510 Conguital. SPECIAL PATHOLOGY OF INFANCY. [Part III. They are all observed in boys, and are the result of the descent of testicle, which passes from the abdomen into the tunica vaginalis, pushing the peritoneum before it. The pouch formed by the peritoneum usually closes at the top of the inguinal ring, and intercepts all communication between the testicle and the abdomen. But when this Clinust occlusion does not take place, a sac consequently exists, communicating with the abdomen, and in which omentum, intestine, or liquid may wn descend. This is the rationale of the development of the inguinal hernia of infants. BRELLYIN This hernia does not always exist at the time of birth, and may become developed at the end of several days, simply under the influence of the cries and struggles of the child. In this case, the anatomical disposition of which we have just spoken still exists, and favours the descent of the viscera. There are even some rather rare cases in which, without hernia, this communication of the abdomen with the tunica vaginalis has been observed a little after birth. A. Cooper has seen two more extraordinary cases, in which, after the closure of the tunica vaginalis at the situation of the ring, the viscera had pressed upon the cicatrix, pushing before it the peritoneum and forming an artificial sac; but this cannot take place until some time after birth. Hunt has operated on a case of this kind in a child twenty days old, and Lawrence in one of fourteen days. These cases belong to the history of accidental inguinal hernia. Congenital inguinal hernia is more serious than umbilical hernia. It is more painful and often causes colic in children. It gives much trouble to keep it in position, and its cure is very difficult. It is never the origin of serious symptoms. Accidental inguinal hernia, coming on a greater or less time after birth, is, on the contrary, very dangerous, as dangerous as that of the adult, and may occasion strangulation of the viscera, or vomitings, constipation, peritonitis, and death, or otherwise the results of a very serious operation, which is that of strangulated hernia. Care should be taken not to be deceived by the descent of the testicle, and not to confound the inguinal tumours formed by this viscus with inguinal hernia properly so called. This is very often done, and I have many times taken off mechanical bandages applied on testicles retained in the ring and regarded as ruptures, that is to say, as cases of inguinal hernia. It is known that the testicle is not always in the scrotum at the time of birth, and that it descends more or less slowly. Consequently, there is no opportunity of recognizing a hernia as long as this organ has not assumed the place which it should occupy. In the case where the testicle appears to have descended we must still be on our guard not to mistake a fold of intestine for the testicle, and vice versa. Pott was nearly thus Book IX, Chap. XI.] INGUINAL HERNIA. the Lutes 2 live or 511 Omentum deceived, for he has seen in three young children a portion of the omentum or of the intestine descend into the scrotum whilst the testicle was still at the ring, or even in the abdomen. The treatment of inguinal hernia in children, whether congenital or accidental, consists in compression methodically exercised. for . By The reduction of the intestine must be effected, and its retention in the abdomen, by means of slightly compressing bandages, which should be often changed, so as to be always dry and to avoid excoriation of the skin. There should be a change of three bandages at least, for they should not be left off at all until a more advanced age. They should be renewed as often as the growth and increase in flesh of the children require it. Lastly, care should be taken each time that the bandage is applied to separate the testicle and to return into the abdomen all the liquid which may have found its way into the scrotum. In the case of inflammation of the skin covering the hernia, emollients, cataplasms, and baths should be made use of. [It is very rare to meet with strangulated hernia in young children, but such an accident may take place, and Fergusson has operated for strangulated inguinal hernia on an infant only seventeen days old. The coverings of the congenital inguinal hernia are the same as those of external or oblique, except that the hernial sac is formed by the tunica vaginalis propria. In rare cases a second lengthening of the peritoneum may descend into the still open canal of the vaginal tunic, by which the intestines, descending into this sac, are separated from the testicle. This encysted hernia, or hernia infantilis, has, as it were, two sacs, viz., one proper sac, and another anterior, composed of the tunica vaginalis, which in these cases is very liable to become the seat of hydrocele (Hey, Pract. Observ. in Surgery; London, 1814). The congenital inguinal rupture is mostly intestinal, because the omentum is very short; it may, however, contain a portion of omentum if it has been adherent to the testicle in the abdomen.] This is the encysted hernia of the tunica vaginalis of Sir A. Cooper, in which "on opening the tunica vaginalis, instead of the intestine being found in contact with the testicle, a second bag or sac is seen enclosed in the tunica vaginalis, and enveloping the intestine. This bag is attached to the orifice of the tunica vaginalis, and descends from thence into its cavity; it generally contracts a few adhesions to the tunica vaginalis, whilst its interior bears the character of a common hernial sac." Cooper considers that in this case "the tunica vaginalis, after the descent of the testicle, becomes closed opposite the abdominal ring, but remains open above and below it. The intestine descends into the upper part, and elongates both the adhesion and tunica vaginalis, so as to form it into a bag, which, descending into the tunica vaginalis, below the adhesion, and becoming narrow at its neck, though wide at its fundus, receives a portion of intestine. The disease does not appear like hernia of the tunica vaginalis, as the testis is not involved in it, but can be distinctly perceived below it. * * The strangulation arises from the contracted state of the mouth of the hernial sac."(The Anatomy and Surgical Treatment of Abdom. Hernia; part i, p. 80.)-P.H.B.] * * * * Compress BOOK X. ON DISEASES OF ANUS AND RECTUM. CHAPTER I. ON VICES OF CONFORMATION OF THE ANUS AND RECTUM. The vices of conformation of the anus and rectum may be divided into curable vices and incurable vices. The curable vices are: 1st. Congenital strictures. 2nd. Simple imperforations. 3rd. Imperforations with an accidental canal opening, externally or otherwise, with abnormal apertures. 4th. Total or partial absence of the rectum. The vices of conformation, associated with complex anomalies, constitute a group of diseases completely beyond the resources of surgical art. I shall content myself with pointing out their existence, and shall confine myself to the history of the vices of conformation of the anus and rectum, of which the physician may undertake the cure; I shall, moreover, devote some few words to the study of the causes which have originated the vices of conformation of the anus and rectum. CAUSES WHICH HAVE ORIGINATED THE VICES OF CONFOR- Sex and hereditary influence have no part in the production of these deformities; their cause varies according to the very nature of the vice of the conformation of the anus and the rectum. Consequently, the vices of conformation must be separated into two classes: A. Congenital vices by contraction or obliteration. B. Anomalies with membranous closure, accompanied or not with abnormal communications. The congenital narrowings alone occupy the first category. Sometimes the contraction exists only at the anus, sometimes it is situated higher up, and the canal becomes solid, or rather it undergoes a fibrous or cellular transformation, and still higher up it disappears. The cause of these congenital defects is, as M. J. Guérin has pointed out, to be ascribed to muscular retraction. The anomalies with membranous closure present themselves in the first rank in the second group. The anus and rectum, isolated at a certain period of embryonic life, increase, the first from the serous layer, the second from the mucous layer. They progress until they meet; their extremities coalesce, and the common conduit is formed when the separating partition has been absorbed. If the complete evolution and the reunion of the blastodermic layers is impeded, an anus without a rectum or a rectum without an anus is formed; if the separating partition remains, the rectum will be imperforate. During embryonic life, the rectum and the bladder communicate; the urinary and genital canals terminating in one common cloaca. If we suppose that the partition which should lead, in the one part, to the formation of a special canal for the excretion of the urine and for the passage of the fæcal matters, and, on the other part, to that of a genital passage; if we suppose, we say, that this partition be incomplete, we shall observe the imperfections with an accidental canal opening externally, or rather with an orifice terminating in the bladder or vagina. Thus, arrest of development readily accounts for the congenital defects characterized by simple imperforations, or accompanied by abnormal communications. 1st. ON STRICTURES OF THE ANUS. ite The strictures of the anus and rectum are characterized by an opening of the anal orifice and of the cavity of the rectum of a degree less than in the natural state. The anus and rectum may offer all the degrees of stricture, from the orifice into which the point of a pin can scarcely be introduced, as in a case reported by Scultet, to thee Ames orifice by which the meconium can be discharged; but the fæcal matters only being voided with the greatest difficulty, as in the patient of Boyer. In the majority of cases, the congenital stricture does not extend beyond the anus. The strictures consist sometimes in a simple diminution in the diameters of the anal opening or of the cavity only of of the rectum, sometimes in numerous multiform folds projecting conta congruital into the rectum; and which, according to their degree of development, may obstruct the physiological function of the last portion of the Strictures large intestine. The signs of congenital stricture are the absence or deficiency of the meconium in the linen in which the child is enveloped, the progressive 4 and painful tension of the abdomen, and vomiting; the pathognomonic sign is furnished by the direct inspection of the anus. Immediate attention should be given to children afflicted with stricture of the anus and rectum. If the stricture is very slight, the rectum is to be restored to its natural diameter by the introduction of a bougie or of a small piece of prepared sponge into its cavity; if the stricture is K K Frativen Should le LUA 2 considerable, and if the symptoms developed on the part of the intestine 44) threaten the existence of the child, the opening is to be enlarged by a bistoury introduced, or a grooved director, incising the anus on one or both sides according to the degree of the stricture. As soon as the incision is made, the meconium escapes, and the symptoms of its retention cease. In order to prevent the reunion of the edges of the incision, a tent covered with ointment is to be introduced, the size being gradually increased and reintroduced each time after the child passes the motions, continuing for many months the use of the tent or of a bougie of Indian rubber. 2ND. ON SIMPLE IMPERFORATIONS OF THE ANTS AND RECTUM. The simple imperforations of the anus and rectum are produced by a closure at the situation of the terminal opening of the rectum; this closure may be formed by the skin, and then the raphé is prolonged on the skin which closes the anal orifice, the rectum terminating in an adherent pouch below; such is the case reported by Saviard. The anus may be closed above the sphincter by the mucous membrane; and of this J. L. Petit has related an example. J. L. Petit has made us acquainted with another mode of imperforation of the anus which is thus characterized: the contracted sphincter enters into union with the inferior extremity of the rectum, and the anus is replaced by a resisting part of considerable thickness, in the midst of which the rectum, usually dilated into a pouch, adheres. Lastly, M. Voillemier has seen a child in whom the intestinal tube was divided by partitions into four distinct portions, of which the first only contained meconium and gas, the others enclosing a thick mucus. Whatever may be the nature of the imperforation of the anus, when the fæcal matters cannot escape by an abnormal aperture, these matters accumulate in the intestine, distend it, and give rise to fatal symptoms, if the infant is not promptly relieved. The symptoms which characterize simple imperforations of the anus and rectum are, absence of the meconium in the linen fastened to the child, tension and pain of the abdomen, restlessness, cries, nausea, soon followed by yellow or green vomitings, injected countenance, prominent eyes, distention of the jugular veins, hiccough, and convulsive movements. When called to a child labouring under these symptoms, the surgeon makes a careful examination of the anus, and easily discovers the imperforation and the nature of this vice of conformation by the presence of a projecting membrane, of a bluish colour, giving on pressure a sensation of fluctuation. Amongst children afflicted with simple imperforations, the surgical * Gaz. des hôpitaux; 1846. |