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 ■■■.'''.'- 
 

 
 a 
 
 ^Vs^Y^e^^ Tco-rvcx*^ 
 
 CA, 
 
 CASE OF 
 
 ABSENCE OF THE LOWER END OF 
 
 THE RECTUM, 
 
 WITH PASSAGE OF F.ECES THKOUGH THE PENIS : 
 SUCCESSFUL OPERATION FOR RELIEF. 
 
 By FRANCIS J. SHEPHERD, M.D., CM., 
 
 m " ■ 
 
 PIIOFKSSOU OF ANATOMY IX M'(iILL UNIVKU.JITY, SURGEON TO THE MONTREAL 
 
 GENERAL HOSPITAL. 
 
 Reprinted from the Edinburgh Medical Journal for August 1884. 
 
 In t}ie March number of the Edinhinjh Journal I notice the 
 report by Dr Wm. Ciaig of a case of imperforate anus, in which the 
 rectum communicated with the urinary tract. As Dr Craig states 
 in his paper that he is not aware of any similar case to his own 
 liaving occurred, and Mr Hohnes, when speaking of cases where 
 the rectum communicates with the urinary tract, mentions that he 
 knows of no case where the bowel has been reached successfully 
 through a perineal incision, I thouglit that it might be of interest 
 to place ori record a case similar to Dr Craig's, where operative ])ro- 
 cedures had resulted ftivourably. On the 16th of November 1883, 
 Dr Molson delivered a woman of a heaiihy male child after a 
 tedious labour. Next day the mother told him she noticed some- 
 thing strange coming from the child's penis. On examining the 
 
parts Di- Molsoii irnincdiately recognised the didcliargc as mecoiiium, 
 and, on f'urtlicr exaniiiiatioii, discovered tlio infant liad an imper- 
 forate anus. Tiie mother having consented to an operation, Dr 
 Molson requested me to take charge of the case. Tiie patient was 
 admitted into my wards at the General Hospital on 19th November, 
 being then three days old, and liaving since birth passed a large 
 quantity of feculent matter by the penis. The child, wiiich was 
 strong and healthy, had some distention and tenderness of the ab- 
 domen, but very slight fulness of the perineum. There was a 
 well-marked median raphc^, and a slight puckered depression at the 
 site of the anus. I decided first to try and reach the bowel through 
 the perineum. After placing the child under chloroform, I made a 
 free incision in the median line, dissecting carefully backwards and 
 upwards in the direction of the rectum, and frequently placing my 
 finger in the wound to feel for fulness or fluctuation. I dissected 
 in this way to a depth of fully 2 inches, when discovering a fluc- 
 tuating tumour, I punctured it with my knife, and was pleased to 
 see quantities of fajces escaping through the wound. I then enlarged 
 the puncture in the bowel, and without much difficulty drew it 
 down to the external wound, and held it there by catgut 
 stitches. 
 
 Almost immediately after the operation the mother removed the 
 child from the hospital, and I did not see it again till 9th June 
 1884. In the meantime Dr Molson had occasionally visited the 
 case, and instructed the mother, in passing bougies, to keep the 
 anus open. The mother, however, did not attend very scrupulously 
 to directions, and after the operation the opening kept gradually 
 growing smaller. When I saw the child last, it was sis months old, 
 and was stout and healthy; the opening had contracted so much that it 
 with difficulty admitted a No. 12 catheter. The mother informed 
 me that the child still occasionally passed fasces by the penis, but 
 only when " opening medicine " was given. I intend, when I 
 can get the mother's consent, to incise the opening, and I shall 
 insist on her passing her little finger twice daily through the anus, 
 as Dr Holmes recommends. 
 
 I forgot to mention that the child was the subject of another 
 deformity, viz., absence of the metacarpal bone, and probably the 
 
3 
 
 tra|iczium of the ri[?ht thumb. It was the mother's fifth confine- 
 ment; all tiie other cliiklren were born perfect. 
 
 In this case it is iiiglily probable that the rectum opened directly 
 into the membranous portion of the urethra, as, if the connexion 
 was with the bladder, it is not probable the bowel would have been 
 reached by a perineal incision. 
 
 Dr Craig remarks in his paper that examining the preparation 
 of his case, it is evident that it was possible to pierce the bowel by 
 a trocar or even a bistoury, but he says, " to have enlarged the 
 opening sufficiently to have cut down upon the rectum would have 
 been an operation such as few newly-born children could have sur- 
 vived, and even if the child could iiave survived, the want of 
 development of the rectum would have prevented a successful 
 issue in this case." 
 
 I cannot agree wit)' "^^r Craig's conclusions, for, if the bowel is 
 not reached the child vvill certainly die, and I do not think fear of 
 the severity of the operation should influence the surgeon in his 
 endeavour to reach the bowel; again, as the rectum is pretty movable 
 in the infant it can be brought down, as is shown in my case, even 
 if the lower end is undeveloped. 
 
 EUINBUKGU : J'lilJSTKlJ BV OLIVKK AN HOVI).