In the presence of narrow fistula conditions are much more aggra vated, the rectum being stenosed either in its entire length or at either end, or it may communicate externally at the normal site through a tubular fistula. Since only fluid or mucous fecal matter can pass through these ducts, there is again intestinal atresia with its sequelm.
Time prognosis is worst in total or partial communication with the bladder. In most cases infection of the urinary passages will be almost unavoidable. Page's case, of a man who up to the age of 54 evacuated the fames through the urethra, is unique in the literature. In the period of rapid infantile development the mucous membrane of the bladder certainly seems to adapt itself to some extent to abnormal contents, and in one of my eases of ano-urinary atresia the anomaly had existed for several weeks without giving rise to any disorder of the bladder, the favorable factors apparently being that the child was breast-fed and that the abnormal communication extended not higher than the urethra.
If the urine is occasionally clear and at other times mixed with fecal crumbs, the diagnosis of atresia ano-urethralis is probably correct; if it is more or less homogeneously mixed with feces, it would rather point to atresia vesicalis. This differentiation, however, does not always apply, Loetsch, for instance, reporting a case of a wide communication between rectum and bladder, verified by operation, in which at times perfectly clear urine Was evacuated. On the other hand, minute fistula' may, under the influence of considerable pressure of meconium, cause permanent turbidity of the urine, although a communication with the bladder need not necessarily be present (Fig. 31, Plate 5).
Treatment.—This anomaly always requires operative treatment, and the time for carrying it out will depend on the gravity of the case.
The relief of total atresia is an emergency operation. The abnormal conditions should he relieved as rapidly as possible, before the sequel2 of intestinal atresia render the prognosis of an operation unfavorable. In other anomalies consisting in abnormal fistula ducts the operation may be deferred until the patient is in a sufficiently favorable condition. Whenever there is communication with the bladder the danger of infec tion of the urinary ducts should never be overlooked.
The operation for atresia ano-vaginalis should be deferred until a suitable period if the communication is sufficiently wide.
The normal procedure in total atresia of the anus consists in search ing for the rectum through the perineum. If there is only an epithelial covering and the rectum, filled with meconium, shines through a thin separating layer, this may be bluntly incised.
Should the layer be of greater thickness, any kind of instrumental perforation should be avoided. The child is wrapped up in the laparot orny position and lightly etherized. Deep anesthesia is inadvisable, since the crying and straining under light anesthesia bulge out the rectum considerably, facilitating its localization.
A median incision from the coccygeal apex is made through an anal fossa if possible, and beyond anteriorly, exposing the intestinal struc ture as the incision deepens, and keeping the incision carefully in the median line. The operator advances along the anterior surface of the sacral bone, paying careful attention to the position of the urinary bladder. A previously inserted catheter furnish information as to its localization. It is of importance always to keep towards the anterior surface of the sacral bone, because in this way the rectum will always be found even in high position, without opening the peritoneum (Fig. 29, Plate 4). The vicinity of the ampulla is recognized by the bluish trans parency of its contents. The rectum is bluntly dissected from its sur roundings and so far mobilized that it can be pulled out to the outer surface of the skin, or as near thereto as possible. Care should be taken not to injure the urinary duets and the umbilical veins. The traumatic opening having been carefully tamponaded, the ampulla is opened by an incision corresponding to the normal width of the rectum and its usually bulky contents evacuated. The mucous membrane is sutured to the outer skin and the deep traumatic funnel closed by figure-of-eight sutures. If it is possible to bring the unopened ampulla to the outer skin without evacuating it and to suture it in that pi)sition to the skin, this would, of course, he preferable to incision, but this can only be done in part of the eases owing to the great tension. Buried sutures are best avoided in this unsafe region, but dissected muscles, if any, should be carefully sutured.