L

which is divided in the two anterior thirds; beneath them the smal oblique, then the transverse, then the aponeurosis. All these muscular layers should be divided transversely, then vertically, in order to have a crucial incision, and the better to ensure the discovery of the intestine; should it be necessary, the external edge of the quadratus lumborum may be raised and incised at its external edge. We then come upon the adipose tissue which envelops the colon, and which must be cautiously raised; after which the important point is to be assured

of the position of the intestine and of its limits.

On the dead body the colon is recognized by its greenish colour. This sign rarely exists in the living. By percussion we may make sure that we are on some intestine; pressure with the finger gives the sensation of resistance of the intestine; nevertherless, to do away with all doubt, the intestine should be laid bare on its two sides. If the intestine is contracted it should be sought for posteriorly; sometimes in this case it is completely hidden under the quadratus lumborum, which should be divided.

When the colon is discovered two needles should be passed through its wall, so that it can be steadied by two threads of silk about one inch apart. In the interval between these two threads a stab with the trocar should be given, the issue of gas or of thin fæcal matters assures us that we are unmistakably in the intestine, and with a hernia knife a crucial incision should be made. The fæces commence to escape their expulsion should be assisted by injections directed towards both ends of the intestine. When the bowels are well emptied, the opening made in the intestine should be drawn forwards by means of forceps; and it should be fixed to the skin by four points of interrupted suture, the mucous membrane being turned outwards.

[Examples of this disease, in any form, are so rare that it is not easy to estimate the comparative frequency of its varieties. Dr. Collins (System of Midwifery, p. 509) only met with one instance of it out of 16,654 children, born in the Dublin Lying-in Hospital, during his mastership; and Dr. Löhrer of Vienna (Canstatt's Jahresber, für 1854; bd. i, s. 456), mentions that he met with it only twice out of 50,000 new-born children. A comparison of seventy-four cases derived from different sources, yielded seventeen belonging to the first class, twenty-nine to the second, and twenty-eight to the third; but it is probable that many instances of simple closure of the anus have passed unrecorded, while all the instances of more serious malformation have been described. (West on Diseases of Children; p. 379.)

If the obstruction be situated at the orifice of the anus, a crucial incision through the membrane which closes it, or the introduction of a trocar, will afford immediate relief. The prognosis in these cases may be very favourable, for in fifteen cases of this kind, all but one had a favourable issue.

"The existence of an anus, and a small extent of gut above it, although a decidedly favourable feature in a case, does not warrant quite so hopeful a prognosis as we might in the first instance feel disposed to adopt. The probabilities

indeed, are, that the distance is not great between the end of the rectum and the cul-de-sac in which the anus terminates; yet a considerable space may intervene between the two; or as in a case which Mr. Arnott was so good as to

communicate to me, the rectum may be found altogether absent, the colon Es ne! terminating in a blind extremity, and floating loose in the abdominal cavity. In the majority of instances the two blind pouches are connected together by the ध्या intervention of an eighth of a quarter of an inch of dense cellular tissue, which sometimes presents an almost ligamentous character; and in some cases the end of the large intestine is situated anterior to the extremity of the cul-de-sac that leads from the anus. Owing to this latter circumstance, the operation for the relief

of this condition has sometimes failed; the instrument, although introduced deep Aest

enough, yet passing behind the distended bowel. Out of nine cases of this kind, eight had a fatal termination; the bowel on four occasions not having been reached at all, while once the opening made into it was too small to allow of the free escape of the meconium. It may be added that in three of the fatal cases there existed such contraction of the calibre of different parts of the large intestine as would of itself have opposed a serious obstacle to the child's recovery."

dis

"In twelve cases the anus was absent, and in some of these instances no trace of it existed, while the rectum terminated in a cul-de-sac, at from one to two inches from the surface. In five of these cases the attempt to open the intestine was successful, and the child eventually did well; while in two other cases, although temporary relief followed the operation, yet symptoms of inflammation of the bowels came on, which terminated fatally in the course of a few days. In three instances it was not found possible to reach the bowel; and in two others, although an opening was made, yet its size was insufficient to afford a free vent to the AA accumulated meconium, and the fatal issue, though deferred, was not prevented. Failure to reach the intestine seems to have depended either on the trocar not having been introduced sufficiently deep, or on its having been directed too far backwards. The danger of hæmorrhage, or of wounding the bladder, of which some operators seem to have been apprehensive, is not much to be feared, for I find but one instance on record in which the bladder was accidentally wounded, and not one of fatal or of even serious hæmorrhage. Better success also seems to have been obtained in those cases in which a sufficiently deep and free incision was made with a bistoury in the direction of the rectum, than in those in which a trocar was at once introduced. The suggestion of M. Amussat, that in these cases the blind sac of the intestine should be drawn down, and its cut edges attached by sutures to margin of the external skin, in order to prevent the infiltration of fæcal matter, between the end of the rectum and the wound in the integuments, and to diminishi the danger of the aperture closing, is worth bearing in mind. It was adopted with apparent advantage by Mr. Waters, in a case of this kind recorded by him in the Dublin Journal for May, 1842, on which he operated with success."-(West, Op. Cit.; p. 382.)

Whing

"

In a case where the rectum opened into the vagina, and after operation the artificial opening of the rectum closed again, whilst the opening of the vagina remained, Barton (Medical Recorder of Medicine and Surgery. Philadelphia; 1824) employed the following method with success: he passed a director throughochur the hole of communication in the vagina and divided the whole wall of the vagina' to the place where the natural opening of the rectum should be. He did not use any dressing, but every day passed the finger, smeared with cerate, into the rectum to prevent its closing. The vagina was perfect and the rectum had a direct opening, except that the stools passed involuntarily. Satchell (Ibid) and Chelius have by this practice obtained like favourable results. Velpeau (Elements de Med. Oper.; vol. ii, p. 979) had proposed this operation on the recommendation of Vicq. d'Azyr.

The result is highly unfavourable when there is a communication between the intestine and the bladder or urethra in the male, for eight out of ten cases of the former kind, and the same number out of nine of the latter kind, ended in the death of the infant. The connection with the bladder is generally established by means of a very slender canal which enters that viscus at or near its neck; but in one instance in which the rectum was wanting, the colon terminated by opening with a wide aperture into the upper part of the bladder. A slender duct is he wise the usual channel of communication between the rectum and the urethra, and this duct generally enters the membranous portion of the urethra, just in front of the prostrate. Cruveilhier (Anat. Pathol.; liv. i, p. lv, fig. 6), however, mentions an instance in which the rectum opened under the glans penis, by means of canal which was formed in the substance of the raphé scroti; and South (Trens. of Chelius; vol. ii, p. 329) mentions a somewhat similar case in which there was a ly small aperture through which meconium passed in front of the scrotum, the rectum was cut down upon full an inch deep, and though much difficulty was experienced in keeping the passage free, yet the child survived, and grew up to manhood. Of the two other successful cases recorded by Miller (Edin. Med, and Surg. Journ.; No. 98, p. 61) and Fergusson (Ibid; vol. xxxvi, p. 363), both were cured, only with much trouble and difficulty.-P.H.B.]

CHAPTER II.

ON PROLAPSUS OF THE RECTUM.

The term prolapsus of the rectum is applied to the protrusion of the mucous membrane of this intestine out of the anus, or to the protrusion of the rectum itself by invagination.

Prolapsus of the mucous membrane is more common than invagination; it is a very frequent disease amongst young children, and one which I have observed a great number of times. It is usually present at the same time as diarrhoea, and may be produced by use of too violent purgatives. It follows a prolonged constipation which requires great efforts to pass the excrementitious matters. It is also said that it may be caused by a disordered state of the digestive functions, or by the presence of intestinal worms, or stone in the bladder; but with respect to this there is nothing positive.

Under the more or less active influence of these different causes, the mucous membrane of the rectum, which is rather moveable on the walls of the rectum, protrudes from the anus, and forms a more or less considerable projection, under the form of a reddish round swelling, transversely fissured, and covered with adhering mucosities. This round swelling presents an opening in the centre, which is no other than the orifice of the intestine. Externally the mucous membrane terminates at the sphincter on the edges of the anus, becoming continuous

Book X, Chap. II.]

PROLAPSUS OF THE RECTUM.

523

with the skin, from which it is separated by a simple groove, whilst in the invagination of the rectum the finger penetrates the intestine between the swelling and the sphincter of the anus.

Prolapsus of the mucous membrane of the rectum is not serious

amongst children; it is only of importanee in the adult and in the then,

old. In youth it is not the cause of serious symptoms, and its radical cure may be obtained without an operation.

In order to cure prolapsus of the rectum we should make use of 22rious.

remedies which are appropriate to the cause on which it depends; but when it persists after every occasioning cause has disappeared, it is a proof that it is dependent upon the relaxation of the intestine, and it is upon the intestine itself that we must act.

The bowels should be kept open, and the system strengthened by a generous regimen.

Then astringent lotions should be made use of, and compresses

Reduce

moistened with red wine, cold water, a solution of sulphate of zinc and a/c,

or alum, about four grains to the ounce. Recourse may be had to

sitting baths of cold water, of the decoction of bark, solution of tannin, ply bet

alum, or the sulphate of iron. Applications of ice, compresses sprinkled

Мидић or supper.

over with myrrh, or dragon's blood, or impregnated with the vapour Mugus of turpentine burnt over live coal, may be employed; or suppositories composed of pomegranate and oak bark incorporated in honey. When a child is subject to prolapsus of the rectum, it is proper, as Underwood has remarked, to take the precaution to support the edges of the anus during defæcation with the two fingers. If the child is not sufficiently old, nor intelligent enough to fulfil this indication, the nurse should be instructed to employ it.

But these

child

Should

According to Underwood, the child should be seated on a chair sufficiently high that the feet do not touch the ground; if it is old Euti enough it should remain standing as long as possible. precautions are only necessary when the disease has lasted a considerable time, and when the portion of the intestine which escapes externally is of some extent.

If it should happen, a very rare circumstance in the child, that the mucous membrane, once protruded, should become strangulated by the sphincter and form a very much congested or inflamed swelling, an enema of cold water, to which several drops of liq. plumbi or off sch laudanum are added, should be administered. After one or two hours,

the inflamed intestine becomes less swollen, and gently returns under hig the influence of the sedative remedy which has relaxed the spasm het of the sphincter of the anus.

When the prolapsus continues, the reduction of the mucous membrane should be attempted by means of the taxis. Bell employed a cone of paper, moistened so as to soften it, and oiled externally. This

wulch!

Acetum the vagina and of the uterus; thus Boyer relates the cases of women He who have lived with a genital anus to a very advanced age, and Fournier cites the case of a woman afflicted with a vaginal anus who became a mother.

y Boyer looked upon the imperforation of the rectum with a vaginal orifice as incurable; at the present day the surgeon should endeavour The most suitable method of

My to remedy this repulsive infirmity.

operating is that of Dieffenbach.

Dieffenbach's mode of practice. The perinæum is to be divided from the vulva to near the coccyx, avoiding the rectum; the cellular tissue which surrounds the extremity of this intestine is to be dissected and thrown back, and it is to be isolated from the vagina in its inferior semi-circumference; and having divided the resulting flap to a small extent, the two halves of this flap are fixed by two points of suture to the posterior extremity of the wound of the perinæum. When this wound is healed, by means of a bistoury the superior wall of the rectum is completely isolated from the vagina. The intestine, thus rendered free, recedes about four or five lines; and when the inferior and anterior parts of the division of the perinæum have been made raw, there only remains the reunion of the edges of the division of the vagina by points of interrupted suture, and the wound of the perinæum, with the exception of the posterior portion destined to form the anus, by two points of twisted suture.

4TH. ON ABSENCE OF THE RECTUM.

Under this title we rank the vices of conformation in which the rectum is partially or entirely wanting. Sometimes the interval which separates the anus from the rectum is supplied by a fibrous cord, sometimes it is occupied by a very indurated tissue; the intestine terminating in a dilated pouch. Sometimes this dilatation is situated even on the rectal portion of the digestive tube, sometimes it is seated on the colon. The symptoms, by means of which absence of the rectum is revealed, are-the complete want of stools, and the inspection of the perineal region. In the simple imperforations, the surgeon discovers on the spot where the anus should be, a fluctuation which does not exist in the case of absence of the rectum. In obscure cases, the surgeon may, with great precaution, make an exploratory puncture over the position of the anus; when the rectum is simply imperforate, there will be a flow of meconium; when the rectum is wanting, no issue of meconium will follow the puncture.

The following is the extract of a case reported by M. Forget,* which throws light upon some of the symptoms which characterize absence of the anus.

médicale; 1850.