Intestinal Obstruction, OWEN O'NEIL, M.D., WILLIMANTIC. Opportunity for abdominal surgery in children is limited, and the indications usually confined to acute conditions. It is for these reasons that all should bear clearly in mind the indications for operative interference, which must be early-if at all. The diagnosis of an acute abdominal condition in a child is essentially difficult and must be based almost entirely on the objective physical signs. While a history, carefully obtained, is important, the ultimate deductions must be reached through a careful and painstaking examination. Doubtless intussusception has many times been confounded with ileo-colitis and dysentery, and hasty conclusions in this respect have, undoubtedly, led to unfortunate terminations where timely surgical intervention would have given brilliant results. Let us review, for the moment, the clinical picture of an infant suffering with intussusception-a condition which is the cause of acute abdominal symptoms necessitating operation in from seventy-five to ninety per cent. of all cases under one year of age. The symptomatology is fairly constant. The child, previously in apparent good health, or suffering from a mild digestive disturbance, is attacked with violent pain, usually followed by vomiting of the stomach contents. The pain is paroxysmal, recurring every few minutes, and is very severe. Here it is important to note that the suddenness of the onset, or evidence of pain, is apparent to even the casual observer. It is extremely severe, causing the child to shriek with agony. The face wears a look of fear as if in dread of the returning pain. The legs are usually flexed over the abdomen. Vomiting is almost invariably present, although it does not necessarily begin early, the time of onset depending on the location of the obstruction. It is always increased when food is given and generally consists of stomach contents, though it may become stercoraceous or even bloody. The stools may at first contain loose fecal material but rapidly change to muco-hemorrhagic or even pure blood. The presence of blood in the stools of infants should always be looked upon with suspicion as pointing to the possibility of this condition. Complete obstruction is an early possibility, but the non-passage of flatus and apparent meteorism shows, usually, an extensive primary pathologic condition or a rapidly fatal termination from the condition not previously recognized. It occasionally happens that the infant's abdomen is lax and flabby, though usually when seen the abdomen is more or less tense and tympanitic. The probability of palpating a tumor through the abdominal wall of an infant restless with extreme pain and with abdomen rigid and distended is oftentimes remote, unless a general anesthetic be given. Failing this, search should be made by digital examination per rectum. Indeed, in most cases, a tumor presenting in the rectum is more easily found than the classic "sausage-shaped" mass so frequently mentioned. In our experience, normal or sub-normal temperatures in cases of intussusception among infants has not been found; on the contrary, high temperatures have been encountered in cases which have been obstructed less than twenty-four hours. This is not at all strange since, as already stated, intussusception frequently follows acute digestive disorders. The clinical picture varies but little regardless of situation of the obstruction. Four varieties, depending on location, are recognized: the ileo-colic, in which the ileum prolapses through the ileo-cecal valve; the ileo-cecal, in which the ileum and ileocecal valve prolapse into the cecum and colon; the ileal, in which the ileum alone is involved, and the colic, in which the colon alone is involved. The intussuscepiens drags with it its mesentery into the intussusceptum, and the intensity of the symptoms varies according to the tightness of the invagination and constriction of the mesenteric vessels. The treatment is essential surgical, and palliative methods are, to my mind, unsatisfactory and obsolete. Both theoretically and practically attempts at reduction of an intussusception by distention or inflation of the bowel are inadequate even dangerous. Not only may perforation occur, but a real or apparent reduction may result from these measures, only to be followed by a reappearance of the obstruction, and during this delay valuable time for the institution of radical measures has been lost. These cases belong to the category of emergency surgery. They usually present a low resistance and the operation should be limited to the relief of the intestinal condition and consummated as rapidly as possible. The following cases of acute obstruction in infants are typical and fitly illustrate the general class. The first two are cases of true intussusception with operation; the third, a case of mechanical obstruction, simulating intussusception with spontaneous relief. Case I. E. P., female, age 4 months. Family history negative. Previous history: normally delivered, breast-fed, well-developed infant. No unusual intestinal condition until August 1st, 1909, at which time undigested curds appeared in the stools, with some mucus. Nothing special was thought of this condition until the night of August 3d, when the infant became very restless, showing evidence of considerable pain. At 6.30 A. M., the following morning, passed a large muco-hemorrhagic stool, followed by intensification of all previous symptoms, especially pain, with continued bloody discharge from the rectum. When seen at 7 A. M. the infant presented a picture of great suffering, crying amost incessantly, legs flexed on abdomen, and had vomited once. Temperature 103° F. (by axilla), pulse 160. From this time until admitted at St. Joseph's Hospital at IO A. M., vomiting persisted, infant evinced considerable pain and diapers were stained with blood and mucus. Examination: heart and lungs apparently normal, abdomen tense and slightly distended, palpation revealed no evidence of tumor or excessive tenderness, auscultation showed active peristalsis; digital examination per rectum revealed an easily recognizable tumor. Immediate operation was advised and patient removed to hospital. Parents opposing operation, palliative measures were attempted and these, to my surprise, seemed to afford great relief. These measures consisted in the high injection, under low pressure, with buttocks elevated, of a considerable quantity of hot normal saline solution. Following this treatment there was relief from pain and the infant slept a number of hours. The tumor was no longer recognizable in the rectum; the bloody discharges ceased. In eighteen hours, however, there was a return of all the acute symptoms and operation became imperative. The parents' consent being obtained, the child was at once removed to the operating room. Operation: Ether anesthesia; abdomen opened through right rectus incision. Upon opening the peritoneum a considerable amount of serous fluid was encountered. Intra-abdominal exploration revealed a tumor in the left hypochondriac region. This being delivered, an ileo-cecal invagination-with ileum, cecum and appendix prolapsed into colon-was revealed. Reduction was accomplished with comparative ease. Because of evidence of trauma about the appendix and its mesentery, the appendix was removed. The abdomen was closed in the usual manner. Two hours after operation the child had a convulsion, which was followed, within the next four hours, by three others. Temperature, 101° F. at time of operation, now rose to 106°. Post-operative irrigation of the bowels yielded two large, brown liquid stools, followed by cessation of convulsions and reduction of temperature. The intestinal condition appeared to be entirely relieved. Forty-eight hours after operation the infant was given the breast, but two days later an entero-colitis developed, when breast feeding was again stopped and artificial feeding instituted. In spite of every effort, the entero-colitis was uncontrolled, the infant succumbing to it the fourteenth day after operation. Case II. G. P. V., male, age 8 months. Family history negative. Previous history: normally delivered, breast fed, well developed infant. Gave evidence of an entero-colitis August 8, 1910, which, under appropriate treatment, subsided in a few days. Following a dose of castor oil administered on the 13th of August, the child was seized with uncontrollable restlessness and crying. There were several evacuations of the bowels, consisting of liquid brown fecal material with mucus. Later, when blood was observed in the stools, the parents became greatly alarmed. When seen at 7.30 P. M. of the same day, the child was extremely restless and by his shrieks gave evidence of considerable pain. Up to this time there had been no vomiting, nor was there at any time during the persistence of the condition. The face was flushed and wore a particularly anxious expression; the arms and legs were kept more or less constantly in motion. The dejections consisted of blood and mucus. Examination: temperature 101° F., pulse 150; heart and lungs apparently normal; abdomen flat, with considerable rigidity of the recti; palpation illicited tenderness over all the abdomen. As in the preceding case, impossible to detect any tumor through the abdominal wall, while digital examination per rectum revealed an easily recognizable tumor and the withdrawal of the examining finger was followed by the discharge of a considerable quantity of blood and mucus. The diagnosis of intussusception being made and immediate operation being advised and accepted, the patient was removed to St. Joseph's Hospital and at once prepared for operation. Operation: ether anesthesia; abdomen opened through a right rectus incision, a slightly excessive amount of serous fluid being encountered. Exploring the abdomen, a tumor of the intestine was found extending from right hypochondriac region transversely and downward toward the left iliac region. This, upon delivery, was found to be an intussusception of the ileo-colic variety, about eighteen inches of the small intestine being invaginated into the large. Some eight inches above the intussusception an annular constriction of the ileum was observed which appeared to be a localized contraction of the muscular wall of the bowel and which disappeared under manipulation. The intussusception was easily reduced without damage to intestine or mesentery. The abdomen was closed in the usual manner. The infant made an uneventful recovery and was discharged from the hospital on the eleventh day. In the post-operative treatment of this case, the infant was fed artificially until the fourth day, when, the stools being normal in color and consistency, |