It is a fact that traces of fattal peritonitis, of possibly sy phili tic or tuberculous origin, are not infrequently found; and, moreover, the persistence of the ductus omphalornesentericus can lead to strangulation of the inte.stine and to occlusion of its lumen. To account for many cases, ulcerative in flammation of the mucosa, with subse quent scar formation, must be assumed as the cause. tither cases are explained by intussusceptions, which arose and \WIT reduced during intra-uterine life (Chiari, Braun), and, still other causes, by compression by congenital tumors of the abdomen (Schukowski), anomalies of the circulation with ischaunia of certain parts of the intestine, or, by obliterating arteritis resulting from inflammatory infectious processes of placental origin (Cordes). Amniot ic bands may be present, by which occlu sion occurs in the form of a transverse septum, to explain which one must assume a productive inflammation of the intestinal wall. Finally, there arc instances in which the most careful macroscopic and micro scopic investigation fails to discover any cause.
According to the pathological anatomy of the condition, stenosis and atresia of the small intestine stands first in frequency, next are those which are localized in the duodenum, and last come those of the large intestine. The intestine appears much reduced in lumen,tor this is absent completely for a section, and replaced by fibrous tissue; or, finally, both ends of the portion of the intestine concerned terminate in blind sacs, which are held together by mesentery. The section of the intestine above the stenosis appears greatly dilated, the portion below it completely collapsed. (.111 these types are clearly seen in the illus trations, taken from the preparations in the colleetion of the Patho logical 'Museum, and, for the privilege of reproducing them, I would especially, thank the Director of the Institute, Prof. Chiari—sec Figs. III and IV on Plate 50.) In most cases, no malformations are found in the rest of the body but not infrequently, in the region of the intestine, such abnormali ties as anomalies in position, an unusual shortening of the intestine, the absence of certain parts, and similar alterations ean be demonstrated. Moreover, multiple stenoses have been repeatedly- described. (The exacit details of more statistical interest are to be found in the collected publications of L. Cordes, Weill, Pehu, Bossowski, and others.) I would call attention to an interesting finding that. was ciiscovered on examination of the intestinal content: this was found to be sterile below the point. of atresia (Bossowski, Wyss, and others), while the con tents above it contained B. con and other varieties. This renders prob able t.he a.ssumption that, in the physiological process, the bacterial infection of the intestine takes place by the mouth and not by the anus.
The diagnosis of this condition, in so far as it rests upon the recog nition of a stoppage of the bowel movements, is relatively easy. The vomiting, beginning soon after birth, the meteorism, in addition, and the failure to evacuate meconium, are such striking symptoms that no serious doubt can arise.
stenosis of the cesophagus, or closure of that passage, which can be determined by probing, the nourishment. is returned imme diately after drinking. In pyloric stenosis the vomitus is never colored with bile, or fecal in character, and the symptoms are developed more slowly; frequently, the movable tumor, corresponding to the hyper trophied pylorus, is palpable. It is true that it is rarely, possible, clin ically, to certainly distinguish a duodenal stenosis, near the stomach and above the ampulla of Voter, from a pyloric narrowing. I have already mentioned that by careful examination of the anal region, and of the rectum, one must exclude any obstruction in these parts. Filially, fcetal peritonitis must be mentioned, as it also leads to vomiting and meteorism, but in this condition there is no absolute constipation; on the contrary-, there are diarrhcea stools; the movement of the fluid in the abdominal eavity is soon evident, and the sensitiveness, on pal pation, as n-ell as the fever, which is rarely absent, all point to the inflammatory character of the disease and to its loealization. The exact situation of the stenosis can be conjectured, from the factors mentioned in the description of the symptomatology, but it can not be certainly determined.
The prognosis of congenital intestinal stenosis and atresia can be designated as absolutely fatal. I can find no single instance in which there has been a successful operation performed, and certainly nothing is to be expected from internal medication.
The treatment can only be operative, and should be undertaken as early as possible. In view of its absolute failure, it is questionable whether it would not be better to spare the little s.ufferers the useless annoyance. Tuffier who (according to Nobkourt) collected 32 opera tions (211 of which were enterostotnies, 4 entero-anastomoses and 2 perineal ileostomies), could not bring forward a single successful case. Braun, who reported 25 operations, had the same results, and Bossow ski, likewise, in two eases of his own and 31 taken from the literature. I have myself, in addition, gathered together a number of observa tions, not elsewhere reported, in which various surgical procedures were undertaken (such as the production of an artificial anus, suture of the large intestine with the rectum after resection of the portion in atresia, entero-anastomosis, etc.), and they all, also, ran a fatal course.