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forate anus, and absence of a portion of the rectum. An opening had been made, but at the time he saw him it was nearly closed : by bougies, &c., the aperture was enlarged, and the child grew and became perfectly healthy, but could not retain his fæces. When between five and six years of age he lost flesh, and became very ill : it was found the artificial opening had closed so much that a quill could not be passed. Mr. Lindsay conceiving the artificial anus was too near the coccyx, made another more anteriorly: ultimately the posterior opening was closed, and the child had perfect control over the bowel.
Mr. Smith, of Plymouth,* had a female infant brought to him 17th January, 1840, thirty hours after its birth, in consequence of there having been no evacuation per anum. The anus was perfect, and admitted the finger to be passed up half an inch. Vomiting of a brownish feculent matter had taken place, and this recurred at intervals till the child died. It lived nine days. An examination after death revealed the colon, nine inches in length, terminating in a closed extremity at its transverse portion. A tortuous prolongation from the anus, ten inches in length, and about the size of a swan-quill, extended up the left side of the spine : it was isolated from the other portion of the intestinal canal. He † Lancet,' vol. i., 1839-40, p. 794.
also mentions another case of a female infant with imperforate rectum which came under his observation. A dense cellular tissue, three quarters of an inch in thickness, separated the bowel from the anus. An attempt to relieve the child by operation was unsuccessful, and it died on the fifth day from its birth.
Mr. Gosse * operated on a child four days old, born with imperforate rectum. The incision was carried more than two inches in depth before the intestine was reached. The child lived till the twenty-fourth day, when it sank without any particular symptom.
Mr. George † attended a lady who gave birth, on the 10th May, 1849, to a child in whom, when two days old, the rectum was discovered to be imperforate. The finger could be introduced up the anus for an inch. Sir Benjamin Brodie saw the case, and decided that an operation would be unadvisable. The child lived five weeks. After death, the terminal portion of the colon was found covered by peritoneum.
Dr. N. Cheverst operated on a male child, five days old, born with imperforate anus, and partial absence of the rectum : the instrument used was a hydrocele trocar, which was passed into the bowel, but the canula proved too small to permit of the escape of the
* • Medical Gazette,' vol. vi., 1848, pp. 16-17.
intestinal contents ; the child died, and the body was thrown into the river by the parents.
Dr. Parker, of New York,* records ten cases of imperforation and partial absence of the rectum. In three ca sesthere was no anal opening; of these, the operation was successful in saving the lives of two of the children. In each of the remaining seven cases the anus was perfect, and a cul-de-sac extended upwards, to a greater or less extent; of these seven children the lives of two were saved; three died within twentyfour hours after the operation ; one died on the seventh day from neglect, and the remaining one died in the seventh week from contraction and closure of the artificial opening.
I imagine few English surgeons would propose to adopt the operation of Littre or Callisen for opening the descending colon, much less putting into practice that of Dubois, of opening the sigmoid flexure of the colon, and passing a strong probe through it towards the perineum, by pressure rendering the end prominent, if possible, and then cutting down upon it. So formidable an operation upon a new-born infant could scarcely be otherwise than fatal. But though the surgeon may not be justified in proposing to open the colon from the groin, he may be compelled to
*New York Journal of Medicine, New Series, vol. xiii.,
undertake it at the urgent entreaties of the relatives of the child. He should distinctly state the uncertainty of a successful issue, and what will be the after condition of the patient if it survives. The manner of performing the operation is as follows: The child being placed on a pillow, an incision about two inches in length is made midway between the anterior superior spinous process of the ilium and the pubis, a little above Poupart's ligament, in a direction parallel with the course of the epigastric artery; the integument, the several layers of muscles, and the transversalis fascia are to be divided ; the peritoneum being exposed, is to be pinched up, and an opening made by cutting horizontally through it; a director. or the finger is then to be passed into its cavity, and the incision enlarged to the extent of the external one. If the intestine be now seen, it is to be brought close to the wound, and two double ligatures, near to each other, are to be passed through it, by which the intestine is to be secured to the margins of the abdominal opening; after which, by making a longitudinal incision between the ligatures, the meconium will escape. If the child live, adhesive inflammation is set up between the peritoneal surfaces in apposition, and closes external communication with the cavity. The evils to be afterwards contended with are, a tendency in the external opening to
close, the protusion of the mucous membrane of the bowel, and excoriation of the integument from the irritation of the excretory matter, and the friction of the bandages, or apparatus used, to occlude the opening
UNNATURAL TERMINATIONS OF THE RECTUM IN THE
BLADDER AND URETARA.
The rectum, instead of terminating at the anus, is sometimes prolonged forwards in the form of a narrow tube, and opens into the posterior part of the urethra. This malformation is more common in males than females ; and in the former is more likely to be fatal, from the length and narrowness of the urethra. In most of these cases of malformation, some imperfection of development coexists, especially of the genitourinary organs. The opening of the intestine is usually very small, and permits only the more fluid portion of the meconium to be evacuated.
In other instances, the intestine opens into the bladder somewhere between its neck and the part where the ureters enter : in such cases the meconium and urine will be mixed; but when the opening is urethral, a jet of meconium, or fæcal matter, will generally precede the urine.
In this species of malformation, the opening for the discharge of the contents of the bowel being so small,