There is a somewhat reversed condition similar to this where the urinary passages connect with the rectum or with the colon.
Most of the anomalies above catalogued produce conditions of acute intestinal obstruction within the first two or three days of the newborn infant’s life. The condition is perhaps first made known by the nurse’s failing to note the presence of meconium upon the diapers. A suspicion of such a condition should prompt immediate investigation, which should be made with the little finger or with a soft catheter properly anointed; the finger making the best probe for purposes of orientation. The first thing is to determine the patulency of the anus. This established, the next procedure is a determination of the rectal condition and of possible communication with other passages. In this the presence of a small sound or metal catheter in the urethra and bladder may be of assistance. If a fluctuating sac presenting downward can be discovered in the location of the rectum its character may be assumed, and, after exploring with an ordinary aspirating needle, one may, if meconium be discovered, leave the needle in situ for a guide and with sharp scissors or pointed knife passed along it carefully cut into the sac, and then gradually enlarge the opening until it be given a sufficient size. The surgeon is fortunate in this respect who has a case of imperforate rectum so simple as to permit of doing this and finding it sufficient.
Every completely obstructed case becomes instantly a surgical one, whose outcome depends not on the operator alone, but on the actual anatomical condition. There is justification, therefore, in going to almost any extreme in the endeavor to open up a passage-way, for no danger can be greater than that of failing to establish it. After a careful search of the pelvis, aided by anesthesia and a metal instrument in the bladder, if no trace of large bowel can be found or if tissues be so dense as to completely mask the anatomical details, then as a last resort an artificial anus may be made in the left inguinal region, if there be no reason for not violating the usual rule and opening the large bowel in the right groin. Colostomy in an infant, under these circumstances, is always a hazardous and serious matter, but it offers the only resource. It is made in exactly the same way as enterostomy described previously, and the operation requires no special description here. Very young infants thus affected make bad subjects, and operation should be performed as expeditiously as possible. Considering the danger of leakage it would be well if practicable to wait a few hours after attaching the intestine to the abdominal surface before opening it, in order that the peritoneal cavity may be more perfectly protected.
Even those cases where the rectum communicates with the urethra or bladder should have a natural anal opening. In cases where communication is into the vagina it may be proper to wait until youth or adult age is reached, when more may be accomplished.
INJURIES AND FOREIGN BODIES IN THE RECTUM.
The rectum may be the site of injuries of various kinds from both extrinsic and intrinsic causes. When weakened by disease it may be burst by accumulation and straining, or it may be the site of perforation of ulcer, just as may any other part of the intestine. Although well protected from most directions it may suffer from penetrating wounds, such as stab or gunshot. It is occasionally injured in fractures of the pelvis, and possibilities of such injuries should be excluded in such cases. It may also be lacerated during parturition. The sphincter and even the muscular tube itself sometimes suffer. It has been indifferently wounded or punctured in operations, especially for stone in the bladder and in prostatectomy.
In the absence of disease a laceration occurring in any of these ways may be repaired by prompt suture, although to make a suitable exposure may require an extensive removal of sacrum, or the performance of a laparotomy with the patient in the Trendelenburg position. The rectum is also frequently injured by accidental or intentional introduction of foreign bodies from without. Museums, especially the foreign, are full of collections of foreign bodies which have been removed from the rectum, most of which have been placed there with intent, malicious or otherwise. They include objects of all imaginable character, shape, and size, some which are easily introduced and are also easily removed; others which have been passed inward under no small difficulties are removed only with a more or less formidable operation, or have even determined the death of the individual. The ignorant have peculiar superstitions, and the criminal most vicious tendencies, toward the insertion of such foreign bodies, and the complications that may be brought about are too numerous to be rehearsed here.
On the other hand, by actual accident serious injuries may be produced; as in one case under my observation where a boy of twelve fell, in the squatting position, over an iron picket nearly one inch in diameter in such a way as to permit it to pass into the anus, scarcely bruising the mucous membrane, yet entering the pelvis for nearly six inches, penetrating the anterior wall of the rectum, the posterior wall of the bladder, and bruising its anterior wall without perforating it. One feature of the accident was the carrying into the bladder of a piece of his trousers. In this case I opened the abdomen in order to be sure that there was no abdominal complication, closed the major part of the wound, and drew a good-sized drainage tube through from just above the pubes out through the anus, after removing the piece of cloth above mentioned. The boy made a perfect recovery.
The danger in all these cases is of infection, either of the bladder or of the pelvic cellular tissue. In the female similar perforating injuries may involve the vagina or the other female organs.
Some of these accidents or conditions above recounted take place during intoxication. The recurrence of tenesmus, pronounced rectal pain, the appearance of blood either at the anus or in the urine, should in every instance prompt a thorough investigation of the rectum, if necessary under an anesthetic.