When incomplete, this consists either in an extension of skin over the border of the sphincter ani, or in a contraction of the extremity of the

rectum.

The complete is a much more common form of anomaly than that which has just been described, and is produced by a lamina of fibro-cellular tissue, surrounded by more or less puckering of the adjoining skin. In most cases this membrane is so thin and transparent, that when the infant strains, the meconium forces it downward, thus constituting a dusky, fluctuating tumor. However, in some rare instances, it is thick, hard and unyielding, particularly at the circumference; for, in the centre, it is almost invariably so thin, that the meconium can be seen through it.

B. Imperforation of the Rectum.

By one partition. The situation of this, says Dr. Bushe, varies from two lines, to an inch or more above the anus. In the majority of cases, it is thin, and transparent, though occasionally thick and hard. The anus is always well formed, but we are soon apprised of the nature of the case, by the retention of the meconium, by the inability of the nurse to throw up injections, and by examination with the extremity of the little finger.

By two partitions. Their site as well as structure differ. In a new-born child brought into the dissecting-room, the upper part of the rectum was loaded with meconium, the partitions were thin and friable, being about three-quarters of an inch apart, while the lowermost was nearly half an inch from the anus.

By puckering and induration of its walls. The only case Dr. Bushe has ever read of, occurred to Engerran. In this instance, so great was the induration and puckering, that it presented the appearance of a knob, or knot in the intestine.

c. Unnatural Terminations of the Rectum.

In the bladder or urethra. "When the rectum terminates in the urinary organs, it opens either obliquely between the ureters into the neck of the bladder, or into the posterior part of the urethra. It generally tapers down very considerably before it arrives at its destination; though, in some few instances, (one of which I have seen,) it terminates cæco fine, about half an inch above which, a narrow tube passes off anteriorly to communicate with the bladder or urethra. In either case the recto-vesical orifice is so small, that only the thinner part of the meconium can be evacuated; and thus it is, that the unfortunate infant generally dies within a week from its birth.

When the opening is vesical, the meconium and the urine are mixed; but, when urethral, a small jet of meconium generally precedes the passage of the urine.

5

This malformation is much more common in males, and from the length, narrowness, and curvature of the urethra, is much more dangerous than in females. It is often accompanied with imperfect development of the genito-urinary organs, especially, with imperforation of prepuce and urethra.

Though rarely, the anus sometimes exists in these cases, and permits the entrance of a probe for a few lines." 42.

In the vagina. The rectum may open into any portion of the posterior or lateral walls of the vagina. The orifice in this case is much larger than in the last malformation, which, together with the greater width and straightness of the vagina, renders it far less fatal. However, the mucous memAs brane becomes more or less excoriated, ulcerated, indurated and fungated, in almost every case, and abscesses form in the adjacent cellular tissue. in the last lusus, there may be an external opening in the natural state of the anus.*

In the sacral region. A portion of the sacrum may be so deficient as to permit the extremity of the rectum to pass through it, and open externally. Dr. Bushe only knows of one case, recorded by La Faye, in the Principes de Chirurgie.

Dr. Bushe examined a healthy child, a few days old, In two extremities. in whom the rectum terminated by two extremities, one being placed a little more anterior than natural, while the other, though also on the median line, was situated nearly an inch further back. This last, which was the smaller of the two, did not discharge more than one-third of the fæces, and appeared to be about an inch and a half in length.

D. Termination of other Organs in the Rectum.

Of the ureters. Cases of this kind are exceedingly rare, and when they do occur, the ureters generally enter a short distance below the line of reflection of the peritoneum. Most commonly other malformations exist at the same time; among which, absence of the urethra in the female is the most frequent.

Of the vagina. This is also a very uncommon anomaly. When present, the urethra generally occupies its natural situation; the menstrual discharge issues from the anus, and impregnation, nay even parturition, has been safely effected in such cases, through this orifice, which will be enlarged by more or less laceration of the perineum.

It may so happen that the vagina, In a cloaca with the urethra, and vagina. urethra and rectum, terminate together in the perineum; thus constituting a species of common vestibule or cloaca, similar to that of the annotrêmes, and of a great number of other animals. Saviard observed an anomaly of this kind, in a new-born infant, which, as far as I know, is the only one on record." 45.

E. Absence of the Rectum.

The absence of a portion is much more common than that of the entire rectum; which, in such cases terminates in a cul-de-sac at a grearter or less distance from the surface.

When this intestine is completely wanting, the extremity of the colon either floats in the abdominal cavity, hangs into the pelvis, or is bound

* We may observe that in the description of these malformations we are obliged to employ the ipsissima verba of the author. Abbreviation is impossible. But we omit the bibliographical notes.

down to the top of the sacrum. In some instances a fleshy, ligamentous, or fatty cord is attached to the cul-de-sac of the colon, or portion of the rectum, that may be present, and passes downwards, following the direction of the sacrum, to be blended, in many instances, with the cellular tissue behind the prostate and neck of the bladder.

"A preternatural anus may exist, and then it will occupy some situation in the face, neck, thorax, or abdomen."* 46.

When the rectum is either partially or totally wanting, the pelvis is generally contracted.

In some instances, the anus is well formed, and permits the entrance of a sound for a few lines; but generally, there is no trace of this opening, the skin being thick, hard, and, in the majority of cases, supported by muscle.

From the retention of the contents of the intestines caused by any of the malformations now mentioned, there arises great pain, as manifested by pitiful cries-abdominal enlargement with tension and shining of the integuments-discolouration and swelling of the face-inflation of the scrotum and penis-difficult and irregular respiration, caused partly by the pain resulting from the descent of the diaphragm on the inflamed intestines, and partly by the increased size of the abdomen-frequency, smallness and irregularity of the pulse-vomiting--straining to stool-hiccup-coldness with flexion of the extremities, and convulsions.

In some instances the colon bursts, and its contents are poured into the peritoneal cavity.

The majority of these malformations are fatal. When there is no outlet, death soon occurs; but in those instances in which there exists a small opening, even into another organ, this event takes place more slowly. On dissection, the intestines are found distended with gas and fæces, and are highly inflamed.

TREATMENT.

For some of the simpler of the preceding malformations, surgery offers not only alleviation but a cure; but it must be confessed that it presents but doubtful chances of recovery from the more severe. Still, in the worst cases, operations have every now and then been fortunate, and the surgeon should be acquainted with those glimmerings of success which twinkle amidst the mass of failures.

* "Mery mentions a case in which the colon opened at the umbilicus, the rectum being absent. (Hist. de l'Acad. des Scienc. p. 40. 1700.) Littre records another, in which the ilium terminated above the pubis. (Mem de l'Acad. des Scienc. p. 9. 1709.) Petit has described a case in which the ilium opened at the left side of the bas-ventre, and thus formed an anus. (Ibid. p. 89. 1716.) Dinmore mentions a remarkable case of an infant in whom the inferior portion of the abdomen was badly developed, while the intestine turned upwards, and opened under the border of the right scapula. A still more extraordinary case is related by Bils, in which the intestine mounted from the pelvis, through the chest, into the neck, and opened on the face by a very small orifice. (Specimen Anat. Rotterdam. p. 10. 1661.)

A. Incomplete Imperforation of the Anus.

When this is caused by a prolongation of skin, the superabundant integument ought to be divided in two or more points, and meshes of lint, or gumelastic bougies, besmeared with simple ointment, then introduced, renewed daily, increased successively in volume, and continued for months. If, however, the extremity of the intestine be merely contracted, it will seldom be necessary to have recourse to the knife.

B. Complete Imperforation of the Anus.

This is very curable too. The membrane which shuts up the extremity of the intestine, should be divided crucially with a sharp-pointed straight bistoury, and the angles of the flaps thus formed, removed with a forceps and curved scissors. The means adopted for keeping the aperture patent should be the same as have been already mentioned.

When the membrane covering the extremity of the intestine is prolonged forward to the perineum, where is a small hole through which the thinner part of the fæces drain off, it should be first divided from before backwards, with a probe-pointed bistoury introduced into the foramen, and the rest of the operation then conducted as above described.

c. Imperforation of the Rectum.

If this is produced by a fine membrane, we may be able to break it down with the extremity of the little finger; but if it be hard, we ought, provided we feel the fluctuation of meconium, to pierce it with a trochar, and then dilate the opening thus formed, with sponge-tents, &c.

D. Termination of the Rectum in the Bladder or Urethra.

If there are urgent symptoms, the surgeon must dissect for the extremity of the intestine. It has been advised to open the neck of the bladder, but this only evacuates the bladder itself. If the bowel opens into the urethra, and the opening is divided in passing the knife into the bladder, the operation will prove unavailing, first, because the division must be in the direction of the rectal canal, secondly, because it must be limited to a small extent, and thirdly, because in these cases, as before-mentioned, the rectum becomes narrow before it enters into the bladder or urethra.

E. Termination of the Rectum in the Vagina or Vulva.

In either of these cases, Dr. Bushe is of opinion, and we agree with him, that if the fæces can be easily discharged, surgical interference is improper. But there have been several opinions to the contrary. Thus, when the opening is vaginal, Vicq. d'Azyr recommended the division of the posterior wall of the vagina, below the opening, and also as much of the subjacent tissues as would admit the introduction of a canula. Martin improved upon this operation in advising the flaps of the vagina to be united in front of the canula by points of suture; and more recently Velpeau has proposed facilitating its performance, first, by introducing a blunt hook into the cul-de-sac of the rectum, and then rendering its extremity prominent in the perineum, secondly, by dividing the parts covering the extremity of the hook, and thirdly, by passing the tube into the opening thus formed. If we perform this operation, Velpeau's method is certainly preferable, when prac

ticable; which can only be when a cul-de-sac exists; for the intestine tapers down very considerably in some cases before it enters. Breschet has proposed the same operation as Vicq. d'Azyr, when the opening is in the fourchette.

F. When the rectum opens through the sacrum-when it bifurcatesor, when there is a common opening for the urethra, vagina, and rectum, surgery can offer no assistance.

G. Partial absence of the Rectum.-When this is the case, which cannot be told à priori, an anus ought to be made, if possible, in the natural situation. The following are Dr. Bushe's directions:

"The little patient being held in the lap of an assistant, with the knees bent and the buttocks thrown forward, the surgeon should make an incision of about eight or ten lines, from before backwards, in the accustomed situation of the anus. If, in the course of the dissection, he discovers the sphincter or the levatores ani muscles, he should separate their fibres carefully, and prosecute the dissection nearly in the axis of the body, or almost perpendicularly, cutting from before backwards, to avoid wounding the bladder; at the same time he should be careful not to get behind the rectum,-a mistake which has sometimes occurred during the dissection. The blood ought to be well sponged out, and the fore-finger of the left hand repeatedly used to seek for the rectum. If after dissecting two inches, or at most two and a half inches deep, the intestine cannot be detected, the operation ought to be abandoned; but, if the bowel be discovered by its blackness and fluctuation, either a trochar, or, what is better, a bistoury, should be forced into it, and the meconium evacuated. The opening thus formed should be maintained by tents of prepared sponge, meshes of lint, besmeared with cerate, or gum elastic tubes, kept continually introduced. The operation ought to be conducted with as much despatch as is compatible with safety, for pain never fails to prostrate babes. Most surgeons who have performed such operations have been unsuccessful; thus Petit mentions three fatal cases, death having occurred within a few hours, in one from convulsions, and in another from exhaustion. However, other surgeons have succeeded; among whom we may mention, Roux-Brignoles, and Sanson.

Should the little patient recover from the operation, his comfort will afterwards depend, first, upon there being a sphincter, and the opening having been made through it, and secondly, upon the proximity of the rectum to the skin. If there be no sphincter, he must be miserable indeed; and should the space between the rectum and the skin be great, he will labour under an affliction not to be endured." 53.

H. It is only when the rectum cannot be found, that there is any pretext for performing an operation, first proposed by Littre-that of opening the sigmoid flexure of the colon. If, after a careful dissection in the perineum, the rectum cannot be discovered, there seems no alternative between leaving the child to its fate, and opening the colon by an operation. Suppose the latter decided on, the steps to be taken are these :

The infant being extended on a soft pillow, an incision of the skin, subjacent, cellular tissue, and fascia, should be made from one to two inches in length, between the anterior and superior spinous processes of the ilium, and the pubes, situated a little above Poupart's ligament. The different layers of the abdominal parietes ought then to be divided successively with a bistoury on a director, until the operator arrives at the peritoneum, which should be pinched up, and