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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, 1814, 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,
* 'Edinburgh Medical and Surgical Journal,' vol. xvii., p. 378.
after which bougies were used daily. The child died of hectic when six months old : caries of the sacrum was supposed to exist.
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 fæces 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. † · Medical Times and Gazette,' New Series, vol. vi., p. 573,
ABSENCE OF THE RECTUM.
The rectum is sometimes entirely absent, or it may be wanting in part only, the latter being the most frequent occurrence of the two. In either case there may be a well-formed anus, and above it a small pouch a few lines in depth, or there may be no appearance of that opening, the integument being continuous from side to side.
When the last part of the intestinal tube is only partially absent, the other portion usually terminates in a cul-de-sac, at a greater or less distance from the surface of the body, or it may be prolonged as a narrow tube or imperforate cord, and blended with the adjacent parts. When the whole of the rectum is absent, the intestinal canal may open in some abnormal situation : cases are recorded of the terminal opening being at the umbilicus; of the ilium opening externally above the pelvis; and two still more extraordinary cases, the one that of an infant, in which the inferior portion of the abdomen was badly developed, and the intestine turning upward opened under the scapula : in the other, the intestine mounted from the pelvis, through the chest into the neck, and opened on the face by a small orifice.
When a portion of the rectum is absent, it becomes the surgeon's duty to do all in his power to establish an outlet for the contents of the intestine, otherwise the child must inevitably perish. If the anus be natural, the prospects of success will be greater, the probability being that there is no considerable interval between it and the intestine: and if the operator succeed in forming a communication, no ultimate inconvenience will be experienced. When the anus is present, the incisions must be made through it; but if it be absent, they should be commenced at the point it ought to have occupied. The child is to be held in the lap of an assistant, who should sit on a table before a good light; the knees and thighs are to be flexed, and the perineum presented precisely in the same manner as if the child were prepared for lithotomy. The surgeon, sitting on a low chair, then commences an incision about an inch long, which is to be caraied more and more deeply in the natural direction of the anus, following the curve of the sacrum ; the surgeon's forefinger of the left hand in the wound must guide the course of the knife. If the incisions be made directly upwards, or in the axis of the pelvis, the bladder or other parts of importance may be wounded; an opposite course, however, must be avoided, or the surgeon will get behind the rectum. The dissection may be continued, if necessary, as far nearly as the finger can reach. Should the intestine
be detected either by the feel and sense of fluctuation, or by being seen at the bottom of the wound, an opening is to be made into it, and the meconium evacuated, afterwards this opening must be maintained by the constant use of tents of prepared sponge, meshes of lint spread with ointment, and gum-elastic bougies. But should we not be so fortunate as to discover the bowel, and as the child must certainly perish unless an opening be made, we must make a final effort to succeed: a large-sized trocar and canula are to be inserted in the direction in which it is most likely to enter the intestine, and if successful, the trocar is to be withdrawn, and the canula left in the wound, and secured there by tapes.
Imperforate rectum and anus ; the rectum descending to half
an inch of the surface of the integument.
I was requested by my friend Mr. Wm. Bennett, to see a child eight days old, having an imperforate anus. The mother had been attended in her confinement by a midwife : no advice had been sought on account of the malformation that existed in the child, and it only came under observation in consequence of the mother being seized with puerperal peritonitis, which terminated fatally within twenty-four hours of the supervention of the first symptoms.
On examination of the child, a slight depression was observed at the ordinary situation of the anus, over which the