« AnteriorContinuar »
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 casesthere 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 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
* 'New York Journal of Medicine,' New Series, vol. xiii., p. 319.
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
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 faecal 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, the child rarely survives more than a week, but instances are recorded of life being prolonged beyond that. Fortunatus Licetus * mentions a woman who voided her faeces through the urethra. Flagini f relates the case of an infant in whom about three inches of the rectum was wanting, the intestine terminating in a canal four inches in length, which passed under the prostate gland, and opened into the membraneous portion of the urethra. The stercoraceous matter of course was voided with great difficulty by the urethra; nevertheless, the miserable babe lived eight months, and then only died in consequence of having swallowed a cherry-stone, which lodged in the recto-urethral canal. Bravais J records the case of a boy four years and a half old, in whom the rectum, after becoming very narrow, opened into and appeared continuous with the urethra. Paulletier § also saw a similar case in a boy three years and a half old.
Mr. Copland Hutchinson || operated on a male child, born forty-eight hours. An incision was first made to the depth of an inch and a half, then a trocar and canula were inserted another inch and half, when the intestine was reached: the opening was maintained by tents and bougies. After three months, the urine was observed to be tinged with faeces: it had not been observed to pass per anum. The child died when about ten months old, from the irritation of dentition. An examination revealed a valvular opening between the rectum and commencement of the urethra.
* • De Monstrorum Causia Nature et Differentiis,' lib. ii., cap. liii., 161(3.
f 'Observazione di Chirurgia,' tome iv., obs. 39.
Mr. Fergusson * reports a very interesting case of a male child, born twelve hours previously to coming under his observation. No anus existed, but the skin where it should have been had a brownish appearance; above this, at a considerable distance from the surface, an indistinct tumour could be felt. An incision was made to the depth of an inch and a half, but the bowel was not reached, nor could it be felt. The next day, meconium being observed to pass by the urethra, Mr. Fergusson determined to cut into the bladder, and he opened this viscus immediately behind the prostate. The boy died of disease of the lungs, when about six years old.
Mr. Windsor,! of Manchester, relates a case of
* 'Edinburgh Medical and Surgical Journal,' vol. xxxvi.; and 'Practical Surgery,' Third Edition, p. 740. t Ibid., vol. xvii., p. 361.