Imperforate anus is a congenital malformation, and hence all children should be carefully examined when born. Sometimes the rectum is perfect on wards to the integuments which are entire, and have a raphe and every indication of a perfect anus ; at other times, there is a distinct external aperture or anus, but the rectum is closed by a a little within or centrad ; at others again there is no ex ternal aperture, but a communication with the va gina in the female, and with the urethra or urinary bladder in the male. In the female, the aperture of communication is occasionally exceedingly small, while in others it is tolerably large ; in the male, the rectum commonly ceases at the promontory of the sacrum, where it forms a puckered purse-like pouch, which either communicates with the blad der by a valvular opening, or descends in a small tubular form, adhering to the bladder, and enters the membranous portion of the urethra in the same valvular manner. The last variety occurs where there is no communication with the bladder or ure thra in the male, or with the uterus or vagina in the female, and no external aperture.
In the first of these cases, where the rectum is close to the integuments, a simple incision with a scalpel, will allow the meconium to be evacuated ; but care should be taken that the bougie or wax candle is inserted daily until all tendency to contract is removed. Some authors recommend that this operation should be done between twenty-four and sixty hours after birth, but in our opinion the sooner nature is relieved the better, as respiration is much impeded until the evacuation of the meco nium takes place, and inflammation not unfrequently ensues from delay, which is to be subdued by a leech or two applied to the hypogaszric region and the warm bath, together with castor oil. Before making an incision in such cases, the skin should be titillated, which causes the child to make efforts to evacuate the feces, and produces a protrusion where the anus is to be made. A trocar and canula is recommended to be used for perforating the in teguments and even the rectum in the other cases, but it is a dangerous instrument. Instead of the bou gie or candle, sponge and sponge tent arc used by some, but these, since they excite ulceration, ought not to be employed.
In the second variety, or where there is an anus, but the rectum has formed a cul-de-sac, the latter is to be opened with a narrow shaped scalpel. In
that variety occurring in the female, where there is a communication with the vagina, characterized by the meconium discharged by this passage and in that of the male where it takes place with the uri nary bladder or urethra, the meconium is dis charged mixed with the urine ; and in the last va riety where none of these characters exist, the ope rator must divide the integuments with a narrow shaped scalpel perpendicularly to the extent of an inch or so, sufficient to admit his forefinger where an anus should be, and which is generally distin guished by some puckering or indentation of the skin. He must next dissect carefully along the con cave aspect of the os sacrum, leaving it sufficiently clothed with cellular substance, until he feels a small distended pouch, which he may rest assured is the rectum filled with feces, and forced down by the ac tion of the diaphragm and abdominal muscles ; this he is to puncture with the same scalpel, and not with a trocar and canula, when the meconium will flow by the side of his finger. After this operation, a tea spoonful of castor oil should be given, and the child immersed in a warm bath, and if there appear the slightest enteritis or peritoneal inflammation, one or more leeches must be applied to the hypo gastric region. The after treatment is the same in this as in the first variety. Mr. Burns directs us, if no rectum can be found, to open the sigmoid flexure of the colon, and Mr. C. Hutchinson the ca put cxcum soli ; but neither we apprehend will ever be required, and of the two we should prefer the former, which we may observe has been done. Cal lissen recommends the colon to be opened in the dorsal region near the left quadratus lumborum muscle, while Mr. Burns more judiciously between the anterior and posterior superior spinous pro cesses of the left os ilium ; the gut to be opened where it is uncovered by the peritoneum, a direc tion difficult to be fulfilled, as it is loosely bound down by the mesocolon. In the Revue Medicale for December 1823, there is an extraordinary case de tailed of a man who arrived at the age of seventy years and who was born with an imperforate anus and urethra, and who vomited his excrements dur ing all that time. He was alive five years ago.