below the obstruction. They afterward become bloody and mucous. This latter symptom was present in 108 of Cole's 110 cases, in 156 of Hess's 160; in the twenty-four cases of my collection they were stated as being present in nine, as absent, in three, and in six no note of it was made at all. The number of fecal evacuations will depend on the higher or lower location of the intussusception and the previous condition of the child's bowels. The bloody stools will depend on the degree of involvement of the mesenteric vessels. Tumor: Under anesthesia the tumor can be felt abdominally in almost every instance. Without anesthesia there are a great many cases in which it is impossible to be positive that it is present. In these cases rigidity of the recti muscles, when associated with paroxysmal pains, is at least suggestive of obstruction of the bowel. By rectum the tumor can be felt in a certain proportion of the cases. It was present in seventeen per cent. of Hess' collection, in 15 per cent. of Wallace's, and in 14 per cent of mine. Its detection is of very little value, as Clubbe has pointed out, since its appearance is usually so late that the condition of the child is hopeless. General Condition: This is of as much value, if not more, in determining the child's condition as any other symptom. To see a previously healthy child taken suddenly ill, and within a few hours to present the appearance of one long ill, ought to call attention to the gravity of the condition. The pulse-respiration-temperature ratio is greatly disturbed. The temperature is rarely high, though in some instances it might go to 102 degrees F., or over. ually it is below 100 degrees F. The pulse is very rapid, and the respiration is usually so when the normal condi Us tion of the thoracic organs is considered. I have noticed in all of the cases I have seen a peculiar character of respiration. I can not describe it better than to say it is a half sigh and half grunt. In fact it has seemed so characteristic that I made a diagnosis of this condition almost from that alone in one case, which was confirmed by operation subsequently. In that case there had been diarrheal movement for three days, and even within an hour before I saw the case. There was no blood, no rectal nor abdominal tumor, no history of pain or vomiting. But the rapid pulse, low temperature, anxious facial expression, and this half grunting, half sighing respiration determined the diagnosis of intussusception in my mind, and made me advise immediate operation; which confirmed the diagnosis. Other Symptoms: The Signe de Dance-a depression ever the right iliac region-has been noted in some cases, but I do not consider it of great value. Noble, of Atlanta, has noticed a faint sweetish odor to the breath in cases of intussusception, but I have not found this mentioned elsewhere. Tympany is not usually present until late in the disease. The abdomen is more often flat, and the muscles rigid to protect the child from pain. In some cases the tumor may be seen, and is found by the mother, but this is rather rare. Tenesmus is more marked in those cases where the tumor can be felt by rectum. The skin is often clammy. The eyes are wide open and the expression is one of great anxiety and fright, the lips are drawn and there is great pallor. Differential Diagnosis: Grisel thinks it important to diagnosticate the variety of the obstruction. I grant that it may be desirable, but not important, for the treatment is the same for all, and no time should be lost in opening the abdomen. You may be sure of the variety then. In adults the affection may be mistaken for mesenteric embolism, biliary colic, torsion, bands, acute hemorrhagic pancreatitis, acute appendicitis, strangulated hernia, phosphorous poisoning, and tabetic crises. The history of the case will help to clear up the diagnosis in many of these affections. In children, however, volvulus obstruction by Meckel's diverticulum, appendicitis, and undescended testicle are the principal affections that may be confused with this; to say nothing of cholera morbus and dysentery, which should never be, but unfortunately are, mistaken for it. Barnard has reported three cases of tuberculous peritonitis that resembled it very closely. In a very young infant pyloric stenosis has to be eliminated. Volvulus may be distinguished by the absence of the tumor, by absence of bloody stools, and by the greater tympany occurring early in the disease. When the obstruction is due to Meckel's diverticulum the absence of bloody stools and of the tumor abdominally and rectally will aid in differentiating it. Appendicitis may be distinguished by the above symptoms, and by the tenderness or rigidity over McBurney's point. An examination of the scrotum should determine the diagnosis of undescended testicle. It seems hardly necessary to go into any detail regarding the differential diagnosis between intussusception and dysentery further than what has been said. The history of the cases should distinguish tubercular peritonitis and pyloric stenosis. I did not care to go into a discussion of the etiology of the affection, but do think it an aid to diagnosis to say that constipated, breast-fed babies are more liable to the affection, and suspicious symptoms occurring in them should be carefully watched. D'Arcy Power has shown that the diameter of the large intestine increases out of proportion to that of the small intestine during the first two years, and that there is a greater mobility of the colon because of the long mesocolon. These etiological factors may help us in diagnosis, if we bear in mind the age of the patient; especially those under two years, in which cholera morbus and dysentery are more liable to confuse the diagnosis. Barnard has urged as pathognomonic this fact. In a suspected case of intussusception he gives two enemata of turpentine in water. If the second is returned without feces and with little force, he says the diagnosis is positive. Huber suggests that colicky paroxysmal pains, associated with rigidity of the recti and localized tenderness over the left iliac region, are sufficient to warrant laparotomy. TREATMENT. The object of this paper was to aid us in making an early diagnosis, so that the early operation might be performed.. I believe this is the only rational treatment. A high irrigation may be used with advantage to aid in reducing the intussusception; but I could not get my consent to advise it, unless operative measures were used simultaneously. However I shall not enter into a discussion of the operation, as my confrere, Dr. Barnett, will discuss this in an early paper. BIBLIOGRAPHY. Addenbrooke-London Lancet CIXX, page 596. Barnard—Clinical Journal, London, 1905, XXVI, 129, 288. Bogart-Brooklyn, N. Y., 1905, XIX, 208. Cole-Intercol. Medical Journal, November, 1904, page 545. Clubbe-Australian Medical Gazette, 1905, XXIV, 459, Durham-Annals Surg., 1905, XIII, 592. Duncan-Intercol. Medical Journal, April 20, 1904. Ellzel-Old Dominion Medical and Surgical Journal, 1995, IV, 185. Grisel-Cong. Nat. Period de gyn.,d'obstetric, et de ped-1904, 629, 674. Hess-Archiv. Ped., 1905, page 655. Huber-Achiv. Ped., 1903, page 742. Nolan Transactions Georgia Association, 1904, page 308. Rutherford-Glas. Medical Journal, 1903, page 426. DISCUSSION ON DR. HULL'S PAPER. Dr. F. W. McRae, of Atlanta: I dislike very much for as good a paper on so interesting a subject to pass without discussion. The Association owes a great deal to Dr. Hull for bringing up this subject. I do not know of anything in surgical abdominal diseases that causes the death of so many children as intussusception, unless it be appendicitis. It is a disease to which children are peculiarly prone, and Dr. Hull has mentioned the only treatment that is effectual in the majority of instances. He has mentioned the time at which treatment must be instituted in order to be valuable. Absolute obstruction of the bowel from intussusception beyond forty-two hours is almost a hopeless condition, if it is not hopeless. Some few cases may recover, but not many. It is only by early diagnosis and prompt resort to surgery that the lives of these little ones may be saved. We are often unable to make a diagnosis of intussusception, but we can practically always make a diagnosis of acute obstruction of the bowel, and whenever we make that diagnosis it matters not from what cause or what may be the cause of the obstruction then it is our duty to resort to prompt surgery, which is just as imperative in this condition as it is in appendicitis. |