation. * An effort should always be made, where there is complete absence of the anuB, to discover whether the rectum ' A. Copeland Hutchinsou: " Piwstioal ObHervations in Surgery," London, OOaOBNITAL UALFOBH^TIOHS OF TBB BBOTUH AKD AHOB. 33 may not haTe some outlet through the bladder or vagina, which shall place the case in one of the olaseea soon to be described. i. The rectum may be the same as in the last variety, and the anus he normal. The septum which separates the rectal and anal poaches in this case 18 generally within easy reach of the anus, and may be so thin aa to per- mit a sense of fluctuation. In most cases, however, the eeptam is thiciier, and is composed of cellalar or fibrous tissue, lined both above and below by macous membrane. It may be perforated, like the hymen, at some point, and allow of the slow dribbling of meconium. There may ^o be more than one septum. Voillemier' reports one case in which the rectum was divided in this way into four distinct compartments, the upper one containing meconiumj and the others mucus. There is gen- erally little difficulty in the diagnosis of these cases, provided only a digital examination be made when the infant begins to show the eflects of the obstmction; but the danger lies in the fact of the normal anus, which is apt to allay suspicion as to the true nature of the difficulty.' ■Oaz. deaHdp.,1846. ■ >■ Dr. H. G. Jameson, of Baltimore (Medical Recorder, vol. v., 1622, p. 290), divided two tnembnuious septa, one above the other, with a button-headed bistoury, which he passed 'into the opening or ring of the septum,' and cut freely down toward the sacrum. This was done in September, 1831. The patient got well. Roser (Arch. fQr Phjaiol, Heilkunde, 1859, p. 126) mentiona a. circular valvular stricture an inch from the anus m a little girl of four, which he treated by diviraon." Tan Buren, " Lectures upon Diseases of the Rectum and the Surgery of the Lower Bowel." New York: D. Appleton & Co., 1881. p. 263, note. 34 DI6BABEB OF THE BEOirrU AtTD XH(J8. 5. The anus may be absent, and the rectum mai/ open by an abnormal anus at any point in the perineal or sacral regions. Whea the rectum terminates ia the glune penis, the labia, or at some abnormal point in the perinenm, the lower portion of it is nsually of a fistulous character, as shown in the plate, but lined by true mucous membrane; and the anus, whether in the perineum or at the base of the Bacrum, or tip of the coccyx, is always narrow and iasnEBcient for its purpose. A modification of this class of abnormalities is found in those cases where the rectum terminates in two openings at a greater or less distance from each other. Fio, 9.-(UoQ14re). Cruveilhier' reports a case of this nature, in which the fistulous pro- longation of the rectum ran subcutaneously m the scrotal raphe, and terminated at the glans penis. Mr. Morgan' has recently reported two modifiations of this species of deformity which are rarely met with, and are easily relieved, In the first, the anus was of the usual size and in the proper location; bnt there was found to be a band of tissue passing from a point corresponding to the apex of the coccyx to the median raphe of the scrotum, with the posterior extremity of which it was continuous. The band was about . three-quarters of an inch long, and was attached at both ends, the re- mainder forming a thick, free cord, which lay below the aperture of the anus, while from the centre of this band there ran a small branch of similar tissue, which was attached to the skin of the left buttock, and was about half an inch in length. The skin covering the central band ' Anat. Pathologique du Corps Humain, t. i., liv. i., Planche vi. 'ThreeCaaesof Unusual Deformity of the Anus. Lancet, October 3 2d, 1881. CONGBNITAL MALFORMATIONS OF THE BECTDM AND ANUS. 35 exactly resembled that of the scrotum, shrinking and contracting upon stimulation, and it was so placed that any passage of faeces must cause it to be stretched, thus accounting for the pain attending each motion of the bowels. The second case was similar. The child was born with an imper- forate anas, bat the membranous septum gave way spontaneously. The child, however, continued to suffer pain on defecation, and on examina- tion, there was seen a small, thick band passing from the median raphe of the perineum in front to the depression between the buttocks posteri- orly, and broadest behind. At a spot corresponding to the anus, on either side of the band, was a depression; that on the right was patent, and allowed a probe to pass into the anus; that on the left, though similar in appearance, proved to be only a cul-de-sac. Pio. 10.-<Mom4re). In a third case, there was a depression at the usual site of the anus, and the parts around were so far natural that the skin was pigmented and puckered, but there was no communication with the rectum. The spot at which the f seces passed was in the median line half-way between this depression and the posterior commissure, but nearer the latter than the former. The opening was very small, and a probe passed up into it, showed an abundance of tissue between the passage and the vagina. The cure consisted in enlarging this abnormal opening posteriorly into the depression representing the natural one. Delans' reports an anal- ogous case in a well-nourished child aged four and a half years. There were two openings, one on each side of a median bridle, which was con- ' Soc. de Chinugie, Uarch 24tli, I8TS. 36 PISSA8E& OF THE BECTUAC AND ANUS. tinuous with the raphi in front and behind, and was composed only of skin and mucoas membrane. Each opening seemed to be the natural one^ but the one on the left was a cuUde-aac fifteen millimetres deep. .The septum was excised, with what result is not stated. 6. The anus may he absent and the rectum may end in the bladder, urethra, or vagina. Of these yarieties that in which the rectum opens into the yagina is the most common. In females the opening is seldom, if eyer, into the bladder, but sometimes it is into the urethra. In males it is more often into the bladder than into the urethra, and in such cases the rectum may terminate either by a narrow duct running obliquely through the bladder and opening in the bos-fond between the orifices of the ureters, or by a free opening. The symptoms of this condition will of course yary greatly according to the location of the abnormal opening. When the commu- nication is between the rectum and bladder the fact will be shown by the mixture of the meconium with the urine, rendering the latter thick and greenish in color. The amount of meconium present will also indicate whether the opening is large or small. This condition is generally fatal from the deyelopment of cystitis, and from intestinal obstruction unless the condition be relieyed by the appropriate surgical interference.' When the communication is urethral in the male, the meconium will often escape independently of the act of urination. The prognosis is not as bad in these cases as in the yesical yariety; seyeral being recorded in which life has been preseryed for a number of years. Gross" relates one case in a man aged thirty; and Bodenhamer cites seyeral others in which children haye liyed three or four years. In the female the prognosis is more fayorable than in the male, from the greater facility with which the meconium escapes. Where the abnormal opening is between the yagina and rectum, and is of considerable size, as it generally is, the prognosis is not necessarily grave. Women haye Veen known to liye to a good old age, even to reach one hundred years in the case of Morgagni, with this malformation, and to perform all the duties of wiyes and mothers without eyen being con- scious of anything abnormal (Fournier, Eicord). 7. The rectum and anus are normal, but the ureters, uterus, or vagina empty into the rectal cavity and discharge their contents through it. This species of malformation is rare and is usually attended by other signs * As showing what the bladder and urethra may bear, however. Rowan's case is of great interest* In it defecation took place through the penis for two months without causing any signs of irritation, though the child was several months old, and the rectum was filled with well-formed hard f sdces. Australian Med. Journal, Mar., 1877. « A System of Surgery. Phila., H. C. Lea, 1872, vol. ii., p. 657. 'Diet, des Sci. Med., t. iv., p. 155. CONGENITAL MALFORMATIONS OF THE BEOTUM AND ANUS. 37 of imperfect deyelopment. It is not incompatible with life or with con- ception. 8. Total absence of the rectum. This variety differs only from the third in the amount of the rectum which may be absent. It may or may not be attended by an absence of the anus^ but is usually only one of the signs of arrested development. The blind pouch of the rectum may hang loose in the abdomen or pelvis; may be attached in the base of the sacrum, or to some of the adjacent parts; or may be continued down as a fibrous cord to the site of the anus. 9. Absence of the large intestine. This is also attended by an absence of the normal anus, the place of Which is supplied by an abnormal opening in the umbilicus, or at some remote part of the body, as, for ex- ample, the side of the chest, or the face. With this abnormal opening the small intestine or what remains of the colon communicates. Thus far only arrests or excesses of development have been mentioned. The rectum.And anus are, however, liable to certain diseases during foetal life which may result in narrowing or completely obliterating their cali- bre. Among these are enteritis and proctitis. Treatment, — The treatment of the class of congenital contractions of the anus and rectum, and of the class of membranous septa, has already been referred to, and is exceedingly simple and generally attended by good results. The treatment of the remaining varieties, except the eighth and ninth which do not admit of surgical interference, may be guided by the following general propositions. 1. An operation should always be performed and performed without delay. There is little to be gained even by waiting for the rectal pouch to become distended with meconium, and there is much to be lost. If the obstruction be complete, death is a necessary result; being produced by peritonitis, by rupture of the over-distended bowel, or by a gradual wasting without acute symptoms. Even in cases where a certain amount of meconium makes its escape by a narrow orifice, and delay is not, therefore, as necessarily dangerous as in cases of complete obstruction, nothing is to be gained by delay, and an immediate operation may avoid a paralysis of the bowel from over-distention.* i' Cripps (Lancet, May 16th, 1880) has reported a most remarkable case bearing upon tlqs point. The condition of imperforate rectum was diagnosticated on the third day, but operation was refused and the child taken from the hospital. Thirty days later she was brought back again apparently quite well; the abdomen waB distended; food was taken well; but three or four times every day she vom- ited faecal matter. In this case, the aaus terminated in a blind pouch and a tro- car was plunged upwards through it. Only a little serous fluid escaped from the peritoneal cavity, and the child died of peritonitis. At the autopsy, the rectal cul-de-sac was found just above the anal pouch, but the trocar had penetrated the peritoneal pouch between the two. There are two noteworthy points in the case. The first is the remarkable manner in which nature accommodated itself to the deformity; and the second is the ease with which the rectal pouch may be missed with a trocar. 38 DISEASES OF THE BBGTUM AND ANUS. 2. If there ie any chance of establishing an opening at the normal site of the anus, the surgeon should at first direct his attention to this pro^ cedure. And, since in most cases it is impossible to tell that the rectal pouch may not be within easy reach from the perinenm, it is generally good sargery to make a tentatiye incision at this point. Before attempting any operation on a child's pelyis, the surgeon should Temember the exceeding smallness of the space in which he is obliged to w^ork, eyen in its natural state; and also that the normal measurements may be decreased in any case of congenital malformation. These normal measurements, according to Bodenhamer who made them on two new- bom, well-developed, male infants; at full term are as follows: 1. *From one tuberosity of the ischium to the other, one inch and one line. From the os coccygis to the symphysis pubis, one inch and three lines. From the os coccygis to the promontory of the sacrum, one inch and two lines. 2. From one tuberosity of the ischium to the other, one inch. From the OS coccygis to the symphysis pubis, one inch and one and a half lines. From the os coccygis to the promontory of the sacrum, one inch and one line. The means at the disposal of the operator for reaching the rectal pouch through the perineum and establishing a new outlet, consist in puncture, incision (proctotomy), and in the formation of a new anus by a plastic operation (proctoplasty). The operation by puncture consists in plunging a trocar through the perineum in the supposed direction of the rectum, for the purpose of establishing an outlet. It may be done without a preliminary incision, or after a careful dissection which has failed to reach the desired point. 3. The use of a trocar as an aid in finding the rectal pouch before or after incisions through the perineum,