In case of anus prteternat. ileo vag. there are originally two separate openings from the intestine into the vagina, the one belonging to the upper, the other to the lower extremity of the small intestine. The vagina represents, as Heine has pointed out, the widened extremity of the intestinal canal which leads into the vaginal anus; the lower extrem ity together with its continuation into the large intestine is shut.off from the fwcal masses. In consequence of the incomplete digestion of the in testinal contents, the patients emaciate and complain of hunger. The retention of particles of fces in the vagina leads to the local irritation of the mucous membrane and of its surroundings, on which we have laid stress.
The outlook for spontaneous cure of an anus prreternat ileo vag. is slight, since from the recorded cases it is apparent that union and closure of the separated intestinal extremities has rarely occurred, the closure being brought about by retraction of the spur, by narrowing of the open ings of the infundibulum. The more interesting, hence, is McKeever's report of spontaneous cure of an anus prmternat. vag. which followed on pregnancy. After absolutely no fces had passed by the rectum for two years, the patient (in the fourth month of pregmancy?) complained of great pain and tenesmus, and a half hour afterwards she had a stool by the natural passage, consisting of a mass of black, hard, frecal nodules. Afterwards the intestinal contents were passed in part by the rectum, in part by the vagina; the amount, however, passed by the vagina diminished gradually for a few months, and finally ceased altogether. McKeever re marks that the influence of pregnancy in affecting the change was marked, and the more so as the uterus project,ed into the abdominal cavity. The patient was delivered at home, without assistance, of a small but living female. The placenta was passed spontaneously, and she nursed her baby. During the puerperal state the intestines were evacuated by the natural passage, and when McKeever examined her the only trace of an artificial anus which he found, was a slight projection on the posterior vaginal wall which marked the site of the previously existing anus. The patient, however, still retained her vesico-vaginal fistula.
Although in Favera's case it is stated that there remained only a small recto-vaginal fistula, yet the particulars in regard to the case are too few to justify the belief that here also there occurred cure of an anus pneter nat. vag.
In regard to diagnosis we must first establish the fact that the abnor mal communication is with the small intestine, and next that it is due to complete opening of an end of the intestine and not to a partial defect in the wall. The first point is proved by the nature of the intestinal con
tents, which consist not of freces, as in case of a recto-vaginal fistula, but of chyme. Frecal matter and foul odor may, however, be present, and then in addition to the intestinal contents, we must note the rapidity with which the characteristic ingesta appear at the fistula. (In case of fistula of the small intestine, characteristic remnants of the ingesta may be passed by the abnormal opening one to two hours after a meal.) To test this point, among other means, the lycopodium seeds answer well, for they are readily recog-nized in the intestinal contents. On the other hand the absence of a communication between the rectum and the vagina may be proved by inserting a speculum into the rectum and injecting milk or colored fluid, which in case there exists a recto-vaginal fistula, will pass out by the vagina. The sunken abdomen, the extreme emaciation, the hunger, these speak for the seat of the fistula being the small intestine. That the communication is the result of an anus pritternat. and not of an ileo vag. fistula is proved by the existence of two openings into the vagina, separated by a projecting spur. If, as in CasEamayor's case, there is but one opening, the examination with the sound or, better, with the finger will prove that the lumen is patent in only one direction, and this speaks for anus prieternat., and also the history that the abnormal com munication followed on the.loss of a prolapsed coil of intestine.
O. Weber and C. von Heine have devised and followed a method of treat ruent of anus prEeternat. ileo vag. which fulfills every indication. It aims at restoring the lumen of the intestinal canal, and then at the closure of the fistulous opening into the vagina. Weber formulated the first steps of the method, and after his death Heine completed it and obtained a per fect result. First the blades of a modified Dupuytren's intestinal scissors (Fig. 36) were inserted into the upper and the lower openings of the in testine to the extent of one and a half inches. The spur between the blades was then cut through by screwing them together and leaving them till the aim was secured. With the separation of the spur the lumen was opened up, and the anus prEeternat. was converted into an ileo-vag. fis tula.