Tracheo-esophageal fistula and esophageal atresia.

Congenital atresia of the esophagus was first described in 1697 by Gibson, who was a grandson of Oliver Cromwell, and physician-general to the army. Neither the clinical history nor the physical findings have changed since his often quoted classical description. It was 245 years later before success was recorded in the management of the condition. Cameron Haight5 in 1941 first established esophageal continuity successfully in one stage operative procedure, by primary anastomosis of the proximal and distal segments of the esophagus. The delayed progress in the treatment of the condition was due, in the past, to the misconception that the condition was extremely rare. Guthrie, in searching the records of the Royal Hospital for Sick Children, Glasgow, found 24 proved, and a further six probable, cases in 6,916 necropsies. The late Sir G. Grey-Turner estimated that the malformation occurred about as frequently as hare-lip and cleft palate. At the Postgraduate Medical School of London four cases of atresia were found in 10,543 deliveries (1 in 2,635 deliveries). It is quite conceivable that the incidence is higher than 1 in 2500 births. Many cases probably are not recognized as such and the deaths are regarded as having been due to atelectasis or pneumonia, without a confirming autopsy. That the condition can be overlooked is easy to understand, particularly when the infant is not supervised by a pediatrician. The early signs are not always definite or even recognizable. The infant brings up some frothy mucus during the first day or two of life. Attempts at feeding lead to regurgitation, choking and probably cyanosis. Excess of mucus in the naso-pharynx occurs in normal infants, but aspirations soon relieve any cyanosis which may have been present. Without the diagnosis and treatment of atresia of the esophagus, pulmonary symptoms usually develop by the second day. This may be diagnosed as pneumonia, and further feeding troubles and respiratory distress attributed to the respiratory infection. With the fatal termination in a week or more, even if necropsy is performed, it is quite conceivable that the diagnosis may be overlooked. The burden of early recognition falls largely on the obstetrician, the pediatrician, and the nursing personnel of the new-born nursery. If they are suspicious regarding any child who has excess mucus, episodes of cyanosis, and who does not take fluid properly in the new-born period, more of these cases will be recognized earlier than at present, before a great deal of aspiration has occurred. There is no real substitute for awareness and careful observation. Although the diagnosis may be made frequently on history alone, physical signs and X-ray film examination are usually necessary to confirm it. The diagnosis is confirmed, when suspected, by the passage of a soft rubber No. 10 or 12 F catheter through the mouth into the pharynx and proximal esophagus, The catheter will be held up 8 to 10 centimeters from the alveolar margin in the usual type of atresia.