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ease evident, no delay in making an opening should take place; but if the membrane be thick, and a doubt exist as to the continuation of the rectum, the operation may be delayed for twenty-four or fortyeight hours, no mischief being likely to occur in that time; and during this period the intestine will become distended, and the condition of the parts be more clearly revealed.
The operation necessary to remedy this condition is very simple, and consists of making a crucial incision through the occluding membrane with a bistoury, removing the intervening flaps with a pair of scissors, and, if required, dilating the opening by the occasional introduction of bougies: dilatation will also most probably be required. I was called to see a child of a poor woman living in the neighbourhood of University College Hospital, that had the anus imperforate. It had been born about eighteen hours; the membrane closing the anus was thin, and rendered prominent by the contents of the intestine. With a lancet two incisions were made crossing each other, and the intervening angular flaps removed: a tent was introduced at first, but no contraction ensuing, its use was very soon discontinued, and the infant progressed satisfactorily. Among the recorded cases are the following: Dr. Thomas Cochrane,* in April, 1780, was sent for to see a child of a soldier of the 55th regiment; it had been born eighteen hours previously, but no evacuation had taken place from the bowels. The abdomen was much distended, and a swelling, the size of a hen's egg, projected from the fundament; this being punctured, a large quantity of meconium and gas escaped. The child did well.
* 'Edinburgh Medical Commentaries,' vol. x., pp. 370-80.
Mr. A. Copland Hutchinson * had a male child brought to him, with imperforate anus. The child was one day old, and when it strained a bulging of the intestine was very perceptible. An incision was made through the occluding structures, and the aperture maintained by the introduction of dossils of lint dipped in oil. After three weeks no further treatment was required.
The anus in some cases is well formed, and the bowel is continuous, but the meconium is retained by a membraneous partition, which may be just within the anus, or an inch or more above it: as in imperforate anus, the membrane varies in thickness, but is usually thin: the nature of the case is made manifest bv the retention of the meconium, and by digital examination, or by using a probe or a small elastic catheter or bougie. Dr. Bushe* mentions having seen in the dissecting-room, a child in whom two partitions across the rectum existed, the one was half an inch from the anus, the other three-quarters of an inch above that.
* 'Practical Observations in Surgery,' Second Edition, 1826, p. 264.
In imperforate rectum the obstructing membrane must be incised by a narrow bistoury, carried up on the finger, or by a pharyngotamus, and bougies afterwards employed. When the membrane is thick, we may not be able to tell whether the intestine is continuous above till we have made the incision; but if it be thin it will bulge down upon the finger, and convey the like sensation as when the anus is closed by a membrane. After establishing an opening in the occluded gut, it is most necessary that as the child grows it should be fully dilated. The evil of neglect of this important part of the treatment has been illustrated by several cases that have come under my observation. In 1855, a gentleman came from Australia to place himself under my care with stricture of the rectum from congenital malformation. When he applied to me the opening in the bowel was only sufficiently large to admit number eleven urethral bougie. He was born with imperforate rectum, which had been punctured with a trocar: alter he was * Op. eit., p. 40.
eleven years old the opening had been sufficiently dilated to admit number four rectum bougie. For some time before coming to England he had neglected to keep the bowel free; contraction ensued with all its attendant miseries. After being under my care some time he was able to pass number twelve bougie, and experiencing none of his former suffering and inconvenience, he returned to Australia.
In 1957; Dr. Hall of Brighton requested me to go down and see a child he was attending: she was about nine years old, and suffered from some contraction of the bowel. Upon examination I discovered two inches from the anus a dense membrane, in which a triangular opening existed barely large enough to admit a goosequill. I incised the membrane in eight or nine points, and dilated it freely with the forefinger. Dr. Hall subsequently continued the dilation with an instrument; and seeing him in the autumn of 1859, he informed me his patient is perfectly well, and the bowels act in every respect quite naturally.
Mr. Wayte * operated on a child born 7th March, IS 14, in whom the rectum was occluded by a septum. The malformation was not discovered till the child was two days old. In consequence of the closure of the opening, it was necessary to repeat the operation on the 23rd of April, and again on the 27th, after which bougies were used daily. The child died of hectic when six months old: caries of the sacrum was supposed to exist.
* 'Edinburgh Medical and Surgical Journal,' vol. xvii., p. 378.
A case occurred to Mr. Jenkins * of a male child born with imperforate rectum: the anus was perfect, and a cul-de-sac extended upward for about three quarters of' an inch. No attempt to remedy the condition of the parts was made till the eleventh day; a trocar and canula were then thrust through the rectal septum, and faeces followed the withdrawal of the trocar. At the time of the report, twenty-one days after the operation, the child was progressing favourably.
Mr. Mason f records the case of a male child born with imperforate rectum.; the malformation was not discovered till it was two days old. The finger introduced* into the anus could be passed upwards for about three inches, at which point the canal was found to terminate. The bladder was distinctly felt anteriorly, and the sacrum posteriorly. A trocar and canula were passed through the occluding membrane: on withdrawing the former, a large quantity of meconium escaped. The child died twenty-four hours after the operation.
* 'Lancet,' vol. ii., 1837-8, p. 271.
t 'Medical Times and Gazette,' New Series, vol. vi., p. 573.