ABNORMAL CONDITION OF THE ANUS AND NEIGHBOURING PARTS.
Congenital malformations.—The lower ex tremity of the rectum and anus not unfre quently present in the new-born foetus con genital malformations, some of which are in compatible with continued existence, while others admit of protracted suffering, with great inconvenience and imminent danger to life; while, again, some may be relieved by the in terference of art. Hence it is necessary to con sider these anomalous appearances with a view to discriminate those which are curable from those in which all remedial attempts are totally useless. The following congenital malforma tions have been noticed by surgical writers, some of which have come under our own ob servation.
1. The anus has appeared at first view to be natural, but on a more accurate examination no canal has been found above it; and after death it was discovered that the rectum was absent, that the left colon ended in a cul de sac, and that a dense fatty substance occupied the situation of the rest of the canal. It is plain that no operative interference could avail in such a case. In some cases of this want of rectum the anus has been absent also.* 2. The anus and rectum have appeared natural, but after death it has been found that the latter was interrupted in one part of its course, and that the intestine had ended above that in a cul de sac. This state of parts must lead to the same practical conclusion as that last mentioned. In these and in such like cases of unhappy malformation, some have suggested, as a " dernier resort," the propriety of opening the intestinal canal at some point in the abdo men, so as to evacuate its contents and establish permanently an artificial anus. The proposal was first made by Littre,t of opening the sigmoid flexure of the colon in the left iliac region. A successful case of this operation is recorded as having been performed by Duset* on a boy twenty-four hours after birth : the child was reported, at twelve years of age, to be in good health, with an artificial anus esta blished in the left iliac fossa.t 3. No anus, but the rectum has opened into, and its contents escaped either by the urethra in the male, or by the vagina in the female. This condition is an approximation to the cloaca of birds, and of some fishes. Life may continue under such an arrangement, particu larly in the female, When the intestine opens into the vagina, with great inconvenience no doubt ; but in the male the prognosis cannot even be so favourable, as the urethra can scarcely suffice to give exit to the faeces after some time ; and as the bladder and organs in its vicinity will be subject to constant irrita tion. Cases are, however, recorded of life
being protracted for several months ; and in one case, a boy, who lived for eight months, on examination after death it was found that a cherry-stone had blocked up the passage of communication between the rectum and ure thra. In such a state of parts it has been ad vised to cut through the perinzeum in the situa tion of the anus, and endeavour to open the extremity of the rectum. The bladder should be previously emptied of urine, and a sound or staff be retained in it, as a guide to the operator to protect it from injury. In the other somewhat parallel condition of these parts in the female, the exit for the alvine mat ters is usually more free ; and several cases are on record of life being continued for several years. These cases offer more encouragement for operative interference than the former. A curved probe may be passed from the orifice in the vagina into the rectum, and then directed towards the perinwum to the situation of the anus. An incision is to be then made upon it; and when the canal of the rectum is thus opened to the surface, the channel is to be kept carefully dilated, in order to oppose the natural tendency in the parts to close.
4. The anus may be open, hut the con tents of the intestine retained, in consequence of a congenital contraction of the rectum at some distance above, owing either to a mem branous septum extending across it, or to a circular thickening and contraction. Such cases may be overlooked, and their cause remain unknown until after death : in cases, therefore, of obstinate constipation at this early age, this part should be particularly examined. Petit I describes this condition, and mentions a case in which he detected such an obstruction in the rectum, about an inch above the anus. This he divided by a pharyngotome, with success. The division may be effected by a bistoury, if situated low down ; or by a trochar, if at a considerable distance from the anus.