THE SURGICAL TREATMENT OF CON- THE RECTUM. BY WILLIAM THOMAS, F.R.C.S. · I WOULD arrange all such cases in three groups, with subdivisions thus: 1st. Imperforate anus or rectum. 2nd. Abnormal termination of rectum.-I. At the surface; 2. In the vagina; 3. In the urethra or bladder. 3rd. Partial or complete deficiency of the rectum.1. Terminal; 2. Intermediate. It is at once obvious that the above arrangement includes many varieties, indeed, we rarely get two precisely similar cases; but I think that all congenital malformations of the rectum may be placed in one of the three groups, and that the study of them will be facilitated by thus limiting them. I have purposely omitted cases in which the rectum is abnormal in consequence of the opening into it of some other structure, as the uterus, ureters, or vagina, such being really abnormal conditions of those organs rather than of the rectum. First group, Imperforate Anus. I would restrict the term imperforate anus to cases where only a thin membrane interposes in the normal situation between the termination of the rectum and the surface of the body. Such cases constitute the most simple of congenital malformations. They frequently are brought as out patients to various hospitals, and many no doubt come under the notice of and are treated by those extensively engaged in obstetrical practice. The treatment by simple incision is usually successful: care should be taken to keep the patient under observation for some months, and to dilate the orifice occasionally, that contraction may not take place-a condition which very frequently occurs, and gives rise to troublesome abdominal distension, and sometimes to a dangerous form of dilatation of the colon. The Second group, Abnormal Termination, inIcludes three subdivisions : 1. The rectum terminates by a fistulous track, which opens on the surface at some distance from the normal site. 2. The rectum terminates in the vagina. 3. The rectum terminates in the urethra or bladder of the male. In cases where the rectum terminates by a fistulous track which opens on the surface at some distance from the normal site, the treatment is usually simple and successful. A director having been passed along the track, a probe-pointed bistoury is passed along it and the fistulous track freely divided into the rectum. The only cases of this description which I have seen have been very simple, the track passing forward toward the scrotum, and therefore easily treated. The rarer forms of this malformation must be treated according to the nature of the case. In the second and third varieties, in which the rectum opens into the vagina of the female, or bladder or urethra of the male, there are three methods of operative treatment. Ist, By opening the rectum in the normal situation of the anus, drawing down the bowel and stitching the mucous membrane to the skin; the recto-vaginal opening being left to close of itself, or being operated on subsequently. 2nd, By dissecting out the rectum from its abnormal position, and fixing it in its normal site. 3rd, By incision through the vaginal opening and perineum, and then keeping the posterior part open until the anterior is closed. The first of these operations is the one that is or has been most usually performed. It is easy, and successful cases of it are reported, though I have never seen one, and the operation has certain disadvantages which militate against its success. Although the bowel may have been freely opened, and the mucous membrane well drawn down and stitched properly, contraction of the orifice takes place after a time, requiring constant attention on the part of the surgeon for many months, tiring out the patience of the friends, who usually decline further treatment. Another drawback is the tendency of the fæces to pass through the abnormal opening into the vagina or urethra. Some authors assert that this abnormal opening has a tendency to close when a free exit is made for the fæces at the position of the anus. Mr. Bryant says, "when the anus opens in an abnormal position, as in the vagina, and the anus made by the surgeon is established, there is a natural tendency for the abnormal anus to close: several cases being on record in which this result ensued. Two have occurred in my own practice." No references are given by him as to the successful cases, nor are any details given as to the two which occurred in his own practice. Among the II cases operated upon, and described in Mr. Curling's table, in only one is it recorded that the vaginal orifice closed spontaneously, and commenting upon that Mr. Curling says, "so fortunate a result is unlikely, and could only occur when the abnormal aperture is unusually small." He further remarks, “I am not acquainted with any case in which, after the formation of an artificial anus at the proper site, a successful operation has been performed for the cure of the rectovaginal opening." Mr. Holmes says, "In those cases which I have myself seen I cannot positively assert that the opening has closed in any, though in two of them it seemed highly probable that it would. One of these was under Mr. Johnson's care, and is included in Mr. Curling's table. A second was under my own treatment; in that case from the rapid diminution in the size of the sinus during the short time that the infant was under observation, and the fact that while the fæces were passing through the natural channel, the unnatural one remained clear, I have little doubt that it was already obstructed in some part of its extent, and would soon become quite obliterated." So far as my own observation goes, there would appear even after a well performed and promising operation to be a great tendency for the fæces to pass forward to the vaginal or urethral opening. Constant dilatation is necessary, for a long period; indeed, from the accounts given of some cases, years are required before the patient can be considered free from relapse. No one who reads the records of such operations can feel that the result is as satisfactory as it ought to be. But the operation has this value, it may be performed as a temporary measure when for various reasons it is not desirable to carry out the somewhat more complicated proceeding of dissecting out the lower end of the rectum, and replacing it in its normal site. This, which is a much more promising operation, was, I believe, first described in Holmes's System of Surgery, edition of 1871. The credit of it is due to Signor Rizzoli, of Bologna, who has successfully performed it in many cases. The scientific and rational characters of it are such that should clinical experience confirm its value, it must of necessity supersede all others. The operation is equally useful in vaginal or urethral termination of the rectum. I myself am able to quote cases of both. soon as possible, lest dilatation of the colon should occur. In forming an opinion much will depend on the surroundings of the little patient, but should there be no abdominal distention, I think any case might with advantage be postponed until the child was three months old, and even much later in some cases. The operation is thus performed-The patient being placed in the lithotomy position and chloroform given, a bent probe, or better, a sharply curved bladder sound, is passed into the rectum through the vaginal orifice; an incision is now made along the median line reaching from the margin of the anal orifice in the vagina to the tip of the coccyx. This incision should be carried deeply enough to reach the surface of the rectum, but care must be taken to avoid opening it. The dissection of the rectum requires caution, any hæmorrhage which may occur should be at once arrested. When the rectum has been as much as possible exposed by this median incision, the knife is to be carried round the vaginal anus, and the remaining part of the rectum separated from its connections until the anus can be placed without much traction in the posterior angle of the wound, as near the tip of the coccyx as possible. This separation of the rectum anteriorly seems to me to be the most important part of the operation. It should be freely done, and after the separation of the anus is not difficult, a few light touches of the scalpel being usually enough to divide the areolar tissue between it and the parts in front of it. The margin of the anus is then stitched in the posterior angle of the wound, next the sides of the vagina are united, and lastly the perineum. This order is of great importance when working in such a small space. It is necessary that all bleeding should have ceased before the sutures are applied or hæmorrhage may take place between the sides and interfere with early union. Usually the fæces pass readily, and no dilatation of the orifice is required, but should this be thought too small it may be enlarged by an incision backwards. It is essential that the anus should be fixed as far back as possible, the tendency of the subsequent cicatricial contraction is to draw it forward, so that after the effects of the operation have passed, it will be found much nearer the vagina than might have been expected, especially should union by the first intention not take place, indeed such union will be found exceptional from the numerous unfavourable conditions. Although instances are on record in which vaginal termination of the rectum has not been recognised until adult life, as a rule such cases come under treatment early, and the first point the surgeon has to decide is whether he should operate immediately or wait for a time. In most rectal malformations we have not much choice, but must operate at once to relieve the symptoms of intestinal obstruction, but in these it is not always so, and where the meconium passes freely and the subsequent evacuations do not give rise to obstructive symptoms, I think it is far better to wait for a time than to operate at once, and for the following reasons. The operation is a severe one for a very young infant, the hæmorrhage often free and exhausting. The parts are very small, the wall of the rectum thin and easily perforated, and not readily distinguished from the surrounding structures. The nutrition of the child is uncertain. There is a great difference in the vitality of infants, and it is Important for the surgeon to estimate this condition beforehand. On the other hand no time should be lost in restoring the normal condition as birth. The following is a fair specimen of an ordinary case of vaginal opening of rectum, cured by Rizzoli's operation: M., æt. two days. July 16, 1883, absence of anus in usual site. Is rather undesized, and has a look of premature There is no sign of anus in the normal bladder or urethra of the male, would appear to be even more frequent than the last, no less than 26 being found in Mr. Curling's table; their treatment, according to the same authoriy, seems even more satisfactory. Several fatal cases are recorded, and in all, even the most successful, much inconvenience seems to have been from the tendency to contraction of the artificial anus made by the surgeon, and from the persistence of the communication with the urinary organs. situation, but meconium escapes per vaginum, namely, where the rectum terminates in the freely. A bent probe introduced into the vagina passed almost immediately backwards, through an opening in the posterior wall into the rectum; there is much distension of the abdomen. July 17. Chloroform having been given, I performed the operation as described above. The lower end of the rectum and anus being freely dissected out, and removed one inch back. Bore operation well, but about three hours after there was rather severe secondary hæmorrhage, which was restrained by compression. 18th. Has passed a good night. Takes food freely; meconium and fæces pass readily; wound slightly inflamed about sutures. 19th. Restless night; several sutures have given way; fæces pass freely; anus keeps well in position. 20th. Better night, but all the sutures in the perineum have given way, and the wound gapes in front of anus. Takes food well, and sleeps well. 21st. Child better; anus keeps in good position, but a large suppurating gap occupies the place of the perineum in front of it. Aug. 5. Looks thin and badly nourished; ordered half a bath biscuit in addition to milk every day. 22nd. Much improved in general health since alteration in diet; wound nearly healed. Sept. 5. Discharged cured. The above case was complicated by the occurrence of secondary hæmorrhage, which prevented union by first intention. Had I been present at the time I should have reopened the wound in the hope of tying the vessels, and removing any clots. Beyond the prolonged healing, it did not seem to affect the result. No dilatation was required, the motions passing freely from the end of the rectum, which was of course already lined by a mucous membrane. Altogether I have seen nine cases of this malformation; of these two died without any operation being performed; two were operated on unsuccessfully by incision; three were successfully treated by dissection; and in the remaining two, treated by Rizzoli's method, the result is not known. It is difficult to see how this operation can be unsuccessful when properly performed, the only drawback to its success is the tendency of the cicatricial contraction to draw the anus forward-the alternative of incising the rectum backwards from the vaginal orifice and making the wound heal at the forepart first (3rd method) has been advocated and practised, and might in some cases be preferable; I have, however, had no experience of it and should expect more trouble in the after treatment than when the anus is dissected out, drawn down, and fixed in its normal position. The third variety of my second group, Mr. T. Holmes, in the 1871 edition of "A System of Surgery," recommends in urethral termination a similar operation to the one I have described, he says,-" the proper course is to begin by performing the usual exploratory operation in the perineum, and if the rectum be met with to separate it from its connections and draw it down to the skin." He adds, "I am not aware of any case in which this has been successfully accomplished." As this is repeated in the edition just published, it gives me pleasure to place on record such a case. Case of rectum terminating in membranous part of urethra, treated first unsuccessfully by incision, afterwards by dissection and replacing in normal position with success. Ernest Wheeler, æt. two days, July 4, 1882. It was stated that he had passed nothing from the bowels since his birth, but it was thought that his motions passed with the urine, which was described as being very dark coloured. On examination Mr. Phillips could find no anal aperture, but thought he detected a very slight bulging in the position of the rectum. He therefore made an incision about 4 inch in depth in the median line over the situation of the anus, but no further indication of a rectum. Seemed healthy, was well nourished, and had taken the breast regularly; but the skin was of a yellowish tint, and the abdomen very tense and enlarged. Chloroform was administered, and Mr. Thomas, having passed a catheter into the bladder, drew off about 2 oz. of urine slightly tinged with bile pigments, but there were no signs of any admixture of meconium with the urine. An incision, 11⁄2 inches long, was made in the median line of the perineum, over the position of the anus, and carried to the depth of 34 inch, when the bulging distended rectum was seen. was freely opened, and a large quantity of olive green meconium escaped. The mucous membrane was easily drawn down, and attached to the skin by fine wire sutures; the child was much relieved at once. July 6, Skin about the sutures seems rather inflamed; abdomen is normal sized, in fact the swelling and tension disappeared immediately after the operation. Child takes milk freely by the bottle. This During next few days patient progressed A Shows the relative position of the parts, and the line of incision (dotted). B Shows the parts separated and the anus dissected out. C The operation completed. D A diagrammatic vertical section to show that when the end of the rectum is dissected out and turned back there is no tension at the extremity. B Bladder. U Uterus. V Vagina. A Anus. R Rectum favourably; the artificial anus was well established, and the fæces passed freely by it. July 19. A small quantity of fæces was observed to pass per urethram-not mixed with urine. This was the first proof observed of any communication between the rectum and the urinary tract; the urine was clear, the fæcal matter semi-fluid, from which it was concluded that the rectum terminated in the urethra, near the bladder, either directly or by a fistulous track. Knowing well the difficulty of obtaining obliteration of such a communication, and the inconveniences of it, Mr. Thomas decided to allow the artificial anus to close, and then to dissect out the rectum, separate it from its connection with the urethra, draw down the extremity, and fix it in the normal position. July 26. Fæces continue to pass through the urethra ; anal orifice contracting. 31st. Fæces all pass through the urethra; anal opening nearly closed. Aug. 3. Anal opening seems quite closed. The rapidity with which the contraction has taken place is remarkable, and well illustrates the tendency to relapse after this operation. Aug. 4. Penis and prepuce being much inflamed, circumcision was performed. Aug. 8. Although fæces passed freely by the urethra, abdomen had become tense and distended, and the child very uncomfortable. The following operation was performed: A sound having been introduced into the bladder to serve as a guide to the position of the urethra, and the child placed in the lithotomy position, an incision was made in the median line of the perineum from the junction of the scrotum with it to the tip of the coccyx. The rectum was caretully sought by increasing the depth of this wound. At about 3/4 inch from the surface, and very near the anterior extremity of the incision, a touch with the point of the knife was followed by a slight escape of fæces, showing the position of the bowel. The dissecting out of the rectum was a task of considerable difficulty, owing to the thinness of its walls, its intimate connection with the urethra, the adhesion of the parts from the cicatrix of the previous incision, and from the hæmorrhage which was severe for so young a child. The bowel having been separated from the urethra, its cut extremity easily admitted the end of the little finger, which was inserted into it for the purpose of drawing it down and facilitating its further separation from the surrounding parts. The lower end of the rectum was cleared for about an inch all round, and its open extremity stitched a little posterior to the middle of the incision, the sides being united in front and for the short distance behind. The child was much blanched after the operation, but had a good pulse and quickly rallied, and shortly after took milk freely. Much fæcal matter escaped, but there was no sickness after operation. Aug. 9. Rather restless night; bowels relaxed. Union by the first intention did not take place; the liquid state of the motions, and the occasional passage of urine along the wound, interfering with the progress of the case. The anus remained distinct, but was gradually approximated towards the urinary fistula, which formed in front and through which a considerable proportion of the urine passed. 21st. Much better; a slight discharge of fæces observed from the urethra; anus was distinct, but in front of it was a large granulating space. Sept. 15. In consequence of cicatricial contraction the urinary fistula is now close to the margin of the anus, so that a small quantity of fæcal matter gets into it and is passed by the urethra; the contraction of the anal orifice tending rather to direct the fæces into the fistula communicating with the urethra. The anus was, therefore, incised backwards, towards the coccyx. After this the patient progressed favourably, and was discharged in Dec. apparently cured; fæces and urine both passing by the proper channels. He was readmitted April 18, 1883, having been much neglected, and suffering from the urinary fistula; nearly all the urine passing by it, and the irritation about the anus producing a troublesome diarrhoea. The diarrhoea was much relieved by astringents, but as the urine still nearly all passed through the fistula, the rectum was dissected out again and placed close to the coccyx. He rapidly improved after this, and for some months has been quite well, no urine having passed through the fistula. In all probability he would not have required a second operation had the rectum been placed far enough back at the time of the first, and sufficient room allowed for subsequent contraction. The opening in the floor of the urethra must have been of considerable size, and it is surprising, under the circumstances, that it should have closed enough to prevent urine passing along it. In the third group-Partial or complete deficiency-where we have partial or complete deficiency of the rectum, we meet with by far the greatest difficulty both in diagnosis and treatment. The variations in this group are numerous, and often more difficult to diagnosę than in the others. The rectum may reach so near the surface that the treatment required differs but little from that of simple imperforate anus. It may be entirely deficient, or, what is still more puzzling, there may be a well-marked anus leading to a tubular cul-de-sac about an inch in length, and sometimes connected by a fibrous cord with the true rectum. I would suggest intermediate deficiency of the rectum as a suitable term to describe this condition. |