eight months old, born with an imperforate 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 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. George3 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 "Lancet," vol. i, 1839-40, p. 794. 2 "Medical Gazette," vol. vi, 1848, pp. 16-17. 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. Chevers' 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 intestinal contents; the child died, and the body was thrown into the river by the parents. Dr. Parker, of New York,2 records ten cases of imperforation and partial absence of the rectum. In three cases there 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 twenty-four 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 1 "Indian Anuals of Medicine," No. 1, p. 296. 2 "New York Journal of Medicine," New Series, vol. xiii, p. 319. 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 protrusion 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 URETHRA. 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 genito-urinary 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, the child rarely survives more than a week, but instances are recorded of life being prolonged beyond that. Fortunatus Licetus1 mentions a woman who voided her fæces through the urethra. Flagini' 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 membranous 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 rectourethral canal. Bravais3 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. Paulletier1 also saw a similar case in a boy three years and a half old. Mr. Copland Hutchinson" operated on a male child, born fortyeight 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 a 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 fæces: 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. 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 tumor 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 1 "De Monstrorum Causis Natura et Differentiis," lib. ii, cap. liii, 1616. 2 "Observazione di Chirurgia," tome iv, obs. 39. 3 "Actes de Lyon," tome iv, p. 97. 4 "Diction. de Science Méd.," tome iv, p. 157. Op. cit. p. 264. "Edinburgh Medical and Surgical Journal," vol. xxxvi; and "Practical Surgery," Third Edition, p. 740. the prostate. The boy died of disease of the lungs, when about six years old. Mr. Windsor, of Manchester, relates a case of ascites in a fœtus born at the full period: there was malformation of the rectum, and other viscera, and absence of the anus. The colon was nine and a half inches in length; it passed in a straight line down the spine, terminating in a constricted tube, which barely admitted the passage of a blowpipe: this constricted part opened into a pouch the size of a hen's egg, occupying the position of the rectum, and between which and the bladder a communication existed by a canal half an inch in length. 2 the Mr. Randolph, of Hungerford, records in the "Lancet, particulars of a male child born without any opening in the anal region. Small quantities of meconium were observed to pass per urethram. The infant died on the ninth day. No operation was undertaken for its relief, as the mother objected. By examination after death, the rectum was found to open into the bladder immediately posterior to the prostate gland. Mr. Lizars, quoted by Mr. Fergusson,3-made an opening into the rectum of a child born with imperforate anus; he had to cut deeply before the intestine was reached. A communication between the rectum and bladder existed. The child lived three weeks; from the time of its birth, a tumor existed over the dorsum of the ilium; fluctuation was perceptible, and the parts had a peculiar appearance. After death, the tumor was found to be an abscess, which extended upwards and opened into the canal of the lumbar portion of the spinal column. Mr. Tatham, of Huddersfield, operated 16th of January, 1835, on a male child, two days old, for imperforate anus. The urine had been observed to be mixed with the contents of the bowel. The bowel was reached by an incision carried to the depth of one inch from the surface. The child lived till the 20th of March. An examination was made, and the bowel found to communicate with the neck of the bladder by a narrow canal, a quarter of an inch in length. 1 Ibid. vol. xvii, p. 361. 2 Vol. i, 1838-9, p. 162. 3 "Edinburgh Medical and Surgical Journal," vol. xvii, p. 367. 4 "Lancet," vol. i, 1835-6, p. 373. |