it was given the breast. Almost immediately fermentation with intestinal irritation was apparent, the child becoming fretful, the stools green and temperature rising from 99.4° to 102°. Artificial feeding being again instituted, the condition rapidly improved. It is needless to say that breast feeding was not again attempted.

Family

Case III. G. H., colored, male, age 15 months. history negative. Normally delivered, bottle fed infant, showing well-marked evidence of rickets. Taken suddenly ill with abdominal pain and vomiting the night of October 7th, 1907. When seen the following morning, the child, still evidently suffering considerable pain, had ceased vomiting. During the night a dose of castor oil had been administered by the mother, occasioning several dejections which, at the time of my visit, had become muco-hemorrhagic. Slight elevation of temperature and acceleration of pulse. Casually examining the abdomen, which was somewhat distended and soft, was surprised to find, in the left lumbar region, a firm and easily outlined, more or less "sausage-shaped" mass, evidently in or about the descending colon-apparent classic evidence of colonic intussusception. A diagnosis of acute intestinal obstruction was made and operation advised. Parents desiring a little time for the consideration of operative treatment, deferred consent to operation until a subsequent visit, which was made a few hours later. At the time of this second visit the mass had descended to the border of the left iliac region, paroxysmal pain and bloody stools continuing. A strange, hard and unyielding mass could now be felt by digital examination per rectum. The general condition of the patient remaining good, immediate operation was not insisted upon-things evidently moving in the right direction. During the afternoon of this same day the infant passed a small china pig, which had evidently been denuded of its prominent appendages previous to being swallowed, thus relieving the intestinal obstruction and concurrent symptoms.

From a consideration of the foregoing cases-which may be taken as fairly representing those encountered in our experience -we learn: first, the necessity of early recognition, in which

the palpation, through the abdominal wall, of a "sausage-shaped” tumor is by no means an unfailing guide, but, in pursuit of which, the consideration of general symptoms-initiative intestinal disturbance, bloody stools, vomiting, paroxysmal pain, exaggerated muscular movements and the finding of a tumor through rectal examination—are more constantly dependable. Second, that vomiting, though fairly constant in acute intussusception, may not be present. Third, the value of prompt operation, limited to the relief of the actual acute condition. Fourth, the uselessness, and even danger, of palliative measures, which may ameliorate the active symptoms of the disorder, even stimulating true reduction, thereby causing serious delay in the institution of radical treatment. Fifth, the unfavorable results of attempting to return these children to the maternal breastit being shown that even the breast milk has not been more or less of a factor in the production of the obstruction; the nervous strain upon the mother, who realizes that her child is stricken with a truly serious condition, is almost certain to disturb lactation. Sixth, that mechanical obstruction by a foreign body in the intestines may present all the general symptoms of an intussusception.

784 Main Street.

DISCUSSION.

DR. JOSEPH M. FLINT (New Haven): We are very much indebted to Dr. O'Neil for the interesting report of his experience with intestinal obstruction in infants with especial reference to intussusception. The conclusions as to the treatment and indications for operation are in keeping with those of other observers who have worked up and reported a large series of cases. In both instances of true intussusception reported by Dr. O'Neil, there was no evidence of an abdominal tumor,—a sign which is variously given in the literature as being present in from 33 per cent. to 66 per cent. of the cases. In this respect, Dr. O'Neil's experience is apparently in accordance with that of other surgeons who have found a palpable tumor in the rectum, together with the abdominal signs and muco-hemorrhagic stools, much more reliable diagnostic indications of the condition than the palpation of the sausage-shaped mass in the abdomen. In both of the intussusception cases presented in this paper the abdominal symptoms were outspoken, even though at operation the invagination was reduceable and gangrene had not occurred. In view of the dangers of palliative treatment to which Dr. O'Neil has referred, it is well to remem

ber that there is also a certain group of cases where extensive gangrene of the gut has taken place without any evidence of the process beeing seen in the general condition of the patient. This fact is difficult to explain unless it may be due to the extra peritoneal situation of the necrotic process, inasmuch as gangrene following pressure on the mesenteric vessels usually occurs within the lumen of the intussuscepiens and actually outside of the peritoneal cavity. It is in such cases, however, where conservative measures are particularly dangerous and are likely to lead to costly delay, as in Dr. O'Neil's first case, even if gaseous or hydraulic distension of the large intestine is not followed by perforation and general peritonitis. Cases of this group are well illustrated by a patient of Dr. Steele's upon whom I operated some months ago. The infant, aged 11 months, was admitted with the history of mucous entero-colitis of about 4 months' standing. The child had been taken from the breast without any apparent improvement of the symptoms. On the day of admission, the infant had had a bloody stool, on account of which it was brought to the hospital.

The general condition of the child was so good that the house surgeon informed the mother as he was admitting the case that it was probably one of simple digestive upset, and a few weeks of careful feeding would restore it to perfect health. The vital signs on admission were practically normal,—the temperature 98°, pulse 100 and the respiration 28. The child had a very anxious expression but gave no evidence of pain during the examination. The general physical examination was negative, except for the abdomen, which was slightly distended; there was no general abdominal rigidity. Nothing abnormal was found in both upper quadrants or the right iliac fossa, but, extending up from the pelvis to the left iliac fossa was a small rounded tumor which was not long enough to be called definitely sausage-shaped. The tumor was not tender on palpation, but the manipulation was followed by the appearance of an intestinal pattern with distinctly visible peristalsis.

Rectal examination revealed a tumor very like an elongated cervix. The lumen at the apex of the intussusceptum felt exactly like the external os and the finger could be freely passed between the intussuscepiens and the intussusceptum. Straining following the digital examination resulted in the prolaps of about 8 cm. of the intussusceptum. This was the most remarkable feature of the case, inasmuch as the operation showed that the portion which projected from the anus was the ileum at a point about two feet above the ileo-cecal valve.

The child was operated upon that night and almost the entire lower half of the small intestine, cœcum, and colon were invaginated into the sigmoid. Reduction was possible to about the middle of the transverse colon, when the gangrenous intestine began to appear, and in order to obtain healthy bowel for anastamosis it was necessary to resect the lower three feet of the ileum, cœcum, ascending colon and one-half of the transverse colon.

An end-to-end anastamosis was performed, and after a serious postoperative period of a week the child began to improve. The Murphy button was passed on the sixth day. The resection of three feet of the small intestine in an infant II months of age, where the total length measures about nine feet, is equivalent to the resection of about six feet in an adult. There was an interesting parallel in the post-operative behavior of this case to the series of extensive resections of the small intestine in human beings and in animals, which I reported to the Society two years ago. The operation was followed by a period of severe diarrhoea, in which the child had from nine to twelve stools a day. In about a week, the patient's condition began to improve until at the time of discharge, six weeks after admission, the infant had not only regained its original weight but showed a net increase of one pound and had but three or four stools in twenty-four hours.

Two series of metabolic studies were carried out, the first covering a period of three days, beginning a week after the operation, when the percentage of diet nitrogen, fat and carbohydrates in the feces was increased, although it was apparently making desperate efforts to maintain itself in equilibrium by the retention of over two grams of nitrogen a day. The second series was undertaken five weeks later and showed a more normal state of affairs. With a nitrogen output of 16 per cent., and a reduction of the fat excretion from 21 per cent. to 9 per cent. and an entire absence of lactose in the feces, we have a confirmation of the observations on adults and animals with shortened intestines, and the obvious suggestion that suitable carbohydrates like the simple sugars should form an important element in the diet of patients with deficient absorption either from operation or disease.

Aside from the suggestion of diet in such cases, I simply wished to call attention to this group of cases with early gangrene without manifest symptoms of the process, and to emphasize, as Dr. O'Neil has done, the possible dangers in the conservative treatment of intussusception in infants.

DR. JOHN W. WRIGHT (Bridgeport): Mr. President and GentlemenI do not understand why I was called upon to discuss this paper, unless it was in order to point out, or to impress upon you the fact that I have never operated on a case of this sort of intestinal intussusception in a child.—The value of the paper is two-fold, and the value of the discussion may also be two-fold: first, to the men who read; and second, to the audience. The value of the discussion lies in the confession of the men who discuss the paper, in order to give prominence to a thought of which you ought to know the value, of their mistaken opportunities. I remember, not so many years ago, of having been called in consultation on two cases of intestinal intussusception. This was the correct diagnosis, without any doubt, as I remember them at the present

time; but they were then mistaken for cases of severe entero-colitis. All the classical symptoms were present, as described to-day in the two cases of Dr. O'Neil; but, unfortunately, the diagnosis was not complete enough to warrant a resort to operation. At that time, so little had been said regarding the value of operative interference in children that advantage was not taken of the opportunity. The diagnosis, also, was not sufficiently clear to enable us to advocate early surgical interference; and both children died.

The danger of intussusception has been called to my mind more clearly much later than the time of the history of the two cases that I have already spoken of. I have found intussusceptions in some cases at the postmortem examination-as many, in one case, as twelve. In this case, which occurred in a soldier in the army, there were invaginations of the ileum all along, producing an acute enterocolitis. In children, I have not, within the last two years, observed any cases of enterocolitis that resulted in intussusception. Therefore, I have not operated on that sort of case. The only one that I recall which was somewhat similar was one of acute appendicitis in a child of nine months. In this case, the symptoms were more of the appendix than of invagination; and the operation was successful.

In Bridgeport, they do not swallow china pigs, as they do at Willimantic; and, therefore, I have not had any experience in that line either. However, they do swallow pigs of another character, and I am not sure but that the presence of such meat in children is not a greater cause of enterocolitis and invagination than is the china pig at Willimantic. I would caution you, therefore, to be more observant of the symptoms present in infancy, so as to avoid the errors to which I now confess, of not being sufficiently accurate in my diagnosis; and perhaps in the future you will find that successful operations will be much more prevalent than they have been in the past. I thank you for this opportunity of making a confession.

DR. JAMES HENRY KINGMAN (Middletown): I wish to speak to the Society of a case of intussusception that illustrates the point of not doing too much at once in this work. This case was brought into the hospital at Middletown. The patient was a child of six years old, who had been ill for four days. The case was first thought to be one of enterocolitis. Then the spasms, the cramps, the distended abdomen, and the bloody stools led to a probable diagnosis of intussusception. When admitted the child was in a pretty weak condition, vomiting steadily, and passing blood from the bowels; and an operation was decided upon. There was great rigidity in the abdomen, and we thought that we felt a tumor in the lower part of the abdomen. The incision was made at the umbilicus, in the median line. I inserted my hand into the abdomen, and brought out a tumor five or six inches long. We