The dilatation of the intestine, by injection with water or air, is used by many writers as a procedure preparatory to operation, intended to render the release of the intussusception easier. Whatever the choice of method may be, the simplest and shortest procedures are best since every delay increases the danger. Only in those cases coming to laparot omy during the first 24 to 36 hours, is it pos.sible to relieve the con dition in a few minutes after the opening of the abdominal cavity, and it is by such a rapid procedure alone that really good results are obtained, as about two-thirds of these cases are cured. When set-ere symptoms of incarceration are present, which take place relatively early in acute invagination, and the invaginated portions are already .so altered that they must be extirpated, or the adhesions formed do not permit of separation, the proportion of cures is markedly lowered, whether one resects, performs enterostorny, or makes an artificial anus. For the details of the operative procedures, the text books on the Surgery of Children are to be consulted.
Intussuseeptions whieh extend into the rectum, or are prolapsed from the anus, do not contraindicate laparotomy if they are not gan grenous. In case this is present, 0310 can remove the portion which can be reached, and, if this does not relieve the occlusion of the intes tine, an artificial anus can be made.
In chronic intestinal intussuseeption, attempts at reduction by means of water and air should he made: these can be frequently re peated if there are no symptoms of incarceration. When these meas ures do not succeed, laparotomy should be done, and the results, as has already been stated in this form, are much more favorable.
((i) MALFORMATIONS IN THE REGION OF RECTIEU AND ANUS The following conditions are met with: 1. Simple atresio of the rectum or anus, of which three types are recognized: (a) simple atresia of anus, in which the rectum eliding in a blind sae extends to, or nearly to, the closed anus (see Fig. 25): (b) simple atresia of the rectum in which an anus is present, which, however, ends blindly and to which the rectum, which likewise ends in a blind sae, is joined, by means of a short bridge of tissue: (c) ano rectal atresia, which really represents only a higher grade of the above types, in which tissue separating the anus', ending blindly, and the blind sac of the rectum is longer and broader.
2. Atresia of anus complicated by communication with an abnormal rectum, including (a) atresia recti vaginalis (opening of the rectum in the vagina. See Fig. I on Plate 50); (5) atresia recti vesicalis (opening of rectum into the bladder, see Fig. II on Plate 50); (r) atresia recti ure thralis (opening of the rectum into the urethra, see Fig. 1. on Plate 50).
3. Atresia of anus with production of fistula from rectum. Tire anus is occluded, the rectum ends in a blind sac from which there extends outward a fine fistulous tract, which opens in the median line of the perineum, in the raphe of the scrotum,' or in the under surface of the penis, or in the vestibule of the vulva.
The pathologic anatomy of this condition is evident, from the illustration made from the specimens of the Museum of the Pathological Institute, and the reader is referred to the explanations accompanying these pictures.
The symptoms of these malformations consist of complete or partial stoppage of the intestinal contents, according as to whether there exists an absolute occlusion or an abnormal opening. If the outlet is suffi ciently wide the condition is not dangerous to life, except in cases where the feces are received in a cavity covered with mucous membrane, and susceptible to infection, which is particularly true of the bladder, which, under these circumstances, can become the siitt of severe, pro gressive, fatal inflammation. Tf there is a complete occlusion there is failure to di.scharge meconium, and on inspection, or digital examina tion, one finds the absence of the anus, or the blind termination of the anal canal after a short course. Symptoms of intestinal occlusion soon set in, in which the child succumbs in the course of a few days, if the operative relief of the stoppage is not secured.
The diagnosis of this con dition is relatively easy. One should never forget to inspect carefully the anal region in every new-born child; whereby, in such a ease as this, it would be noticed that instead of the normal anal opening a shallow depression is present, covered by the usual skin, or, the finger introduced in the apparently normally formed anus pushes against a firm obstruction. Frequently, when the bridge of tissue between the rectal and anal blind sac is a small one, the former may be felt, particu larly as it bulges down upon the finger-tip during crying, or in any increase of abdominal pressure. The results obtained through examination with a probe or in bimanual exploration, by rectum and vagina, are less accurate, since it is rarely possible in this way to take the rudimentary end of the rectum between the fingers.
When there is an abnormal outlet of the rectum it is evident from the emptying of meconium from it. One endeavors then, by probing, to determine the course and length of the channel. The opening of the rectum into the bladder, or urethra, is recognized by feces in the urine.
Treatment.—If there is a complete blocking of rectum or anus, an operation must be quickly performed, in order to avoid the dangerous consequences of intestinal occlusion. There is not such haste necessary in the difficult plastic operations, in cases of abnormal outlet of the rectum with free passage; these can be better postponed to a later period.
If the rectal blind sae is felt low down an attempt is made to unite it with the normally situated anus. If the bridge of tissue separating the rectum from anus is very wide, an artitizial anus must be made. An artificial anus can first be made to satisfy the pressing indication of producing a free passage; and, from this point the level of the outlet of the rectal blind sac can be determined, and, later, the union of the rectum with the anus brought about through the perineum.
In regard to the surgical details of the operative methods, and to the plastic procedures attempted in an abnormal outlet of the rec tum, reference must be had to special works.