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 Licetus' 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 Hutchinson3 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 foetus 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.

Mr. Randolph, of Hungerford, records in the "Lancet," the 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.

4

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.

Dr. York,1 of South Boston, punctured with a trocar the intestine of a male child born with imperforate anus; the operation was performed when it was three days old. The canula was left in the bowel for a week, after which the opening was dilated by a sponge tent at the end of six weeks the opening was still more increased by incision, and a silver tube three-eighths of an inch in diameter was inserted and retained for a year. The tube becoming corroded when the child was about six months old, fæces were observed to pass per urethram. The child died when eighteen months old, from the effects of a fall: for two months previously, the fæces passed entirely by the urethra, the artificial anus having closed in consequence of the tube being left out.

Dr. Williamson,2 of Aberdeen, saw a child, twenty-four hours after birth, in whom there was no indication of an anus, “its usual situation being covered by smooth skin, of natural color, continued from the perineum over the buttocks." An attempt was made to open the bowel by incision, which was carried more than two inches in depth, without the object being accomplished. On the fourth day from the child's birth, fæces were observed to pass by the urethra, and in a fortnight afterwards they began to pass freely, in which condition the child lived till it was eight months and twenty-two days old.

Dr. N. Chevers3 had a male child, five days old, brought to him by its father, a Hindoo ryot. No indication of an anal aperture existed; the abdomen was much distended. An operation was performed, and a small canula introduced into the bowel. On the following day feculent matter was observed to pass by the urethra. The case terminated fatally on the thirteenth day after the operation. An examination 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 membranous portion of the urethra," was found to exist.

When the rectum terminates in the urethra, the surgeon must endeavor 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,

1 "Boston Medical and Surgical Journal," vol. xlii, p. 273–4.

2" Medical Gazette," New Series, vol. ii, p. 767.

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