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tion of the parts was made, and “ a narrow duct passing from the fore part of the intestinal cul-de-sac into the neck of the bladder, or membraneous portion of the urethra,” was found to exist.
When the rectum terminates in the urethra, the surgeon must endeavour to dissect down upon the extremity of the intestine, and establish a more convenient and larger opening than that formed by nature. If the urethra opens in the under part of the penis, as is not uncommonly the case, it may be possible to pass a probe into the intestine, which may be felt by the finger in the wound, and then cut upon. But if the intestine terminates in the bladder, the operation must be conducted in the same manner as if the rectum were wanting. It has been recommended to cut into the neck of the bladder, but a successful issue would be more than doubtful.
IN THE VAGINA.
When the rectum terminates in the vagina, the opening is much larger than when it terminates in the urethra. This form of malformation will also admit more easily of being remedied than that forming the subject of the previous section of this chapter, and may be situated either in the posterior or lateral wall of the vagina.
Although there is a greater probability of an infant living with this condition of parts, yet much suffering and inconvenience must arise from it: thus the mucous membrane will be excoriated, ulceration induced, and abscess may form in the adjacent cellular tissue.
Should the rectum terminate in a pouch, an opening from the natural position of the anus may very readily be made into it, by passing a blunt hook or bent probe through the recto-vaginal aperture, and rendering its extremity salient in the perineum, which will then be a guide for the knife. The artificial opening must be kept patent by tents and bougies. But sometimes the rectum tapers considerably before opening into the vagina : in which case an incision must be carried backward to a sufficient extent through the portion of the vaginal partition that is below the opening; a canula is then to be passed into the bowel, and retained by tapes. The anterior part of the wound is to be brought together by sutures ; great attention to cleanliness will be necessary to promote the union of that which is to form the recto-vaginal septum.
Imperforate anus ; the rectum opening into the vagina.
Mrs. B- , in consequence of fright, from the house in which she lived taking fire, prematurely gave birth, when seven months and a half advanced in pregnancy, to a female child.
It was diminutive, and its vital powers were low. For the first few days no malformation was suspected, as meconium and small quantities of fæces had passed; but the child at length appearing to suffer pain, and the abdomen becoming distended, an examination was made, when it was discovered that the anus was imperforate, and that feculent matter passed per vaginam. No means were taken to remedy the condition of the parts.
When the child .was about four weeks old, it came under the observation of Dr. Gibb, who desired the mother to consult me: she accordingly brought her baby to my house. On making an examination, there was no indication of an anus, the integument being continuous from side to side: at about the junction of the sacrum and the coccyx a depression existed, but no sinus or canal led from it. Externally, no other defect in its developraent was to be observed. Separating the vulvæ, at a quarter of an inch within the vagina, an opening was seen large enough to admit a number ten catheter: through this excrementitious matter oozed ; a bent probe passed through it, and its point pressed downward, could be indistinctly felt externally. On considering the nature of the case, I proposed to establish an opening in the intestine more conveniently situated than that formed by nature. The parents being very desirous to have anything done that offered a probability of remedying the defect and saving the child, gave a willing consent that I should perform the necessary operation.
Dr. Gibb fully concurring in my views, with his kind assistance I operated on the infant the day following that on which I first saw it. The child being held with the perineum
presenting, a strong probe bent was passed through the rectovaginal opening, the point being pressed firmly towards the surface; an incision three-quarters of an inch long was made through the integument midway between the commissure of the vagina and the point of the coccyx; the point of the probe was then cut on and brought through the wound. I now discovered that the communication between the bowel and the vagina was by a narrow tube, and that by firm pressure at the bottom of the wound the pouch of the intestine could be indistinctly felt pressing downward when the child strained. The incision was cautiously continued to a depth of an inch and three-quarters, when the bowel was reached, and a puncture made with the point of the scapel : a probepointed bistoury being then introduced, and the opening enlarged so as freely to admit the finger, on the withdrawal of which a considerable quantity of fæces were discharged. About two ounces of blood were lost during the operation. A full-sized lithotomy tube was secured in the wound; and retained for eight days, being removed only when it was necessary to clean it, and in examination of the parts. The artificial opening evinced a strong tendency to contraction, which was counteracted by the daily introduction of the finger for the first fortnight, and subsequently a number four rectum bougie which has been introduced and retained for some minutes daily. The bowel is also washed out with three ounces of thin gruel. The child is now two years and a half old, and has progressed most favourably; its health is good, it feeds well, and the bowels act freely, and it has control over them. The size of the bougie has been gradually increased.
Mr. Mantell* operated, in September, 1786, on a female child with imperforate anus : a small opening existed between the rectum and vagina. In the spring of 1788, he had to repeat the operation in consequence of the closure of the artificial anus : another surgeon had previously performed the operation for the second time.
Mr. Copland Hutchinsont was consulted respecting a female child, four weeks old, in whom the anus was occluded, and a communication existed between the rectum and vagina, through which the fæces passed freely. The mother would not consent to any operation. Mr. Bathurst, of Strood, had a child under his care in whom the fæces passed per vaginam; there was also an external opening at the anus, but not larger than would admit a probe; it was dilated by bougies, and the abnormal aperture between the rectum and vagina closed spontaneously.
OPENING IN THE SACRAL REGION.
La Faye, in page 358 of Principes de Chirurgie,' records a case of deficiency of a portion of the sacrum, the rectum opening at the lower part of the back.
* Memoirs of the Medical Society of London,' vol. iii., pp. 389 392.
† Op. cit., p. 265.