The Early Era AD 21900

ARM have been a source of concern for centuries and have been recognized in animals since the time of Aristotle in the third century BC [6]. Soranus, who is considered the first pediatrician of Rome, changed the prevailing public attitude in the second century AD by not allowing neonates with anomalies to die and described dividing a thin anal membrane and dilating the opening [70, 144]. Paul of Aegineta pierced an anal membrane and used a wedge-shaped tent dilator in the seventh century [119]. In 1576, Galen described the anal sphincters, levator muscles, and coccyx [46]. There were few recorded references regarding these conditions until 1676, when Cooke treated a child by making a small incision over a blind anal membrane and dilated the aperture with an elder pith. He emphasized care of the sphincter muscles to others who sought to duplicate his success [26, 28]. In 1693, Saviard was the first to attempt treatment of a high termination of the bowel by plunging a trocar through the perineum [143]. In 1787, 94 years later, Benjamin Bell performed the first perineal dissection in two newborns, finding the blind-ending rectum at variable lengths from just above the anal area to the level of the coccyx [10]. A trocar was inserted and fecal content evacuated. Prolonged bouginage was required to preserve the open passage using a sponge tent, gentian root, or other substances that swell with moisture [10, 34]. Bell also described instances of rectovaginal and bladder fistulas [10]. In 1792, Mantell published a report concerning a girl with a recto-vaginal fistula [101]. In 1786, he had performed an incision in the perineum and carried it up to a probe placed through the vagina into the fistula, creating an anal communication. Reoperation was required 2 years later for "anal" stricture [101].

Colostomy was popularized in the eighteenth century in France. Following an autopsy in an infant with rectal atresia in France in 1710, Littre proposed that the bowel be brought to the surface of the abdomen to function as an anus [94]. The first successful sigmoid colostomy (termed an "inguinal colostomy" or "procedure of Littre"; Fig. 1.1) was performed by Du-ret in 1793 on a female infant who survived into adult life [39]. The results described by others were not as successful [31]. In 1798, Martin of Lyon suggested insertion of a sound in the colostomy and pushing distally to identify the blind-ending rectum during a later perineal dissection [102]. In 1856, Chassignac reported successful use of this technique in two infants with a colostomy [22]. However, colostomy in the newborn was neither a popular procedure nor was it widely accepted at the time [34].

In 1834, Roux of Brignoles attempted to preserve external sphincter function and used a midline longitudinal incision extended toward the coccyx [141]. The incision continued through the elliptical sphincter ani muscle and levators and when the rectal atresia was palpated, a bistoury (trocar) was inserted into the

Second Sphincter Bowel
Fig. 1.1 Illustration of the inguinal colostomy (procedure of Littre) popularized in the eighteenth century in France

bowel, releasing meconium. Dressings and bouginage were required to prevent occlusion of the opening [1]. In 1835, Amussat performed the first proctoplasty by suturing the opened rectal atresia to the skin in the midline (Fig. 1.2) [4]. This was a landmark procedure at the time and gained wide acceptance, and was used frequently for the rest of the nineteenth century. Amussat used an extensive T-shaped incision that basically destroyed the sphincter mechanism. In some instances he described removing the coccyx to aid exposure and mobilization of the rectum [4]. Techniques to repair rectovaginal and rectovulvar fistulae were described by Dieffenbach in 1845 [36] and Rizzoli in 1854 and again in 1869 [136, 170]. In 1852, Dunglison described the relationship between the longitudinal smooth muscle fibers of the rectum and the external sphincter muscle and mucous membrane [38]. By 1860, Bodenhamer noted that in some, but not all instances of high rectal atresia, the sphincter muscles were detected [12, 13]. Despite this observation he shunned colostomy and recommended that an artificial anus should always be established in the perineum. He championed the midsagittal incision first described by Roux 27 years earlier. In 1873, Verneuil reaffirmed Amussat's observation that coc-cygectomy facilitated the dissection of a high blind-ending rectum [4, 167]. In 1879, McLoed described an abdominoperineal (AP) procedure for instances in

Imperforate Anus
Fig. 1.2 JZ Amussat performed the first proctoplasty for a patient with imperforate anus

which the blind rectal atretic end was not found below [107]. By 1882, Amussat's procedure had gained favor in the USA [4, 18]. Before that time only sporadic anecdotal reports concerning ARM were noted in America [53]. Prior to the introduction of the aseptic technique by Lister, the operative mortality for both proctoplasty and colostomy was greater than 60% [34]. In 1886, McCormac was one of the few to suggest a two-stage procedure-preliminary colostomy and subsequent proctoplasty [108]. In 1897, Matas combined a sacral approach to rectal atresia with sa-crotomy to aid exposure in instances of high-lying anomalies and predicted that this would be the route of choice for these procedures in the future [106]. Matas was not a proponent of colostomy and favored a one-stage procedure in the neonatal period [106]. His bias influenced the care of babies with ARM for the next four decades.

During the pre 1900 era, appreciation of the pelvic and perineal anatomy was influenced by the observations of Vesalius (1543) [168], Galen (1576) [46], and Santorini (1724) [142] who described the anal sphincters, the levators, and the coccyx. In 1874, Robin and Cadiat reexamined these observations and defined the sphincter ani externus [138]. Gowers described the automatic action of the sphincter ani in 1877 [49], and Holl was the first to describe the puborectalis muscle as a separate entity in 1897 [65].

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Constipation Prescription

Constipation Prescription

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