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A narrow probe-pointed bistoury being passed up on 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 fæces 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 ; fæces 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 dose 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 twenty-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 fæces, 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 Febrvary, 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 terminated in a closed sac. The preparation was presented to the Pathological Society, and the particulars of the case are published in the Society's Transactions.* The anus was perfect, through which an incision was made by the surgeon in attendance, but he was unsuccessful in opening the bowel, and the child died on the ninth day.

Mr. Benjamin Bell met with two cases in which the intestine was very distant from the integument. In both he succeeded in forming an anus, but found it very difficult to keep it pervious. A very eminent author remarks, “Though keeping the opening dilated may seem easy to such men as have had no opportunities of seeing cases of this description, it is far otherwise in practice.” In the ninety-eighth number of the · Edinburgh Medical Journal,' is recorded a case in which the tendency to closure in the artificial anus was so great that the operation had to be repeated ten times before the child was eight months

old.

In Dr. Baillie's ‘Morbid Anatomy 'is a drawing of a. specimen of imperforate rectum terminating in a cul-de-sac ; the anus was perfect, and a short and narrow canal extended upward to within a short distance of the intestine.

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Mr. Copland Hutchinson* attempted, by means of a scalpel and trocar, to open the intestine of a child to all external appearances similarly malformed to the one already alluded to, but was not successful in accomplishing the object, probably owing to the absence of the rectum. Some hæmorrhage took place, which was restrained by application of lint saturated with turpentine. with turpentine. In an

In another instance of a male child with the anus natural, but occluded half an inch from the surface, Mr. Copland Hutchinson endeavoured to establish an opening in the bowel, by thrusting a trocar for more than three inches in depth without success. The child died a few hours after the operation; and a post-mortem examination revealed the intestine separated from the anal cul-de-sac by a quarter of an inch. The trocar had passed behind the intestine, and grazed its walls.

A female child, born the day previously, was brought to Mr. Meymott :f there existed no opening into the bowel. A depression existed just at the point of the coccyx, but there was no. opening in the skin; the vagina was also occluded : a probe could be passed into an aperture corresponding to the meatus urinarius, but no urine was observed to pass. An incision was made into the perineum to the depth of

* Op. cit., pp. 264-274. .
† • Lancet,' vol. ii., 1829-30, p. 189.

two inches, and the bowel reached, which was made evident by the free escape of meconium. Castor oil, calomel, &c., were administered to the child : it died seventy-six hours after birth. No examination was made.

Mr. D. O. Edwards * records the following: a male child born twenty hours previously, had had nothing pass per anum, and refused the breast ; its abdomen was distended and painful on pressure; the lower limbs were rigidly contracted on the pelvis ; respiration was difficult, and the child constantly moaned. The anus was perfectly formed; the introduction of the finger detected an obstruction an inch from the surface. Forty-eight hours after birth this was incised with a bistoury, but the bowel was not penetrated; the bladder and blood-vessels were felt by the finger introduced into the wound: the child died the following day. An examination was made: the rectum terminated in a cul-de-sac at the middle of the sacrum, having a meso-rectum in its whole length, and a complete peritoneal, covering. The space of half an inch intervened between the termination of the rectum and anal cul-de-sac.

Mr. Lindsay,f in December, 1929, had brought to him a boy eight months old, born with an imper

* Lancet,' vol. i., 1829-30, p. 637.
† Ibid., vol. i., 1835-6, p. 361.

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