Imperforation and partial absence of rectum; operation performed three times.

A lady and gentleman, residing in the neighborhood of Westbourne Terrace, brought their infant daughter to me, in October, 1856, requesting my advice. The child was fifteen weeks old, and when born was apparently well-formed and healthy. After a day or two it was observed that nothing had passed from the bowels, and on examination it was discovered than the anus was imperforate. An operation was performed, and a canula introduced into the bowel, through which meconium and fæces passed: proper means not being taken to keep the opening patent, it soon contracted and closed, and the operation had to be repeated, but due precaution not being taken, the opening again closed. For two days previously to the child being brought to me nothing had escaped from the bowel; vomiting occurred when it took food; it was thin and pale, and the countenance indicated long suffering. The abdomen was much distended and tympanitic. No anal depression existed, the integument being extended from side to side: by careful examination, a small opening was discovered; an ordinary probe could not be introduced, but one of half the usual size was passed upwards for its whole length. From the failure of the two operations the parents were fearful the life of the child could not be saved. I expressed an opinion that if an opening of sufficient size were established and maintained, there appeared no reason why the child should not live. Accordingly, I was requested to do whatever I thought necessary; and on the 14th of October, with the assistance of Dr. Sanderson, I performed the operation in the following manner. The little patient being held in a position as for lithotomy, I passed with some difficulty a fine probe into the bowel, and having made an incision three-quarters of an inch in length through the integument, a director was introduced by the side of the probe, which was withdrawn; four notches were then made with a narrow bistoury run along the groove of the director: the tissues were dilated with the forefinger of the left hand, and at about an inch and a quarter from the surface the point of the nail could be got into a small aperture, the margins of which were very dense and resisting. 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 rectumbougie 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 favorably. 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 February, 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 imper

forate 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.

1

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.

2

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.

Mr. Copland Hutchinson3 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

1 Vol. i, p. 280.

3

Op. cit.

pp. 264-274.

2 Fasciculus 4, plate 5, fig. 4.

absence of the rectum. Some hemorrhage took place, which was restrained by application of lint saturated with turpentine. In another instance of a male child with the anus natural, but occluded half an inch from the surface, Mr. Copland Hutchinson endeavored 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: 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 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 mesorectum 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,3 in December, 1829, had brought to him a boy,

angle on the rectum, and dipping down into the pelvis. This portion of the colon was distended with meconium; it was considerably dilated on one side, and adherent to the small intestines. Trying to separate these adhesions, the colon was lacerated, the tissues at this point being of a deep color, and much softened in structure. It was this portion of the intestine which was felt bulging against the finger when pressure was made externally; and which would have been opened had an operation been performed.

The anal integument being reflected, a pale, thin, but distinct external sphincter was observed, in which no central aperture existed. The specimen, from which the engraving (p. 265) is taken, was presented to the Pathological Society.1

Partial absence, imperforation, and malposition of the rectum.

My opinion was sought in the following case, with the request, that I might perform any operation that might be advisable. The child was five days old when it came under my observation, and when born had the appearance of being strong and healthy. It took the breast readily at first, but vomited after being suckled a few times. From the third day, this recurred the moment nourishment entered the stomach. Urine had been excreted, but nothing had passed from the bowels. The countenance indicated suffering; the abdomen was much distended, and tympanitic; slight pressure gave pain, and caused the child to cry violently. The anus was perfect; on introducing the finger, it was arrested about threequarters of an inch from the surface; no bulging of the intestine above could be felt, and by pressure the anal cul-de-sac could be pushed up into the abdominal cavity.

No hardness or irregular fulness in any part of the abdomen existed, indicative of where the alimentary canal terminated. Under these circumstances, I deemed it unjustifiable to have recourse to any operative procedure. The child died on the seventh day from its birth.

After death, I was permitted to make an examination. The

1 See "Transactions," vol. v, p. 176.