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 development 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 distinctly 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 recto-vaginal 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 scalpel: a probe-pointed 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 favorably; 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 Hutchinson 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

1 "Memoirs of the Medical Society of London," vol. iii, pp. 389, 392. Op. cit. p. 265.

case of deficiency of a portion of the sacrum, the rectum opening at the lower part of the back.

TERMINATING IN A COMMON OPENING WITH THE GENITO-URINARY ORGANS.

As Andral expresses himself, there sometimes appears to be a tendency in the terminal orifices of the digestive, urinary, and genital canals, to be confounded together in a cavity more or less analogous to the cloace of birds. Sometimes the urethra occupies its normal position, and the recto-vaginal septum may be partially or entirely absent. All these malformations depending of course on an arrest in the development, in various degrees, of one or other of the stages through which the parts pass in their formation.

OTHER ORGANS TERMINATING IN THE RECTUM.

The lusus of the ureters opening into the rectum has been seen, but it is an anomalous condition, extremely rare.

CHAPTER XX.

HABITUAL CONSTIPATION.

HABITUAL Constipation is one of the most prevalent and troublesome functional disorders to which mankind is subject. Its sympathetic effects extend to every organ of the body, and often occasion great distress and anxiety to the sufferers, leading them to apprehend the existence of the most serious organic disease. Neither can it be doubted that many of the pathological changes in structure of the viscera of the head, chest, and abdomen, have their origin in functional derangement, induced either sympathetically by constipation and consequent derangement of the assimilative organs, or by the retention of excrementitious matter. Of the sympathetic effects on the brain and nervous system thereby induced, we have evidence during infancy and youth in convulsive fits, chorea, and other nervous affections, and in adults in the giddiness, drowsiness, headache, pains extending to various parts of the body, and that distressing mental depression denominated hypochondriasis, which not unfrequently terminates in permanent perversion of intellect, or even in a more distressing manner. sympathetic effects on the lungs and heart are indicated by cough and palpitation. The reaction on the stomach is marked by disordered appetite, vomiting, eructations, and a sense of gnawing and sinking at the precordia. We have evidence of the kidneys being affected in their morbid secretions, as marked by the various deposits we find in the urine. The exhalant functions of the lungs and skin also become deranged, as indicated by the fœtor of the breath and perspiration; and many of the distressing and unsightly diseases of the skin have their origin in constipation and morbid accumulations in the bowels. Nor do the genito-urinary organs escape: thus urethral, vaginal, and uterine discharges and

The

irritability of the bladder are frequently induced. The countenance of those who are the subjects of habitual constipation is dull and heavy, the eyes lack their lustre, and the tongue is observed to be deeply notched transversely. It has been shown that many of the affections treated of in the preceding chapters, often have their origin in this common cause.

To enter fully into the causes, symptoms, and remote sympathetic diseases and effects of constipation, would far exceed the limits and objects of the present work, but a few remarks on the most common causes of constipation, depending on torpor of the colon, and the means of obviating that condition, will not be out of place.

Habitual constipation as a constitutional effect occurs in those whose vital powers are naturally low: thus during the earlier periods of life we most frequently meet with it in delicate females; but as age advances, and the organic functions become enfeebled, we find it prevailing in either sex. The most frequent accidental causes are sedentary habits, and the very common practice of not attending to the first calls of nature to evacuate the bowels. Fæcal accumulations are thus favored, the bowel becomes distended, and in some instances to an amazing extent : its vital contractility is diminished, and it is rendered incapable of expelling its contents. Yet, notwithstanding this condition, frequently neither the patient nor medical attendant suspects the real mischief that exists, from the fact that diarrhoea may at the same time be present, consequent on the irritation induced by the overloaded state of the bowel. I have many times been consulted by patients suffering from the effects of fæcal accumulations, who assured me their bowels invariably acted regularly each day; and what they asserted was quite correct; yet they were the subjects of torpor of the colon and fæcal accumulations. On inquiring more particularly into such cases, it will be discovered, that though the bowels have been moved daily, the evacuations have been scanty, and that a sense of fulness and discomfort in the bowel remains; the fact being, that accumulations had been gradually increasing, and the softer and more recent excrementitious matter had passed over that which had been retained and become hardened.

The habitual use of large and warm enemata relax and distend