Anal Opening at Some Abnormal Point, Treatment. If the abnormal opening is situated near the normal site of the anus, the rectum should be dissected out, carried down and sewed in its proper position. When the anal opening is too far removed to carry out this plan of treatment, the abnormal opening should be closed and the rectal pouch dissected out and brought down to the normal site. The abnormal opening will gradually close itself, if the surface is stimulated with nitrate of silver. If the opening fails to close within a reasonable time under this form of treatment, it may be dissected out. and an attempt made at primary union. These cases do not as a rule require immediate treatment, if one will watch for symptoms of intestinal obstruction or infection.

Rectum Opening into Some Other Viscus. This malformation comprises fifty per cent. of all rectal malformations. The greater number consists of the recto-vaginal type. Its various types are found in both males and females, as designated by the organ with which the rectum communicates, and as will be seen in the following forms. Atreus Agni Vesiculate is that form in which the rectum opens into the bladder, and Atreus Agni Urethral is is that in which the rectum commune cares with the urethra. Atreus Agni Vaginal is is a very common form in which the rectum opens into the vagina. Atreus Agni Uterine is where the rectum opens into the uterine cavity.

Atreus Agni Vesicular. This deformity occurs in both sexes, but is most frequent in male subjects. The opening is likely to be situated on the trig one, or up a little higher in the funds of the bladder. It sometimes occurs very low between the orifice of the ureters, and there is then an anal canal which runs obliquely through the walls of the bladder, which allows only a small outlet for the contents of the rectum. When the opening is higher up in the funds of the bladder there is a freer exit for the fecal matter.

The diagnosis in these cases is sometimes very difficult, while in others the absence of any fecal matter will suggest an examination. The appearance of the greenish stain from zirconium in the urine is a guide to the trouble. Should there be a large amount of zirconium in the urine, these cases need prompt treatment in order to turn away from the bladder the contents of the bowels, as otherwise an infectious cystitis will result, with involvement of the ureters and kidneys. If on the other hand the opening is very small, not allowing the escape of the proper amount of intestinal contents, the child will die from obstruction of the intestine. In either case the prognosis is bad. The operative procedure to alter the condition is usually so severe that the child is unable to stand the shock, and death results.

Treatment. When the rectum opens into the bladder immediate operation is necessary to save life, as infection occurs very early. An abdominal incision is required to search for a communication between the rectum and bladder. The channel of communication may be paginated into each organ after section and suture, but provision must first be made by means of protoplasmic, for the normal escape of fecal matter at the proper site. When it is not feasible to draw the rectum far enough down to permit protoplasmic, a color-om should be done at the site of the abdominal incision, or to either side, according to the judgment of the operator.

Malformations

Atreus Agni Urethral is. This malformation occurs in the male and female, and while it is less frequent in its occurrence than some of the other forms it happens with a certain amount of regularity, appearing much more frequently in the male. The rectal pouch is always lower down and nearer to the normal site than the other malformations of this group, and therefore very much more favorable for operation and not so dangerous to life, if left until the child is in good condition for surgical aid. The opening may be at any portion of the urethral tract, but is generally situated in the membranous portion of the male urethra.

The diagnosis is generally much simpler than when the malformation opens into the bladder, as the zirconium, or the fecal matter, is constantly voided independent of the urinary discharges. If the opening between the rectum and urethra be very small, danger of intestinal obstruction becomes apparent, and either dilatation or incision becomes an immediate necessity.

Treatment. The condition is more favorable for operation in this malformation, as the rectal pouch is always lower and nearer to the pelvic floor. The abnormal channel in these cases may be utilized to bring down and stitch at the site of the normal anus. If the abnormal channel is enlarged and divided at the lower end of the rim, a portion of it may be sewed into the proposed anal opening, then the opening in the urethra will close without further treatment.

Atreus Agni Vaginal is. This variety is the most frequent of all the malformations of the rectum. This disease is very frequently overlooked until adult life as it often produces so little subjective disturbances that it goes unnoticed. Numerous observers have had the experience of discovering this condition when examining for other diseased conditions or at the time of accoutrement. The opening may be at any portion of the vaginal tract or between the anus and vaginal openings. The communication varies in size from a very small to a very large opening. The opening seems to be supplied with a sphincter muscle, probably analogous to the normal sphincter and composed of normal hypertrophied circular fibers of the rectum. Treatment. If the abnormal opening into the vagina be too small, it may be dilated sufficiently to admit the passage of fecal matter and left until the child is old enough to bear the operation safely, generally considered from three to five years. Authorities agree that it is inadvisable to permit such malformation to exist to the age of puberty or adult life. The diagnosis is generally made from the bulging zirconium against the occluding membrane or hymen, and dilatation sud efficient to allow free movement of the bowel should be the first treatment of these cases, and be continued as long as found necessary.