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apex reaching the umbilicus, and its base nearly filling the brim of the pelvis.*
Mr. Listonf removed from the rectum half a jawbone of a rabbit, which had been swallowed in a plate of curry.
Mr. Lawrence had a case in which a man had broken the neck of a wine-bottle into his rectum; he gradually dilated the sphincter, introduced his whole hand, and removed it.
Mr. FergussonJ removed a bougie from the rectum of an old gentleman who was in the habit of using such an instrument: on one occasion he passed the bougie within the sphincter, and could not withdraw it. Several unsuccessful attempts had been made to remove it, previous to Mr. Fergusson seeing the patient: with some difficulty he succeeded in seizing the end with a pair of lithotomy forceps, and withdrawing it. The bougie was nine inches in length, and an inch in diameter.
* 'Medical Gazette," vol. xxx., pp. 605, 606. f 'Practical Surgery,' by Bobert Liston, Fourth Edition, 1846, p. 431.
X «Practical Surgery,' Third Edition, p. 750.
MALFORMATIONS OF THE RECTUM AND ANUS.
Malformations and congenital deficiencies of the intestinal canal and its terminal aperture, occasioning entire obstruction or admitting of but a very partial evacuation of its contents, demand the especial attention of the surgeon, from the necessity of prompt interference, and the certainty of a fatal issue unless the defect is remedied, by establishing a free outlet for the meconium and excrementitious matter of the alimentary organs. The accomplishment of this object is thought by many who have not had to treat such cases a very easy and simple matter; but to the practical surgeon various difficulties present themselves. The diagnosis, when the case is not one of occlusion of the anus by merely a thin membrane, is attended with doubt, as the symptoms and physical signs do not in the majority of cases afford a definite clue as to how much of the intestine is deficient, or as to the relative position of its termination to the external surface; consequently an attempt to reach it by cutting instruments is attended with much uncertainty. More* •
over, supposing an operation to have been performed, and an opening into the bowel made, this is only the beginning of the surgeon's anxiety and trouble, for the proneness to contraction in the artificial aperture is so great, that it is only by the most constant attention for weeks, months, or even years, that it can be maintained. In many of the recorded cases, an operation has been performed several times, in order to re-establish the opening: a short time since, I was requested to operate on a child fifteen weeks old, that had been operated on twice previously; the case will be again referred to under the proper section of this chapter. The result of the majority of published cases is by no means encouraging; and if the history of others were known, there is reason to believe the view presented would be still less so, and that little hope exists of an infant thus born ever attaining a mature age: still, as it must inevitably perish unless relieved by art, it behoves the surgeon to make an effort to preserve the life of the child, if the nature of the case can be so far made out as to offer a probability of success.
CONTRACTION AND OCCLUSION OF THE ANUS.
The anal aperture is sometimes preternaturally small, either in consequence of a contraction in the extremity of the rectum, or from the skin extending
over the border of the sphincter. The opening may be only sufficiently large to allow the more fluid part of the meconium to drain' away, or the size of the orifice may be such as to cause a difficulty in passing, but not entirely preventing, the escape of excrementitious matters.
When the anus is merely contracted it must be dilated by tents and bougies. If an extension of the skin beyond the margin of the sphincter abridges the anal opening, several slight notches may be made in it with a blunt-pointed knife, and afterwards it may be dilated by the pressure of bougies.
Sometimes two anal apertures exist more or less distant from each other; the one may also be larger than the other, and give exit to the greater part of the contents of the bowels. If the two openings are close together, and not large, it will be advisable to divide the septum between them; but if any great thickness of tissue intervenes, it will be better to enlarge that opening which corresponds most nearly to the position of the natural outlet, and to procure the closure of the other: to accomplish the one object, it will be necessary to have recourse to dilatation by pressure and incision, and when this has been effected, the other may be brought about by the application of strong nitric acid, nitrate of silver, or the actual cautery.
In other cases total occlusion of the anus exists, an anomalous condition much more common than either of the preceding forms of malformation. The structure closing the anus is not generally a continuation of the integument, but a lamina of fibro-cellular tissue. It is usually thin and transparent, permitting the meconium to be seen through it, and forming a small roundish prominence, which is most distinct when the child cries or strains. This bulging membrane communicates to the finger a doughy feel, and sense of obscure fluctuation; by pressure it is made to recede, but it reappears immediately the finger is taken away. In some rare cases the membrane is very thick and dense, especially at the circumference; the protrusion will then be less prominent, and the meconium will not be distinctly felt or seen.
This form of malformation will probably be discovered before any symptoms of obstruction arise; but if by carelessness it is overlooked, some days may elapse ere the child betrays any evidence of inconvenience or suffering: but sooner or later it will be observed to cry violently, to strain much, and although at first it may have taken the breast readily, and retained the milk, sickness sets in, and if no relief be afforded, the infant perishes with all the symptoms resembling those arising from strangulated hernia. When the membrane is thin and the nature of the