« AnteriorContinuar »
the Hnger, 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 eclat attending the use of his knife, than actuated by a just and due consideration 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, 185.5.*
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 cauula introduced into the bowel through
* See 'Transactions,' vol. vi., p. 200.
which meconium and faeces 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. A narrow probe-pointed bistoury being passed upon the finger, seven or eight notches were made on its margin, the tissues were dilated, and the finger passed into the bowel; on its withdrawal a large quantity of faeces passed. An elastic tube, three-eighths of an inch in diameter, was secured in the wound; the child was put to bed, and shortly fell asleep.
On the following day, the child's appearance had much improved; feces had passed freely through the tube, which was removed and cleansed. I introduced my finger its whole length, and broke down the adhesions, which had commenced forming at the points of incision. A doso of castor oil was directed to be given.
After a week the tube was left out; and a number four rectum-bougie directed to be passed up the bowel, and retained five minutes once in the tweuty-four hours: after its removal the bowel was to be washed out with three ounces of warm thin gruel. For several weeks I saw this child daily, and introduced my finger to prevent the part contracting, the tendency to which was very great.
The child in a short time had perfect control over the discharge of the fteces, and showed no symptoms of distress or uneasiness; it gained flesh, and became lively and intelligent. The size of the bougie was increased to number five, and then to six. With the exception of occasional indisposition from cold or other accidental circumstances, no child could progress more favourably. I continued to visit it once or twice a week, and saw it alive on the 31st of January, 1857, when it appeared remarkably well and lively. On the 5th of February, I received a message to say that the child had died suddenly while in bed, about half-past eleven o'clock. The mother had seen it ten minutes previously, it was then breathing easily, and appeared quite well. The following day I made a post-mortem examination. The thumbs were firmly contracted into the palms of the hand. The stomach was much distended, and contained a large quantity of undigested food; the intestines contained a small quantity of feculent matter, and the colon was empty. The rectum was normal in size, and terminated at an inch and a quarter from the surface.
Most surgeons who have performed this operation have been unsuccessful in saving the lives of their patients; however, a few cases have succeeded. An interesting case of a child with imperforate rectum is recorded in Langenbeck's new 'Surgical Bibliotheca:' the malformation was not discovered till twelve days after the child was born, when it was seized with hiccough and convulsions; the abdomen was protuberant and hard, pain was produced by pressure, and the child was much depressed. An incision an inch in depth was made in front of the coccyx, but it did not penetrate the intestine; it was then extended another inch, but with no greater success. The operator then had recourse to the pharyngotamus, with which he succeeded in piercing the rectum. Clysters and tents were afterwards used, and the child lived. I have in my possession a preparation given me by my friend, Dr. Quain, namely, a case of malformation of the rectum, in which the intestine