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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 on Impartially 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; tlte 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 integument was continuous. By pressure with the point of the finger, a bulging and obscure sense of fluctuation was perceptible, conveying the idea of the rectum terminating in a cul-de-sac at a little distance from the surface; the abdomen was slightly distended; vomiting had occurred once. The child was in articulo mortis when I first saw it, and it was evident the time had passed for an operation to be of any avail, therefore no attempt was made to remedy the condition of parts. The child expired in a few hours afterwards.

On post-mortem examination, evidence of inflammatory action was observed, the whole of the intestines being agglutinated together by lymph. Tracing the large intestine, the rectum was found empty and collapsed, and terminating about half an inch from the external surface, the intervening space being occupied by dense cellular membrane: the onward passage of the contents of the bowels was prevented by the colon being bent at an acute angle on the rectum, and dipping down into the pelvis. This portion of the colon was distended with meconium; it was considerably dilated on one side, and adherent to the small intestines. Trying to separate these adhesions, the colon was lacerated, the tissues at this point being of a deep colour, and much softened in structure. It was this portion of the intestine which was felt bulging against the finger when pressure was made externally; and which would have been opened had an operation been performed.

The anal integument being reflected, a pale, thin, but distinct external sphincter was observed, in which no central aperture existed. The specimen, from which the

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Partial absence, imperforation, and malposition of the rectum.

My opinion was sought in the following case, with the request, that I might perform any operation that might be advisable. The child was five days old when it came under my observation, and when born had the appearance of being strong and healthy. It took the breast readily at first, but vomited after being suckled a few times. From the third day, this recurred the moment nourishment entered the stomach. Urine had been excreted, but nothing had passed from the bowels. The countenance indicated suffering; the abdomen was much distended, and tympanitic; slight pressure gave pain, and caused the child to cry violently. The anus was perfect; on introducing

* See ' Transactions,' vol. v., p. 176.

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