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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
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.
the finger, it was arrested about three-quarters of an inch from the surface; no bulging of the intestine above could be felt, and by pressure the anal cul-de-sac could be pushed up into the abdominal cavity.
No hardness or irregular fulness in any part of the abdomen existed, indicative of where the alimentary canal terminated. under these circumstances I deemed it unjustifiable to have recourse to any operative procedure. The child died on the seventh day from its birth.
After death, I was permitted to make an examination. The organs of the thoracic cavity were normal in structure and position, as also were the stomach, liver, pancreas, spleen, and kidneys; the small intestines, much distended with flatus, were found occupying the left and anterior part of the abdominal cavity; the ascending and transverse portions of the colon were normal; this intestine then descended a short distance on the left side, and recrossing the abdomen to the right side, terminated in a dilated pouch, as shown in the engraving. This portion of the intestine was distended with meconium, and reached a little below the crestof the ilium, from thence a membraneous prolongation connected it with the anal cul-de-sac. On opening the intestine, it was found perfectly impervious.
The correctness of the decision not to perform an operation was manifested by the relative position of the parts as described. Yet this conclusion has been impugned by a surgeon who, if he were to operate in such a case, would, I fear, be more influenced by the imaginary éclat attending the use of his knife, than actuated by a just and due conşideration of the preservation and well-being of his patient, based upon a deliberate and sound judgment. It is evident that had an incision, or a thrust with a trocar been made, as is generally recommended, the peritoneal cavity and small intestines would have been wounded, but the terminal portion of the large intestine would not have been opened. The specimen was brought before the Pathological Society in March, 1855.*
Imperforation and partial absence of rectum ; operation
performed three times.
A lady and gentleman, residing in the neighbourhood of Westbourne Terrace, brought their infant daughter to me, in October, 1856, requesting my advice. The child was fifteen weeks old, and when born was apparently well formed and healthy. After a day or two it was observed that nothing had passed from the bowels, and on examination it was discovered that the anus was imperforate. An operation was performed, and a canula introduced into the bowel through
* See • Transactions,' vol. vi., p. 200.
which meconium and fæces passed : proper means not being taken to keep the opening patent, it soon contracted and closed, and the operation had to be repeated, but due precaution not being taken, the opening again closed. For two days previously to the child being brought to me nothing had escaped from the bowel ; vomiting occurred when it took food; it was thin and pale, and the countenance indicated long suffering. The abdomen was much distended and tympanitic. No anal depression existed, the integument being extended from side to side: by careful examination, a small opening was discovered; an ordinary probe could not be introduced, but one of half the usual size was passed upwards for its whole length. From the failure of the two operations the parents were fearful the life of the child could not be saved. I expressed an opinion that if an opening of sufficient size were established and maintained, there appeared no reason why the child should not live. Accordingly, I was requested to do whatever I thought necessary: and on the 14th of October, with the assistance of Dr. Sanderson, I performed the operation in the following manner: The little patient being held in position as for lithotomy, I passed with some difficulty a fine probe into the bowel, and having made an incision three-quarters of an inch in length through the integument, a director was introduced by the side of the probe, which was withdrawn ; four notches were then made with a narrow bistoury run along the groove of the director: the tissues were dilated with the forefinger of the left hand, and at about an inch and a quarter from the surface the point of the nail could be got into a small aperture, the margins of which were very dense and resisting.