CHAPTER XV_
IMPERFORATE ANUS.
A correspondent addresses the editor of the Journal of the Americas Medical Association (September 8, 1906) to this effect:
“Mrs. B., a perfectly healthy woman of twenty-eight years of age after a normal pregnancy, gave birth to a fine eight-pound boy, well nourished and healthy looking, and perfect in every way except there was no anus nor sign of any. A small amount of meconium was being passed through the urethra. The next morning a local surgeus was called in counsel and an incision was made through the floor of the pelvis and dissected up along the coceyx, but no rectum was found nor trace of a gut until the sigmoid flexure was reached in the free peritoneal cavity. A large opening in the sigmoid was followed by a discharge of feces. No attempt was made to stitch the gut to the wall or the integument, ‘The opening was not closed in any way and no dressing applied, except that the nurse was directed to keep the site of the operation sponged with a saturated solution of boracie acid after each evacuation of the bowels. The child nursed well afterthe operation and has continued to do so. It sheeps nearly all the time, but has bad oo elevation of temperature; the passages come free and the urine is passed normally. Can you suggest any means of treat- ment that will permit the child to grow up with at least a slight contrel of bowel movement ?"
‘That is the question which occurs to every doctor compelled w0 deal with these cases, which are fortunately rare, ‘The little being’® life rests upon the doctor's readiness to act; and if it survives, whether or not it carries a life-long disability depends largely upon his skill.
It usually happens in the course of such cases that no meronium passes within a reasonable time after the baby's birth. Tt grows restless, perhaps vomits, and for the first time it és suspected that there
és some abnormality about the rectum or anus, which an examination 4
(it il
OPERATION FOR IMPERPORATE ANUS, 585
verifies. It is imperative to relieve the condition at once and if no specialist is within reach, the doctor must undertake it. He may find it quite easy or he may find it impossible.
Tn the first instance, the anus and rectum may be both fully devel- oped, but in passing a finger or probe into the orifice, a thin bulging membrane can be felt, apparently almost ready to burst when the infant cries. A sharp-pointed bistoury, wrapped and introduced along the finger or a grooved director, easily punctures the membrane, followed by a free passage of meconium; and thereafter the bowel
Pio. ¢37,—~Tocision for imperforate anux (Veun)
readily empties itself. The mother is directed to dilate the opening daily with her little finger, and that, with an occasional stretching with a bougie, is sufficient.
In another case there may be no depression where the anus should be. The median raphe extends unbroken from the scrotum to the coccyx. The anus is absent and it may be practically impossible to tell how high up in the pelvic cavity the rectal cul-de-sac may be; and yet it is one's duty to hunt for it through she perineum.
Operation,—Put the patient on its back with thighs flexed and pelvis elevated—in short, in the lithotomy position. Employ a light chloroform anesthesia, not that there is any danger i the anestacda.
586 IMPERPORATE ANUS.
is carefully conducted, unless, indeed, the operation has been toolong delayed, but that a little straining on the patient's part may help to locate the bowel.
Make a median incision from the base of the scrotum or from mear the posterior vaginal wall to the coccyx, which must be exposed (Fig- 437). A number of eventualities may present:
(x) One may find immediately beneath the skin some of the Sbers of the external sphincter, a favorable indication, Split these Shen by blunt dissection, Free incision may spoil their usefulness, Be
Pie, 4)1—Retmtion exturn (Vem)
neath the muscular layer appears the lobulated fatty tissue peculiar to the new-born, which is to be next divided. Here one must go sowly, keeping in the middle line and all the time working towan! the coccyx. The danger is in front. If toward the hollow of the sacrum, a fluctuating pouch is felt or a brownish rounded tumor i seen, one breathes casy, knowing that the imperforate gut is within reach. But do not be in a burry to open the gut. It # first to Be secured by passing = suture on each side of the middle line or by catching the bowel wall with forceps, ‘The suture should not per forate the bowel. = Making gentle traction on the bowel, proceed to free it by careful bhant dissection. Do not we kvile ot sdmors to divide what seem
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OPERATION FOR IMPERPORATE ANUS, 587
to be fibrous bands, for it is possible they contain the blood supply of the bowel; and, if divided, dangerous bleeding may occur or the tissues become gangrenous,
‘As the pouch is freed, it is gradually pulled down into the wound; and if they were not passed before, two sutures are now passed with which eventually to fasten the gut to the skin opening (Fig. 438). Now is the time to open the pouch and let the meconium flow out, It may require several minutes for the bowel to empty itself, Evert the mucous membrane, enlarging the bowel wound a little if necessary.
Fic. 430°—-Mucmenitancous suture, (Vea)
Suture the mucous membrane directly to the skin; no other tissues should intervene (Fig. 439)»
Irrigate thoroughly and apply a gauze dressing, which is changed as offen as soiled, ‘The functional result is often surprisingly good. Broncho-pneumonia may develop when the operation has been too Jong delayed and septic absorption has begun.
(2) The pouch cannot be drawn down. In that case when the bowel is opened the discharge will have to flow over the raw eurfaces of the flesh wound which will need to be kept open with bougies. Infection is a constant danger, not to speak of lack of control af bowel movement,
Better than to leave the wound in this condition, the coccyx and a part of the sacrum may be removed and the gut brought wat your
a
588 IMPERYORATE ANUS,
tiorly, Still better, open the peritoneal cavity, find and draw dows a loop of the sigmoid to fasten in the wound.
(3) The pouch cannot be found. Oltain more room by resecting the cocyx, follow the sacrum a little higher, open the perituneal cavity and search for the cul-de-sac; if possible, draw it down inte the wound ‘and suture.
Af all these measures fail, there is nothing to do but make an artificial anus in the inguinal region. Indeed, there are those who adivive thi: from the first with the idea that later the operation for the construction ‘of a normal anal orifice can be better undertaken.
Tuttle says (Diseases of the Anus, Rectum, and Pelvic Colon) that where there is no evidence that the rectal pouch can be easily reached, and where the child is in an enfeebled condition with distended ab- domen, fecal vomiting, and nausea in progress, one should not hesitate to choose the abdaminal route, perform an inguinal colotomy at qece and thus afford an immediate exit to the intestinal contents, and am escape for the gases which are causing the distention and the comsti- tutional disturbance,
To this same volume the reader is referred for a full discussion of these problems, and for consideration of those other forms of fect development in which the anus has abnormal openings Sack cases are not strictly emergencies, for usually there is a partial means of escape for the bowel contents.