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·INTUSSUSCEPTION IN INFANTS AND CHILDREN ·Frontispiece - The pathological changes in the acute form of invagination are chiefly of tuo kinds I Obstruction of the bou el 2 Strangulation of the intussusceplum The obstruction is due not only to the narrowing of the lumen of the bou el by the intagination but also to the swelling of the invaginated portion caused by the constriction of the blood vessels supplying the intussusception at the neck of the intussuscipiens The ach) of the symptoms is alu ays proportionate to the severity of the strangulation at this point The circular constriction interferes uith the return of venous blood from the intussusceptum which is follou ed by edema complete stasis and gangrene of the constricted portion an acute invagination becomes irreducible by ordinary means urthin a feu hours on account of the appearance of edema in the intussusceptum If the strangulation is less intense the passive congestion precedes a plastic inflammation of the serous surfaces held in apposi tion and adhesions form u lich again oppose or render a reduction impossible Nicholas Senn 1893 The vast majority of intussusceptions in infants and children are of the kind shown herc The intussusception begins at or near the ileo cecal valve and there is no obvious local anatomical lesion to cause it From the first moment there is simultaneous interfcrence with the patency of the alimentary canal and with the vascular supply of the intussusceptum The drawings indicate the manner in which the mesenteric vessels are dran necneen the layers of the intussusception and compressed The slight interference with lymphatic and venous drainage which occurs almost at once results in edema and an increase in the tissue pressure This further increases the resistance to the return of venous blood Venules and capillaries become enormously engorged Edema increases until there is complete obstruc tion to venous outflow As arterial blood continues to pump in the tissue pressure rises until it is higher than arterial pressure and gangrene ensues The drawings indicate the sharp Ushaped turns of the bossel and of the mesenteric vessels at either end of the intussusceptum The outer coat of the intussusceptum is isolated between these two sharp bends and is understandably the first to become gangrenous Gangrene miles its appear ance in this coat near the tip of the intussusceptum and progresses backward towards the nech of the intussusception Identical changes follow in the innermost layer of the intussusceptum The intussuscipiens is rarely damaged

·Intussusceptum
Enlarged
Ileogenic
Voss
Blood vessels
drawn in
layers
leocecal
valve
Terminal
Weum
Cecum
Intussusceptum
Kinking and
Compression of vessels
leads to engorgement
and edema
Splentc
flexure
Intussusceptūns

·PEDIATRIC SURGICIL MONOGRAPH SERIES
Edited by
MARK M RAVITCH MD
Associate Professor of Surgery
The Johns Hopkins University School of Medicine
Surgeon in Chef The Baltimore City Hospitals
Baltimore van land

·INTUSSUSCEPTION
IN INFANTS
AND CHILDREN
B)
MARK MRAVITCH, MD
Associate Professos of Surgery The Johns Hopkins nu esity School of Medicine
Surgeon in Chiel The Baltimore City Hospitals
Baltimore Maryland
BOOKS
LDERSTAREN
TBOL
CHARLES
C
THOMAS
Springfield Nlinois
PUBLISHER
USA

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This book is humbly dedicated by one of the many men and icomen
in medicine chose lives and careers he so profoundlı influenced

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·PRCTACE Very The field of pediatric surgery las expanded pressure reduction of Clubbe and of Hipsley so rapidly in recent years that there would appear then of Hirschsprung and his successors in Scan to be a place for a series of monograplus des oted dinavia I became enthusiastic about -te to its various phases The body of information to try the method These attempts began in 1939 available is iton much greater than can be satis when I was a junior Assistant Resident That I factorily handled in the limited space afforded was permitted to make these attempts was due in a textbook Some of these monographs wall the support and encouragement of Dr E A Parl deal with single conditions or diseases others of then directing the Hartiet Lane Home for Inva wider scope with organ systems or specialty lid Children and Dr Warfield M Fıror fields within pediatric surgery directing the Department of Surgery Since 1941 Only a few years ago in the limited field these studies have profited from the warm inter which was then pediatric surgery intussusception est of Dr Alfred Blaloch Professor of Surgery occupied a prominent place It therefore seems and Director of the Department of Surgery eminently suitable that the first monograph in In a hospital where from its inception ti. the series should deal with this subject of tradı ward services have been almost wholly in the cor tional interest in pediatric surgery trol of the Resident Staff I owed much to this In 1933 Dr Dean D Lewis then Professor of Pediatric House Staff who were enthusiastic Surgery at the Johns Hopkins University School from the first and to my various predecessors in of Medicine returned from a meeting of the the surgical residency who varied from toliau American Surgical Association at which Dr E H to warm cooperation but were always helpful – Miller of Chicago had presented a paper on Doctors E S Stafford David H Sprong Jr Intussusception Dr Miller had described his August F Jonas Jr James M Vason III ar own results which he considered poor and re William G Watson ferred to the remarkable results of Hipsley in In recent years the surgical house staff has cor Australia with reduction of intussusception by tinued the program more or less independently hydrostatic pressure Dr Lewis at a student and it is a pleasure to report that the clinical clinic in customary fashion read to us directly results have steadily improved from the writings of those concerned with the Dr Robert M McCune Jr while still a problem under discussion--in this instance the cal student contributed heauly to the laboratory classical work of Clubbe-the great Australian experiments and clinical analyses upon which I student of intussusception I was a third year have drawn freely student at the time and interested in pediatric Intussusception as a disease has fascinated pe problems Reading of the work with hydrostatic diatricians surgeons and pathologists in the P ·those whose connection with the subject tons of films talen during such reductions It 2 noten orthy are Jolin Hunter D Arcy has been our observation that few pediatricians Rokitansky othnagel Nicholas Senn or surgeons who hue had experience of the n Hutchinson Hirschsprung and Sir method in operation in seasoned lands have Clubbe failed to be convinced of its lue The numer put attempting to write a monograph so ous roentgenographic films reproduced which us to repel the more general reader, se constitute a series of illustrated case histories ed to treat in systematic fashion the his will it is hoped serve as a body of clınıcıl expe pathology and the clinical features of rience for those un cquuinted with this metliod ise and its therapy Because of our special and is an atlas for reference to illustrate the vari in the hydrostatic pressure reduction of ous appearinces of intussusception during the ception under fluoroscopic control re barium enema treatment cluded a substantial series of reproduc M M R ·TABLE OF CONTENTS PP 311 CHAPTER I MATI ERS OF HISTORICAL INTEREST CO\CERNING INTUSSUSCEPTION First descriptions p 3 treatment pp 4 5 6 7 (non-operatne PP 4 5 Operative pp 6 7) radiograpluc diagnosis pp 8 9 10 barrum enema reduction P 10 pp 11 27 CHAPTER II THE CLINICAL PICTURE OF I TUSSUSCEPTION Incidence p 13 sex p 14 race p 14 age p 14 seasonal incidence p 1. birth rank p 16 nutrition and previous health p 16 Presious attacks spontaneous rcduction p 17 Spontaneous sloughing p 18 Symptoms p 19 pain p 19 blood p 20 constipation p 20 diarrhoea p 20 Examination p 20 fever p 20 white blood cell count p 21 prostration p 21 dehydration P 21 associated diseases p 22 abdominal resistance p 22 mass p 22 peristalsis p 22 prolapse p 22 Duration p 23 Occurrence of specific lesions causing intussusception pp 23 24 25 26 CHAPTER III ERRORS IN THE DIAGNOSIS OF INTUSSUSCEPTION Inexcusable errors p 30 errors because of prolonged duration PP 30 31 because of pre existing severe illness pp 32 33 34 35 because of suspected dysentery PP 35 36 37 38 PP 28-40 PP 41 53 CHAPTER IV PATHOLOGICAL AND EXPERIMENTAL STUDIES IN INTUSSUSCEPTIO Reported observations pp 41 42 experimental technique pp 42 43 44 45 46 bacteriological studies Pp 47 48 49 histologic studies pp 48 49 50 51 52 pp 54 117 CHAPTER V TREATMENT OF INTUSSUSCEPTION A Operative pp 54 to 66 Simple reduction pp 54 59 resection methods pp 56 to 62 operative results pp 62 to 66 postoperatne therapy p 66 B non-operative pp 66 tol17 Development of the method PP 66 67 68 tech nique pp 69 to 79 criteria of reduction Pp 80 81 82 83 84 85 Results Pp 89 to 117 Johns Hopkins series Pp 85 113 recurrence pp 85 86 confirmatory operation p 87 operative completion of reduction pp 100-109 subsequent mechanical intestinal obstruction p 107 enema reduction at operation pp 110 111 indications p 111 collected results pp 112 113 114 objections pp 115 116 Y

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·INTUSSUSCEPTION IN INFANTS AND CHILDREN

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·Chapter 1 MATTERS OF HISTORICAL INTEREST CONCERNING INTUSSUSCEPTION Accustomed as we are to considering intus Soranus of Ephesus by way of the translation into susception as a common disease of infancy with Latin of Caelius Aurelianus Here there is a very an easily recognized striking and pathogno long section on Acute Intestinal Obstruction monic clinical picture it comes as something of which the Greeks call Ileus He states that the a surprise to realize that intussusception has been various terms for intestinal obstruction were known and recognized probably no more than given because the patient has a feeling that the three hundred years Otto Leichtenstern who folds of his intestine are tied up and twisted or wrote extensively on intussusception in the because the pneuma is blocked and shut off the 1870 s is authority for the statement that J C resulting involution of the flow producing Peyer in 1677 first clearly recorded the clinical cramps and twisting pains or else because the differentiation between volvulus and intussus violent pains over the parts affected cause the ception Barbette a few years earlier clearly patient to be bent over twisted and doubled described intestinal invagination up He goes on to discuss other designations Discussions of the historical aspects of intussus and their etiology with their origin and meaning ception regularly state with confidence that Hip such as fence obstruction etc nowhere is there pocrates advised the use of enemata and the a suggestion of invagination or insolution The bellows injection of air for intussusception and symptoms described are the symptoms of mechan that Prixagoras of Cos even advised operation ical intestinal obstruction but any mention of 1 for the same disease A close reading of the perti bloody discharge from the rectum is conspicu nent sections of Hippocrates which are to be ously absent and there is no mention of any spe found in the Littré translation show that he was cific type of ileus peculiar to children or infants talking simply of ileus and that there is no sug In the Eighteenth Century Intussusception gestion or indication that he was speaking of was well recognized and John Hunter s paper in intlissusception or knew it as a specific form of 1789 described the specimen from a fatal intus ileus He did it is quite true talk of the use of susception in a nine month old child He reid his enemas for ileus although they seemed to be oil paper before a small group that met monthly at injection enemas and not enemas of large vol Slaughter s Coffee House in St Martins lanc ume He did specifically state that if these failed and called themselves A Society for the Improve 1 bellosis should be connected to the anus and ment of Vedical and Chirurgical knowledge the bon el inflated with air The only informa This was a select society of twelve members tion we live on Praxigoris is that which has selected from the staff of St Bartholomeus St come down to us from the lost Greek writings of Georges Cuy s and St Thomass Hunter s ana ·1\TUSSUSCEPTIOII\rs ID CIUILDRE ical olsen ons were accuntc but his ther would appear that most physicians did not carefic suggestions lerle something to be desired fully and consciously employ these in 1) offəsi in erything the cun increase the action of the reluce the intussusception by hydrostatic pres sunes downwards is to be particularly sure It is equally obvious that ouliers did 1cm)p> ded I should therefore advise gims tornits just tinut knowingly Air 175 also frequently in 1a 121 10 211 ert the peristaltic motion of the jected into the rectum cither is a bellous or gas uin ng gut whai wit ase a tendency 10 from a generator of one kind or another The 1g the intestines into their naturi situation tise of 1 kind to repose the intestines then n Periough intissusceprion 15 well known in seandard practice as it had been for some content Fighicenth Century it 15 astonishing that ? en of a consulerable number of rexibooks of respost 175 as ineffectie as it might be expected to be Vorc ittention seems to hre been parse ery and textbxols of the diseases of children to the construction of the 11 771) and the chancier » unul she second frif of the seteenih itur almost no menuon of intussusception of its tip in to the hopelessness of its tised common preference in the Vineteenth Century tusstisccption in the mid Nineteenth Cen * 75 recognized as a nearly unisersilly fatal seemed to be a wholelone {xugle with a soft 75 1 exchansern pointed out that the mot Cas cring ly in repxirici casCS 11 75 88% in the first six The following letter to the chior of the lan nihis of liſc 89% in the next six months of life cel xhuchipperred in the issue of Varch 18th 7%, from two to ten verts 1838 ander the mile Indussusception in Chi xerase thicrop 175 nrels undertalen dren gnes some ader of the therapeutic argu sters of various types were employed but it ments at the time Sur The subject of intussusceptron haring latels been discussed nt the inn pun mpal medical socielies in I ondon and nothing neu har ing been clocated on these discussions 1 tahe the liberty of suggesting to the profession through the medium of Tour ialuable penodral the inal of inflating the bou els in means of a Cister ppe attached to common pair of bellous It has fallen to my Int to ustness sacral of these distressing cases in children The nature of the obstruction uns foretold during life and unfortunately renfred in postmortem examination The last case of the fund u huch came under my care about tuo genss since presented all the wmal smpinms intolerable restlessness the most obstinate sickness the singularly distressed state of countenance and shrunken features the usual reme dies ar had recourse in it unim boilis giysters anodyne frictions as the abdo men er but without at all is a forlorn hope I made trial of Inflation in the abore means uitha most kapta result the sickness immediately ceased the child <!!hen an hour passed a natural stool fell into a sleep and in shr morning wat almost u thout ailment I am Sır your constant reader and obedirnt sengte Samuel Tuchell Surgeon Angston on Thames Irfruary 26 1e3e ·INTUSSUSCEPTION IN INFANTS AND CHILDREN 5 A quotation from J Lenis Smith s A Treatise course the sooner it is out the better the chance on the Diseases of Infancy and Childhood will of success give a picture of the disease in 1872 just before The employment of quicksilver by the rec the reports of Hutchinson and Hirschsprung tum with the thighs elevated has been suggested Prognosis- Intussusception is in its nature so to me as a dernier resort grare in accident that the physician called to a As for operation I apprehend that there are cise should altı ays expect to predict a fatal result fess surgeons at the present day who would per Cathartic remedies act as a vis a tergo and may form or recommend this mode of treatment in a child cluse 1 still further descent of the inverted intes In the first edition of the famous Text On tine Quicksilver was similarly condemned He then Tient on to state The proper treatment the Diseases of Infancy and Childhood by L consists in attempts to reduce the peristalsis by Emmett Holt the treatment of intussusception pressure from below and is applied either by which is advised is insufflation with the bel liquid inject ons into the rectum or which is lons and simultaneous manipulation through for more preferable inflation of the lower intes the abdomen If one preferred it was accept tine by air or gas If reduction is not effected able to employ an enema holding the reservoir after sufficient trial the indication is to maintain four to five feet above the patient and raising the strength of the patient and give palliative it if necessary to six to eight feet operation to remedies in the hope that recovery may take be performed if these failed In 225 collected place through the process of sloughing and adhe cases in children with the use of air or fluid sive inflammation Holt pointed out there had been only one rup An apparatus for the production and injec ture of the intestine tion of carbonic acid gas has been invented by Nicholas Senn the brilliant and many fac Schultz and Warner of this city (Nen York) and etted surgeon of Chicago who had studied intus is manufactured by them It consists essentially susception experimentally felt that gas was of two glass chambers one over the other in the infinitely preferable to fluid His are the first lower one a bicarbonate is placed and in the upper an acid in a liquid state By the gradual employed hydrogen gas either manufactured experiments evaluating pressure reducuion He admixture of the tho carbonic acid is set free elsewhere or manufactured on the spot in a gen An elastic tube conveys the gis from the lower erator with zinc chips and sulphuric acid and chamber This apparatus has been used by phy sicians of this city for the reduction of intussus stored in a large rubber balloon ception and other purposes and is a useful in ments in which intussusceptions were produced in animals and the animals then operated upon 36 hours later he states the bowel at the point The same firm and several others in this city prepare for the shops quart bottles of fughly of operation was very vascular and the neck of charged carbonic acid water from which hen the intussuscipiens covered with plastic exuda tion inverted a powerful current of carbonic acid gas The sutures (previously inserted to pre can be obtained Two or three of these bottles vent spontaneous reduction) were removed and with a portion of the tube from Davidsons syr the rectum distended with purpose of inge which can be readily attached to the stem effecting reduction As soon as the colon had from which the gas escapes constitute all that is become thoroughly distended the adhesions required for an ordinary case which had formed gave way with an audible Whether air or carbonic acid is employed st noise and complete reduction followed in such a is necessary to produce distention of the intestine manner that the point last invaginated was first to its fullest extent belons the seat of the com released As the force necessary to rupture the plaint without endangering rupture and of adhesions and reduce the bonsel produced no In experi vention gas for the ·I\TUSSUSCEPTIO\\I\IAUTS I\D CHILDRE outcome iry of any kind to the intestine below or 10 cd in Hululand s Journal February 1825 Thuis sell of ini ngmation this experiment would was a man of 28 Fuchsis not only operateri d to prove that insufflation can be prac successfully but opened the bowel to aid in the i successfully in cases of ini gination of ses resection and sutured it so skilfully thirt no days duration The pressure upon the rub fecrl fistula deseloped Orlloon should be uninterrupted and almost The first certain laparotomy for intussuscep c\cced to pounds to the squarc inch tran in a chuld 17s by Gerson and is reported nginition is cffccted by inflation by to by Ilachmann of llumburg in 1810 This 75 inct forces In the first place the steady a 12 cel oli infunt gooul poruon of the Il pressure of the gas distends the boucl intussusception was reduced before gangrenous use the sheath and the returning cylinder bowel suddenly delivered and tort with a ful ich makes traction upon the nech of the intus pions wlule thic column of g7s by its pres The next recorded oper?uon for intussuiscepiganst the per of the intussusccptum tion #75 Successful, and 17s the first one in the 15 1 direct reduction force United States It was in operation perforinca Recliction 475 resisted after 1 time cither by Doctor John R. Wilson of Tennessee und the suollen odernous intussuscepium or by 175 reported by his papil Vir W T Thomplesions of the neck of the intussuscipiens or son to the Transylı ama Journal of Medicine and seen the scrous surfaces throughout the in the associated Sciences, 183 Volume 18 page cd portion of the bonel From these 362 The paper is titled A Case of Imirosuss ariations 1 live come to the conclusion that ception in sluch an Operation w7s Successfully 11on by gentle but efficient distention of Resorted to by Jolin RW Wilson VD of bowel below the invigination would suc Rutherford County Tennessee in December in the majority of cases of thus procedure 1831 The patient was 7 negro sic who lze practiced before cither of the two princi failed to respond to the customary treatment of conditions which cause irreducibility have actic purgition and metallic metcury by time to make their appearance mouth The reduction was casily afectai this time honcsc thc feasibility of ор operation and the nuthor concluded his recor Hon upon mfants with intussusccption hind cry was ripid u entire Tlc success of established this case in such the operation 176 so long 1 Barbeite 1 surycon of Imsterdım ist deferred and at last perforined under such in the middle of the Seventeenth Century infzvorbic circunstances wruns the pro Sestcal that rither thin illou patients with priety of resorting to it in the disease mi intussusception 10 dic it inight be prefer proses that relics may oxcasionally be aſſorded lc to cut through the abdominal muscles and by this means stien all others live failed? 11 the imaginel mostines spart with the Wilson s grandson O1 111sou l'rofessor nois Vues cose 175 reported by liller in I incrittis of l'altatrics : Sandebuit lnuscrsity I hic purient 175 1 womm of 50 who School of Medicinc reports the finding of Dox uscrol for Jolin R Wilson s day bowl with an entry for Ihre verond oneni soun ohne buen oper lovember 201831- $300 for operation of I un for Intussusceprion was an adult of Custrotomy on Chis Dements \ lsoy with mpcrata ujx111 bis l'rofessor Ohle of Dros 1 sm ord of scicral subsequent visits 110C 1 and 10px»tri) in 1917 bus I Ficcller cijough memorandum of an historic Oxrition fus fuftent dial I herc uete 3 (mis other reptieel cases of ne tud rise and thic stond sitt rossful one op*rron fot intusstixeptions in adults and in that oprolol ning tussitis zo 10pmt iníuns Jo, them unsuccessful of tations in ·INTUSSUSCEPTIOV IN INFANTS AND CHILDREN 7 England by Spencer Wells the renowned died of the consequences of intestinal obstruc ovariectomist one of the founders of Gynecol tion In such cases the tight adhesion of the ogy and in Russia by Pirogoff the great mili intussusceptum and the intussuscipiens at the tary surgeon On November 11 1873 Jona nech of the intussusception maintained the con than Hutchinson read before the Royal Medical tinuity of the bowel although there frequently and Chirurgical Society his first paper on Intus resulted as a secondary manifestation either susception reporting a successful operation per chronic intestinal obstruction from cicatricial formed in 1871 on a two year old infant stenosis or secondary perforation through the referred to him by Warren Tay He stated, poorly healed area with peritonitis and death Our first measure of treatment consisted in This is best described by Leichtenstern- Nu putting the child under chloroform and then merous trustworthy observations shou that sep whilst she was held up by the feet distending aration of the intussusceptum may lead to com the rectum to the utmost with warm water plete cure of the invagination But this mode By this means the involuted part could be of termination has many changes which threaten forced up into the abdomen so as to be quite life The separation may tale place too early out of reach of the finger and once or twice I before there is solid union at the neck of the tried to hope the reduction had been effected invagination Perforation or rather rupture On each occasion however when the lower is the result or a part of the intussusceptum bowel was allowed to empty itself the intussus remains and causes a nen insagination by in cepted part became prolapsed as before and crease of what is left in the old one In other showed clearly that we had gained nothing cases constriction of the intestine takes place at It was very evident from the child s condi the inactive line of separation increases more tion that unless relief were afforded she would and more and often causes death after some not live long and I therefore felt justified in years Finally torpıd ulcers of the mucus mem telling the parents that although an operation brane may remain at the place of separation and would become in itself very dangerous yet I cause perforation long afterwards or defective felt that it afforded the only chance nutrition as a result of diarrhoea Among the He made a lower midline incision withdress rarer illustrations we find death by septicemia the six inch long intussuscepted mass reduced -thromboses-metastatic abscesses in the liverthe intussusception without any difficulty and perforation and formation of a fecal cloaca replaced the bouel The operation had been It is one of the ironies of medical progress an extremely simple one and had not occupied that just at the time that Hutchinson was dem more than two to three minutes onstrating the feasibility of operative reduction From this time on although it is obvious intus of intussusception in infants Hirschsprung of susception was still an extremely grase disease Copenhagen discouraged by the high mortalıy and carrying in spite of all a high mortality of intussusception instituted a plan of con 1t was considered a disease in which the out trolled hydrostatic pressure reduction of intus come could be materially affected for the better susception by proper treatment Theretofore recovery fol Hirschsprung s first report was in 1876 By lowing rectal injection had been irregular and 190Hirschsprung was able to report on 107 uncertain and operation had rarely been at personal cases of intussusception His results tempted Such survivals as did occur were were so superior to those previously reported due in the main either to spontaneous reduc that his contemporaries doubred his conclusions tion of the intussusception or to gangrene of the He was forced in self defense to publish a intussusceptum and passage of the sloughed paper reporting each of his 107 cases intussusceptum by rectum before the child had sented a 15% mortality in a disease sluch up He pre ·IT SSL SCEP110\I\I\F\TS AD CHILDRE njun of any kind to the intestine belon or at ed in Iluſeland s Journal Februar) 1825 Thuis lie scat of invagination this experiment would was a man of 28 Fuchsius not only operatel end to prove that insufflation can be prac successfully but opened the bowel to aid in the cal successfully in cases of invagination of ses resection and sutured it so skilfully that no rral days duration The pressure upon the rub fecal fistula developed ber balloon should be uninterrupted and almost The first certain laparotomy for intussusccpnever ciceed 10 pounds to the square inch con in child was by Gerson and 1428 reporter! Disiniagination is effected by inflation by to by Hichmann of Hamburg in 1810 This W75 distinct forces In the first place the steady 1 1? leek old infant good poruon of the elastic pressure of the gas distends the bowel intussusccption was recluced before Singrenous between the sheath and the returning cylinder Lonel suddenly delivered and tore with a fatal which makes traction upon the nech of the intus outconc suscipiens rule the column of gas by its pres The next recorded operation for iniussuscepsure unst the ape of the intussusceptum tion was successful and was the first one in tlic 100s as a direct reluction force United States It was an operation performal Reduction was resisted after a time either by Doctor John R. Wilson of Tennessee and bs the swollen elemrtous intussusceptum or by 175 reported by his pupil Vr WW Thomp adhesions of the nech of the intussuscipiens or son to the Transylı ana Journal of Medicine and betucen the scrous surfaces throughout the in the Associated Sciences 183, Volume 18 page saginuce portion of the boucl From these 362 The paper is tuled A Case of Introstiss observanons I have come to the conclusion that ception in which in Operation was Successfully reum tion by gentle but efficient distention of Resorted to by John RW Wilson V D of the lonel bclou the invagination would suic Rutherford County Tennessee in Decernber ccel in the majority of cases of this procedure 1831 The patient 1175 n negro sluc nho lind MCC prcticed before cither of the two princi failed to respond to the customary treatment of pal conditions such cause irreducibility fire active purgauon and metallic mercury by Ind time to inrlc thcir appearance mouth The reduction was castly efficiod 10 Bi thus time however the feasibility of op operation and the author concluded lous recos cration upon mfants with mtussusception had cry 1125 rapid and entire The success of been established thus case in which the operanon 175 so long Prul Barbouc 7 sturgeon of Imsterdum utit deferred and at last performed under such ing in the muddle of the Seventeenth Century unfavorable circumstances 1rints the pro- Sukhotel the nther than allou patients with priety of resorting to it in thc disease and in intussusccption to dic it might be prefer proves that relief may ocasionally be afforded able to cure through thic axlominal muscles and by tlus nicans when all others liric failed pull tlıc inviginnad intestines 7235t with the Il'ilson s grindson O !! Wilson P'rolessor fingers \uchs case was reported by Taller in Emeritus of Pediatrics at Sanderbilt University 1751 Ile patient was a woman of 50 who School of Vedicinc reports the finding of Dex Italiaal tor John R Wilson s day book with an entry for The second patient inonn to have been oper November 20 1831- $300 for opcrtion of ated upon lor intussuscption was an adult of Custrotomy on Clas Dements loy til 51 axratal un b Irofesor Ohle of Dres 1 record of ses cral subsequent visits 1 laconic dent and reportel in 1917 h I Fiedler enough memorandum of an luustoric operation This puisent dial TheTC ucre a few other toprontal cases of This thuir case in the con successful one operations for musstisccptions in adults and in was that ofiniai ten bs Fuchsius und report infants among them tisuccessful oxitions in ·INTUSSUSCEPTION IN INFANTS AND CHILDREN 7 - England by Spencer Wells the renowned died of the consequences of intestinal obstruc ovariectomist one of the founders of Gynecol tion In such cases the tight adhesion of the ogy and in Russia by Pirogoff the great mili intussusceptum and the intussuscipiens at the tary surgeon On November 11 1873 Jona nech of the intussusception maintained the con than Hutchinson read before the Royal Medical tinuity of the bowel although there frequently and Chirurgical Society his first paper on Intus resulted as a secondary manifestation either susception reporting a successful operation per chronic intestinal obstruction from cicatricial formed in 1871 on a two year old infant stenosis or secondary perforation through the referred to him by Warren Tay He stated poorly healed area with peritonitis and death Our first measure of treatment consisted in This is best described by Leichtenstern- Nu putting the child under chloroform and then merous trustworthy observations show that sep whilst she was held up by the feet distending aration of the intussusceptum may lead to com the rectum to the utmost with warm water plete cure of the invagination But this mode By this means the involuted part could be of termination has many changes which threrten forced up into the abdomen so as to be quite life The separation may take place too early out of reach of the finger and once or twice I before there is solid union at the neck of the tried to hope the reduction had been effected invagination Perforation or rather rupture On each occasion however when the lower is the result or a part of the intussusceptum bowel was allowed to empty itself the intussus remains and causes a new invagination by in cepted part became prolapsed as before and crease of what is left in the old one In other showed clearly that we had gained nothing rases constriction of the intestine takes place at It was very evident from the child s condı the inactive line of separation increases more tion that unless relief were afforded she would and more and often causes death after some not live long and I therefore felt justified in years Finally torpid ulcers of the mucus mem telling the parents that although an operation brane may remain at the place of separation and would become in itself very dangerous yet I cause perforation long afterwards or defective felt that it afforded the only chance nutrition as a result of diarrhoer Among the He made a loner midline incision withdrew rarer illustrations we find death by septiccini the six inch long intussuscepted mass reduced -thromboses--metastatic abscesses in the liverthe intussusception without any difficulty and perforation and formation of a fecal cloaca replaced the bowel The operation had been It is one of the ironies of medical progress an extremely simple one and had not occupied that just at the time that Hutchinson was dem more than two to three minutes onstrating the feasıbility of operative reduction From this time on although it is obvious intusof intussusception in infants Hirschsprung of susception was still an extremely grave disease Copenhagen discouraged by the high mortality and carrying in spite of all a lugh mortality of intussusception instituted a plan of con it was considered a disease in which the out trolled hydrostatic pressure reduction of intuis come could be materially affected for the better susception by proper treatment Theretofore recovery fol Hirschsprungs first report was in 1876 By lowing rectal injection had been irregular and 1903 Hirschsprung was able to report on 107 uncertain and operation had rarely been at personal cases of intussusccption His results tempted Such Strurials as did occur were so superior to those previously reported due in the main either to spontaneous reduc that his contemporarios doubted hiss conclusions tron of the intussusception or to gangrene of the He was forced in self defense to publisha ? intussusceptum and passage of the sloughed paper reporting cach of his 107 cises intussusceptum by rectum before the child had sented a 15% mortality in a discase winch up Tere lle pre ·INTUSSUSCEPTIO IN II\TS IN CITILDREN 1 big (a) There must of course anis a certain number sery castly felt in the midline just anc the simt nicus of cases in which the carlı diagnosis is difficult for such 7 he diagnosis was of course simple but I had a bumuth casos I beliese that the ray with buismuth injecuons may Injection guen in hopes of causing pintual reduction and Lyc ich useful During the last fci months I have thus facilitating the operation This end was n acco emploved this methout three times inice to see if I could pushed the pounon of the tumor remained unchanged facilitate the operation by causing pirual reduction with but the plate houssery clearls how useful that perx cilure encia and once for diagnostic purposes Plate I was taken Inight be in a case where the diagnous was difficult Vors of an infant six months old who was brought on the hos the ceruit ble shape of the advancing part of the inium pital almut I hours after the onset of symptoms. Thiese sixoption and hon dutinctly this is shown in x wittun Consisted of intermittent attacks of alxlominal pain fo! thelminets the I smuth clinging to the wall of the intim lowed by tumiting and blxxl stools, with sen histle feces. suxspiens cutending back once it ( WL Lapo Anton Ile alxlomon was not distendel and the mass coul I le fed + lurg 1913) ·INTUSSUSCEPTION IN INI ANTS AND CHILDREN 9 Aus der chirurgischen Universitatsklınık Rostock Ein Fall von Invaginatio ileocoecalıs im Rontgenbilde Von Dr C Lehmann in Rostock Im folgenden will ich hurz uber eine Beobachtung von Invagination in Rontgenbilde berichten, die wir im November 1911, unmittelbar nach der Veroffentlichung von Haenisch über seine Methode des Wismutenlaufs auf dem Trochoskop (Munch med Wochenschir 45,1911) machten Leider ist die Platte verunglucht, so daß ich den Befund nur in einer Slizze wieder geben kann Mir sind bisher entsprechende Falle aus der Literatur nicht bekannt geworden, nach mundlicher Mitteilung hat Hzenisch selbst einen ahnlichen gesehen Es handelt sich um einen 18 jalırigen Jung ling, der seit drei Wochen an holikartıgen Schmer zen litt, Stubl war abwechselnd angehalten und durchfällig und enthielt haufig Blut Bei der Aufnahme am 18 November 1911 fand sich ein wurstformiger Tumor im Epigastrium der der Palpation nach dem Querkolon angehorte Die Differentialdagnose lautete auf Tumor oder Invagination, resp beides Bei der Röntgenuntersuchung, die genau nach den Vorschriften von Haenisch ausgefuhrt wurde, fullte sich rasch das Rektum, die Flexur und das Deszendens man sah die Wismutsaule die zunachst noch keine Haustrenzeichnung zeigte an der Flexur umbiegen und ins Querkolon fort schreiten nach einer kurzen Streche machte sie halt, und das gefüllte Ende des Querkolons blahte sich machtig auf Es fiel uns auf, daß die WVus mutsäule an der Stelle wo sie das Hindernis fand, vollständig glatt abgeschnitten erschien und sich nicht etwa zapfenformig cuspitzte, wie man das wohl bei einem stenosierenden harzinom hatte erwarten kunnen Es wurde nunmehr eine Aufnahme gemacht, die bei benaver Betrachtung noch etwas mehr zeigte, als das Schirmbild (vgl Shizze), auch hier war die Wismutsäule plötzlich scharf abgebrochen ubrigens war inzwischen die Haustrenzeichnung bervorgetreten -, von den wulersten Echen der Unterbrechungslinie aber setzten sich sei sclimale 05--1 cm breste 01 hitta Getod Regenet shleo 71 XXI Fig 1 (b) lehmann s report in 1914 of the use of bismuth encmus in ligno ing intussusception He described the radiologic picture cleats apologuing for the fact that the plate was poor and the sketch had to be substituted for it in publication The observation had been made three cars carlier in 1911 The patient was an 18 year old boy sith a three heck history and a palpable tumor Lch mann was apparently satisfied 10 1121e made the diagno. 375. There is no mention of a therapyutic effort with the enena The intussuseprion was successfully reduced at operation ·INTUSSUSCEPTIONIS INFANTS IAD CHILDREN to the time 175 fatal in over 80% of the casts vnys and this was reported simultancously bus In 81 patients treated by Hirschsprung with Pouliquen in France Olsson und Pillin in Scin cnem? zlonc, the mortality *75 23% These fig dins11 ind by Retun und by Stephens ? tl's tires compare favorbly with those from The count Johns Hoplins Hospurl m the period from 1929 The first successful resection of an intussus to 1938 more than 35 years later Interest in ception in a child was the reported by Clubbe the hydrostatic pressure reduction of intussus of lustralia, in 1897 che scuond ly Collinsori (cprion bas been muntiincd in Scandinuicer of London ten years later since with from time to time, ruempis ta rdd The first successful resection of u missus transabdominal manipulation to it In plus ception in this country was reported by Peter inlin, Irrgely due to the influence of Hipsley son in 1908 Actually in the 21 jers between f1ydrost 1410 pressure has been used anth spectac 1896 and 1920 Clubbe could find only 15 rc ulur results ported instances of successful resection of intus The use of the 12y in the diagnosis of intis susception in infants and it con cll be assumed susception is first suggested by Ladd in 1913 that i cry fest successes kad escaped report One and by Lehman in 1911 Ladd sited- There of the brilliant cirly successes 135 that ol must of course wise a certain number of cises in Doud ulo in 1912 reported resection of icrans which the cirly diagnosis is difficult for such nal leum and right colon in r fne dry old cases I bchce that the my uit bismuth baby injections may be ету useful During the As it has 1 hrbit of doing in such maters last feu months 1 Arte employed this method time las affected the permitency of most of thic three times tuace to see if I could facilitate the prguments for or against primary operate or (parition by cousing pirul reduction nith cne primary hydrostatic pressure reduction The esa mr ind once for dignostic purposes (Fig dence is Ouershelming 112 from 1877 to 1915 11) Ladd 17s cominced that this was a good the results in clinics employsig bsydrose{IC dsagnosesc device and 1 useless thenspeuesc one pressure reduction were substantially superior Tinis as despite the fact that the improved to those obtained in the closes employing Oper Ikortadsty winch le reported in thus piper from file reduction primarily This was mily the Chuldren s Hospital in Boston * is still 15% incasured in terms of operatine montilly ---Puglier this Hirschsprungs series seported the last decade, in the clima nih ihe greuir's in the previous decade Ladd himself ascribed mterest m surgical diseases of chukiren leiths prsoru; of she use of the Roentgenogrim in from intussusccption have been limited essery the clignosis of intussusccption to Ichman al tually 10 those children hopelessly morn at flow, ladds publication appeared carlier the ame of admission respecuyc of whiculier Ichun dor's sun that he was reporung in treatment 35 by opxration or buy Indon110 obsen ntion made three years carlier when bis The TriSST" 536 not muth ch.75 were first described by Hienisch bisci 011 subrics criter!? which are liv usses! 533 Ictiman XIIKIzes for the fact that huis place detail in z laser chrapies nas su poor kr 1 sheath (Fig 10) had no se BinitOCRAMIS substituted for it in this publication The se sule kokerer is 127 Dr Ladis Jeport contains Ishluss folur Jr On lapuotomy or aludossa) sertion as times for nursinception *st thic first published photograph of the roentgen trlley slynas shc results of the operation in ologic pictures of intussusception (2901 ni słus allerson and in those of otlint (1y883 The use of the consist them to provide us of 200ft olasuctkant of the innels u1l conrol of hydrostitu pressure raluce:OR $35 1c 186 1871 Turchanty Caes. Om deute was onstant a natural consequence of the 17}{rxduction of pressure rcduction ·INTUSSUSCEP CION IN INFANTS AND CHILDREN Chromic Diseases Ed and Tr by I E Drabkın Lehmann C Ein fall von invaginatio ileocaecalis Chicago Uni Chicago Press 1950 in rontgenbilde Fortschr Geb Röntgenstrahlen Barbette Paul Thesaurus Chirurgicae 3rd Ed 21 36l 1914 London Moses Pitt 1676 p 324 Leichtenstern O Intussusception invagination Clubbe CPB The Diagnosis and Treatment of und darmeinschuebung Ziemssens Cyclopaedia Intussusception 2nd Ed Edinburgh 1907 Lon of the Practice of Medicine 7 610 624 1877 don 1921 Mitchell Samuel Intussusception in children Dond CN Resection of one third of the colon Lancet 1901 1837 1838 for irreducible intussusception in an infant five Nuck Anton See Albertus Haller s Disputationes days old Ann Surg 57 713 717 1913 anatomicae selectae Gott 7 126 1791 Fagge CH and House H G A case of intussus Olsson G and Pallın G Uber das bild der akuten ception in an adult without symptoms of strangu lation treated successfully by abdominal section darminvagination bei roentgenuntersuchung und Med Chir Tr condon Ser 41 89 98 1876 uber disinvagination mit Hilfe von hontrastlave ments Acta chur scandinav 61 371 383 1927 Fiedler F A Magazin für die gesammte Heilkunde 2 253 1817 Pouliquen Met De La Marnierre Indication du Fuchsius C lleus mit Unuber windlicher Verstoplavement bismuthe dans certaines formes d invag fun, als Folge einer Einschiebung der gedarme inations intestinales Bull el mem Soc Mat de durch operation geheilt Hufelands Journal der Clair 5, 1016 1021 1927 practischen Heilkunde 60 42 64 1825 Power D Arcy The Hunterian lectures on the Hachmann A case of intussusception Ztchr Ges pathology and surgery of intussusception (Ib Med 14 289 303 1810 stract) Brit M J 1 381 453 514 1897 Hipsley P L Intussusception and its treatment by Power D Arcy Some points in the minute anatomy hydrostatic pressure Based on an analysis of 100 of intussusception J Path Bact 4 181 1897 consecutive cases so treated M1 ) Australia 2 Ravitch Varh M. Jonathan Hutchinson and intus 201 206 1926 susception Bull Host Med 25 342 353 1951 Hirschsprung H It Tilfaelde af Subakut Tarmin Retan GM vagination Hosp Tid 3 321 327 1876 Mon-operative treatment of intussus Hirschsprung H 107 Falle von Darminsagination ception Am J Dis Child 33 765 770 1927 bei hindern Behandelt in honigen Louisen hın Senn Intestinal Surgery Chicago 1 1 derhospital in hopenhagen wahrend der Jahre heener Co 1893 1871 1901 Alett Grenzgeb Med Cher 14 595 Smith J Lewis Treatise on the Diseases of In 574 1905 fancy and Childhood Philadelphia Lea 1872 Holt L Emmett The Diseases of Infancy and Stephens V R Ileocecal intussusception in infants Childhood Nes Tork Appleton 1897 11th special reference to fluoroscopic findings Hunter John On introsusception Tr Soc Im Surg Gynec é Oust 45 698 700 1927 prore A Chur knoul 1 103 118 London 1793 Stephens VR Acute intussusception manipula Hutchinson Jonathan A successful case of abdom the reduction under fluoroscopic control Am 1 Dis Child 35 61 61 1928 inal section for intussusception Proc Roy Af Chir Soc 7 197 198 London 1873 Thompson 11 11 A case of introsusception in Hutchinson Jonathan Notes of a second case of which an operation was successfully resorted to by abdominal section for intussusception into the Jolin R 1 Wilson VD of Rutherford County colon with remarks on the decails of the opera Tennessee in December 1831 Translania tion Med Chir Tr Roy M Chir Soc 2nd Ved S486 895 Ser 41 99 102 1876 Trees F Intestinal Obstruction London Castle Ladd 1 E Progress in the diagnosis and treat & Co 1901 ment of intussusception Boston Af &SI 169 Wilson O H Intussusception in 1831 / Tennes 512 514 1913 sce Ad +2 53 51 1919 ·Chapter II THC CLINICAL PICTURE or INTUSSUSCEPTION TIF IXIL SSL SCFI TION The inscles of the bou el u all are stron And by their strength the force the food along In rhithmicumcs contracts ns come and go Saking the intestmal contents flou of through an kod of morbid state 4 bit of bou el u all inunginale The muscle u all mas force it on and on Until far dou n the lumen it has gone The gur belou dilates for its reception In 1 thus sou get u hat s called intussusception Behold a year old boun lal, boy Ilis father sinde his mothers constant, » In restful sleep-quite health ilu ould seems II hen suddenly he u akes up with a scream Ilus pink face pales his pufils may dilate Ile drous his legs up for the pain is great But in a uhile the spasm seems to crase And once again he may have sleep in peace I et not for long for soon he u akes amain The pain and screams recur and he may strain Ind pass some blo d stained mucus on his natin This renders I oth his parents most unhain Ind so they call the doctor to their an! Of something seni rus tha aic, ou afrai! The frocess starts from undue stimulation I duced/) so ne slight cause of irritation Isollen imers fraich a small loponn 1 Weckels processer af pilloma U just a rece of solid food sn gul II here nicore such fod had ne crteen fut This stalci sent to the striking fact gutes meanin - si intussustations ro re at tune of u cant in MRF STAL MK INTUSSUSCEPTUM 12 ·INTUSSUSCEPTIOV IN INFANTS AND CHILDREN 13 The doctor uith his gentle nice te arm hands The colon as 1ou knou a common site is Palpates the belly as the case demands For inflammation-here knou n as colitis The R.I.F feels empty (Signe de Dance) Is hich may from time to time cause doubt I fear But higher up his search recals perchance For blood and mucus may in stools appear A su elling rather sausage like which oft But usually the pain s not so sez ere Gets sometimes harder sometimes lax and soft And since the motions uill shou faecal stuff It may be felt in epigastrium These points distincire should be quite enough Or one or other hypochondrium (Though colo i inflammation oft may render Or sometimes it may zery slou ly slide The whole course of the colon to be tender ) Lou dou n fou ards the pelvis on left side Then may a finger in the recium put Not long ago the doctor a hen in doubt Feel the soft at ex of adtancing gut Tould grze an anaesthetic to find out And on the uithdrau n finger u all be found If there uere any tumour on palpation- Some blood and mucus smeared all around If so then that u as clearl confirmation But in these days there is a better u ay Sometimes the doctor urll be horrified li hich may the need for anaesthetic stay To see a fleshy mess protrude outside For if an enema of barium And then the long soft su ellung may perhaps Be flou ed into the bou el per anum Be easily mistaken for prolapse And then obsen ed minulely by x rays But if you put your finger in the rectum 4s it ascends the colon surding uans It goes tunt u all and intussusceplum One then can see if there s ini agination But not uith prolapse-for there is a seplum And not depend upon imagination This means a radi logist Should often be consulted to assist From 7ETA The Acute Abdomen in rhyme The he classical case of intussusception occurs Reproduced with permission of the publishers HK Lenis & Co Ltd in the well nourished male child eight months old who is awakened from sleep with what ap pears to be violent abdominal pain flexes his NCIDENCE thighs cries out vomits and passes a normal Intussusception seems to be appreciably more stool Thereafter he vomits repeatedly has common in some parts of the world thin in oth obvious bouts of recurrent peristaltic pain and ers At the Johns Hopkins Hospital where at begins to pass bloody mucus per rectum Be the Harriet Lane Home there is an extremely fore long he becomes apathetic pale and soon active Outpatient Department and where we presents evidence of dehydration The intesti have long had a special interest in intussusccp nal obstruction which has existed from the first tion we see no more than six to eight cases a moment does not become manifest for many year It does not appear that other clinics in hours The condition is fatal in three to five this country see appreciably more At the Den days if not interrupted The intrissusception ver Children s Hospital (Pachard and Illen) begins at or near the ileo ciccal valve Exami there were 55 cases in ten yeurs lc thc nation of the bonel shows no obvious local Children s Hospital in Los Angeles (Snyder anatomical cause for the intussusception hraus and Chaffın) 143 cases in ten years This is the classical picture and so typical the Charity Hospital in New Orleans (hihic) that the diagnosis may frequently be made over 54 cases in eleven years in Vilkauhec at the the telephone and is commonly made by the Children s Hospital (Thatcher) 60 cases 1917 dispensary nurse on the patients inrl in the 1953 The Children s Hospital in Boston Accident Room or Outpatient Department (Gross) where there is exceptional clinical However the variations of the picture are of experience in all fields of pediatric surgery sau some interest and are of great importance in 258 cases in the thirteen years 1941 in 1917 permitting the diagnosis of the atypical cases not quite twenty per year The Children s llox which are the only ones in whom a fatal issue pital in Cincinnati (I ing) reports 12 cases is at all likely today 1917 19,2 Babies Hospital in \en lori (5ın ·ITUSSUSCEPTION IN FINTS AND CHILDREN tulli and Ferrer), 41 cases 1919 1931 bocii 612 male for Bisiningham (MacWilion) about eight coses per ser The Childrens 68% in London (Perrin and I indsay} (310 Vemorial Ilospeal in Chicago (rou) Ind 00 in Szcuey Australia (Ilipsley) 60cm Los An casts 1915 1956 only ten pas yeur ind the St geles (Snyder et al) The rito oſ cliree 10 tko Lorus Children's Hospital (Thussion Holo scems to be fzerly constant although in our NCHI wch and VcCoy) 116 cases in the seventeen 17 cases 1932 1938 the incidence his licct 29 years 1934 1931 or agam only seven per year miles and 25 feurs presumably a temporary in contrast with thus American experience one statsstical abertation uluck: further e perselitt om of the Royal Hospral for Sick Children in 1l correct No $311sfactory a plantion 1178 Glasgos (Dennison) in the sen years berueen been vltered for this sille preponderake 170 1987 and 1916 admitted 237 cases of intussus Mahon offers 21 interesting malysis of the sex uption-29 to 24 cases per ser From 1946 to ruo ac different iges Below the age of une 1936 Dennison has had the great lotil of 399 months males are only slightly all acess of fl (BCs almost 40 cach yeart Helmers material miles 55 4.6 lter ame inomlis, elle excess is from the University of Luni covers 162 cises very marhed 777% Hic found the difference seen in three yeurs $4 cascs per year Norden un se\ ratio bcineen these 1110 periis ca le 223 coſt of Copenhagen collected 440 cases of szeus plus or minus 56 «luch 176 sigmfscom susccpiron between 1928 25 1935 63 cases per Race War These have appointly been very few precise In our onginal maternal 69 1% nere in whne Children and 369% kore in negro children statistical studies of the incidence of intussus Since the proportion of negra co white classes aprion is the absence of such comparable sta sir sisits 175 60 to 10 11 Subbested that intus (istics one shouk perhaps 1174€ some reserva con " assering that intussusceprion is a good susception is somewhat more common m ube ihan m negro chlann In our new 17 07604 den more common in Britain and a Scandina 17 were white and 30 kgto Tufkommy the »11 than in the limited States Vnexion uns in the Char made a aque study of intussusception in de change in dispensary populutuan ity Ifost 1} on cu Orkans hok ttposts are (ils of Berismgham Lngland using ? blostus 51617) incidence to be propmart1353] so the lucrspas Il approrch In the entire city of Birming sol admission rate hur li found furth sen year zerrel 1915 0 $4 20 (uniormed cases of intussusception Age 183 Cidren under the age of ich jers 71 inch is seen in Figure 3 Intussis (piron (xcurs deste of I 14 px51m00 Inc birihs Spence and largels the first year of life und on that your wurt for the five year peruxi 1911 10 1919 in 111035t commonly in the period from the fifth to lunastican Tyre found 137 OSCS the umuh month Or our coral of FW (750 claske ol 98 per 1000 116 births In both 57' Ketired in Culdren who rere forse 10 I hus i tre fou elle lub Studies In Irener yers of study it 175 for deres fonts of page th1: the number of users lox med 176 trpreis uirt of Vircinhon who found that s Ibisamb nuty dober pxxsilily the result of improsen? 2) Woof the patients set fimler on your DC Nisou repassed from the Royal Ilampussy for wich Children in C1,0 791 17 cases for at inalysis of 152 c7ses at the Jolins llop inder a year of 79€ I fuis lotset trk odesso Lmns Blomual (", of the 191111ssisk opkins wiC is claras iftist af refws<< frauss pussely prexhURIC {}} male children and 14mm female Guldren funpuinks in els micrral the freak of HICS I luglite igreo clensely will alle ligures of denne 1px 37813 10 lx 193 the sesculs se cilities 131 Inics 76ertritt itt ·INTUSSUSCEPTION IN INFANTS AND CHILDREN 15 THE JOHNS HOPKINS HOSPITAL INTUSSUSCEPTION 1893-1958 AGE INCIDENCE RELATED TO MORTALITY 199 CASES ORECOVERED DIED NUMBER OF PATIENTS no deaths since 1946 1 2 3 4 5 6 7 8 9 10 11 12 MONTHS 13 14 15 16 17 18 19 20 21 22 23 24 MONTHS 3 12th YEARS AGES OF PATIENTS IN MONTHS AND YEARS Fig 3 The peak of the incidence is in the fifth to ninth month age period and 59% of the intussusceptions oc curred in children from four to eleven months of age Over 80% of the children were under tho years of age In the days when deaths occurred the mortality was high in the youngest infants atresia gives the months This is somewhat later than the inci The reason for the development of the dence in MacMahon s series which was highest intussusception in the fetus is unknown but in the period through the sixth month Denni the resulting gangrene produces destruction of son found 102 cases under six months of age and the botsel and a fibrosis which appear- 70 cases between six and twelve months of age ance of a congenital failure of formation of a Again a somen hat earlier age incidence by segment of bowel However in the distal segmonths than our own A number of other re ment of bou el in such cases the end of the intus ports Perrin and Lindsay Hipsley show the susceptum can at times be found and the pres peal of incidence at fue or six months ence of Janugal hairs and squamous cells of the Intussusception in the new born infant is of vernix caseosa in the distal segment all indispecial interest Rachelson reviens ed almost six cate that the bowel had at one time ben patent thousand reported cases of intussusception in the Season of Year literature and found that three tenths percent Some writers hue noticed 1 seasonal varia hid occurred in the first month of life In the tion in the incidence of intussusception usually past 150 years 28 cases were reported in the finding the incidence maximal in the si first month of life 18 of them in the first week months and attributing this to the greater frc of life Viost of the babies were mature full quency of gastro enteritis in such seasons As term infines in good vigor The symptoms seen in Figure I in our maternl there appears to were in no tise unustial be a sustained peal from Varch through August Intussusception has been quite clearly shown and another in December through January con to occur in utero and to be a cause of intestinal cenably reflecting the persoxls of enteritis and of ·16 INTUSSUSCEPTIO I\I\I\TS AND CHILDREN SEASONAL VARIATION OF INTUSSUSCEPTION 20 OF CASES 10 Inli... NUMBER MONTHS OF THE YEAR 118 Tere is an apparent sustained peak Parch enteritis and of respiratory infections. through luguse and another in December through Jan Incl Volunc lediał 3. 1920) uir concenabls reflecting the maximal incidence of (From Ravitch upper respiratory infections Is noted the max Birth Rank mrl incidence of intussusception is in the sch We have previously noted that 1 surprising anth and cighth months of life in our material mumber of our patients occupied the higher Ilus seasonal varntion in the incidence of intus birth rinks in their families although on the susception does not merely reflect a correspond comrary Wiley and Achinson and long and ing pxnk in the local birth rate seven to cight Donovan found 1 lugh percentage of patients months previous since the number of ine births who were first born Vallahon studied this in Baltimore from month 10 nionth yer in and tissusception series and 1 comparison sumple ser out viries by no more than plus or minus Isith respect to birth rank and to incrul ngc 1. Bollni, loud Intussuscepuon most com url found no signuficant differences Mon in the summer montlis Close confirms I here is no cuence that there is any in thus finding for younger children but found in creased lilclilood of inttissusception in 1 sils his material that altcr one year of age the condi lin, oncc onc child of the family los lxccus tion is most common in the months of Docun allccted Thuis of course docs not include the byer through March Fitzwilliams found 7 lugh instances of misstisccption occurring 111 the incidence a Virch and December and l'irrin excisional fimul suth inherited multiple pwlyps and I may report peaks of incidence in Ipril in thic sin all iwwel and Jamury but long ud Donoi ut and I hopes Vac Icy found laule or no seasonal variation Nutrition and Previou. liralık Mahon found no cuidance of seasonal variation Intusstisccption tends to sclert sturdy well in fus study of the total incidence of inttissus nourished inlunts The tendency for gewul nu <option in the aty of Birmingham trition is s outstanding that Ilirschsprung ·INTUSSUSCEPTION IN INFANTS AND CHILDREN 17 1 could say-- Ich errinere mich auch nicht jem is associated with the fact that children there als bei einem atrophischen kind eine invagina are more frequently breast fed and that the tion gesehen zu haben Of 119 of our 152 subsequent change from breast milk to cows cases in which notation was made of the state milk plays a part in the occurrence of intussus of nutrition in 98 it was said to be good in ception The possibility that this is a factor or eleven fair and in ten poor illingsn orth and that the change from milk to a more solid diet Dich offer the somewhat hypothetical suggestion alters peristalsis so as to initiate in intussuscep that in vigorous male infants with strong mus tion can be no more than guessed at culature the tone of the bowel muscle is greater than its ability to relax the motor mechanism Previous Attachs, Spontaneous Reduction develops before the inhibitory one and in early It may well be worth emphasizing the fact infancy the parasympathetic nerves are rela that of our first 152 patients ten had lustories tively weak which clearly indicated previous attacks of incus With respect to previous health in 119 out of susception with spontaneous recovery This 189 cases in which the histories were adequate 19 not often commented upon in reports on in it was found that previous health had always tussusception and we were unprepared for this been good In 23 cases diarrhoea had been finding The intervals between previous attacks noted previously in 13 cases constipation had and the intussusception which finally brought been a prominent feature and in ten cases there the patients to the hospital varied from ten had been symptoms of intussusception on previ days to six months OUS Occasions Search of the history for common It is significant that nine of these ten chil predisposing causes was not particularly fruit dren were operated upon (most of these cases ful There were 23 children who appeared to were earlier in the series) and of these nine have definite bouts of diarrhoea before a sud in three polyps were found and removed It Is den change in the character of the symptoms probable that an operative search for polyps indicated the onset of intussusception Four should be made whenever there is a strong his children had received cathartics for constipa tory of previous attacks One of the few cliscus tion just before the onset of symptoms and sions of spontaneous reduction of acute intus three others liad been severely constipated A susception in children is that of Goldmin and good many of our children had upper respira Ellman in 1940 They presented fue cases of tory infections Of the last 47 7 had severe intussusception four in chuldren much older upper respiratory infections Horever Denni than the usual group in whom they felt there son states, On comparing notes with our med was good evidence of spontaneous reduction of ical colleagues we found no relationslup be one or several attacks of intussusccption Three thleen intussusception and seasonal diarrhoea of these children were operated upon and found but an almost constant relationship with upper to have no inciting cause such 15 tumor or respiratory infections As non specific mesen Vleckel s diverticulum Ictually in one instinct teric adenitis usually follons upper respiratory the history was of the wechs duration sith inter infections and mesenteric adenitis is common mittent attacks of pain and another 175 of one 11? intussusception it is reasonable to assume week s duration 11hile these the cases incl that the lymphoid hyperplasiz involves Peyers very possibly a third of Coldman and Illmans patches and the collar of lymphoid (issue five cases represent chronic non stran, ulating which is so marked in the terminal ileum of intussusception rather than repeated currences infants certainly ciery surgeon has had the expXTINCE It is frequently stated that the high incidence of operating for in obuous intussusception only of intussusception in some European countries to find that it had reduced spontaneously some ·18 I\TUSSUSCEPTIO\ II FINIS AND CHII DREN time between the last evammation of the abdo comes gangrenous and sloughs the bowel fusing men and the opening of the peritoneal cavity at the neck of the intussusception and retaining hahle found fue instances of spontaneous its continuity The intussusccptum is passerl and complete reduction of intussusception in 71 by rectum and recovery ensues At tumes sucli cscs Thurston et al, list 15 patients with the recovery is permanent but in some instances clinical diagnosis of intussusception eight of late perforation occurs in the Ime of fusion of whom were not operated upon because of appar the proximal and distil intestine and mother ent spontancous rcduction or indiertent re instances a progressise cicatricial constriction duction by diagnostic barium cnemi In an occurs at thus spontaneous anastomosis proluc additional seven patients operation confirmed ing intestinal obstruction once more Today spontaneous reduction It is not stated hon such instances of sloughing of the intussuscepmany of these patients with spontancous re tion are only rarely seen and under conditions duction had liad diagnostic birium enemas and of gross neglect and mosdugnosis or in the ab this may merely represent i testimonial to the sence of medical care In cirlier days such ? lase with which some intussusceptions are re spontaneous passage of 1 gangrenous and sop duced by barium enema The same report pre Trated intussusception was the pruents only sents one additional case of well documented hope and is late 7 1906 Harvey Cuhings re spontaneous reduction of an intussusception corded in the lustory of a child with an intussus Jones from Newcastle on Tyne reported six ception that operation was postponed in the spontaneous reductions in 103 cases MacFar hope that sphacelation might trke place in the lanc and Thomas cite four cases of recurrence splicelus be passed entire per rectum In con of intussusception ifter operativ reduction and trast to the rarity of such cases today I cichten during the same hospital admission stern in 1894 reported 42 collected cases of Smulli reports a 5% over all incidence of spontaneous resolution of intussusception by recurrence since 1923 In lus 41 most recent sloughing The bonel sloughied in periods vary cases there were four recurrences one 1 month ing from 11 10 21 days after thic onset of the after birium enemi reduction confirmed at intussusception and the separation w75 usually operation mother fue months after buruum Such instances were rire in infants 2 1 rucs dc cnema reduction confirmed at operation and occurred cluefly in older children another 21 hours after birtum cncini alone scribed the mechanism of the slougli sctunn ou The fourth recurrcnL #75 four months after to explain the observation that at tuinos the Fox reports i re slouglı 1 75 pissed with the mirosa side out and primary operate reduction currence rate of 1% in 90 mitussusccptions oper at tum rith the inconsidem lic con Tied upon at the Childrens Memorial Hospital cluclul that if the innermost loop of bowel sop 111 Clucigo cuclusive of one child with multiple rites first the intusstisceptum will completely Court polyp who required four operations (iert itself within the bowel so that it wall ise and Jones report that in 16 of their 121 chul mucost out and seroki in and when finally the dren all opxrued upon primis in incidence Cluming layer of the intussusceptus separates of almost '. recurreres excurred In one of the segment is passecl essennully inside out the returning loop separates first at the nath of these chuldren recurrencos occurred on flic xe the intussusception it is posseel down over the sions in one on three occ Istoms in 180 ON SHO entering loxsp imuil the entire intitastiseprem excc7510ns and in the rot on one (Csion lios estonded in the lonel scrosal sule ont und Spontaneour Sloughing of the Intu« u«ceptum passes when the catering lexup separates ne the from the carliest dws 10 his boch konn neck that in seanc instances the minissusception lic A rendkable case is reported by Rochilum alcal ·IN TUSSUSCEPTION IN INFANTS AND CHILDREN 19 Pain SYMPTOMS OF OYSET of a new born infant which at the age of 30 199 cases of Intussusception hours passed an eight centimeter length of gan grenous bowel mucosal side out The child 0 Tuo Tuoé Orer (irs of 1ge) (Irs of 1ge) Entre Group became obstructed and a lprodol enema showed a typical intussusception at the mid transverse 69/161-1307 29/39–7607 93/199-490 colon which was reduced to the terminal ileum Vomiting 63/161-390 3/38-801 66/199-310 Blood 20/161-1207 3/38- 80+ 23/199--1207 where complete obstruction to the further flow Refusal to eat 8/161-30% 1/38- 3 9/199 -- 450 of contrast material occurred Operation was undertaken when the baby was 56 hours old Prolapse restlessness diarrhoea constipation distention nau sea listlessness feser and convulsions were the first symptoms Incredibly the ileum was found completely di recognized in the remainder of the cases vided and both ends sealed off The only possi ble explanation is that this was a gangrenous Fig 5 Pain is the commonest simptom at the onset of intussusception part of which had sloughed and intussusception vomiting next and bloody rectal dis that the lipiodol had reduced so much of the charge third in the infants pain was not appreciated by the parents as frequently as in the more articulate older intussusception as remained allowing the two children ends of the bonel to separate and that in a Pain new born these ends were able to seal off for the 24 hours betu een the lipiodol enema and the A history of apparent pain at some point in operation the course of the disease was obtained in 60 7% of infants under one year of age and in 81 8% SYMPTOVIS of the infants one to two years of age and 91 3% The chief complaint in 44% of our cases was of the children over two years of age This pre vomiting and in 42 8% of the cases was the pas sumably reflects equally on the articulateness sage of blood per rectum The patients being of the patients and the perceptiveness of the largely infants only 23 70% of the mothers con mothers Gross and Ware report that rhythmic sidered abdominal pain the chief complaint In pain was observed in more than 95% of their some instances pain and vomiting or pain and cases hahle states that pain was present in every bleeding or vomiting and bleeding formed joint patient and was the first symptom in all but two chief complaints in the remainder of the cases of his series Nordentoft noted pain at some prolapse of the intussusception distention con stipation diarrhoea fever prostration and many time in 93% of his cases and again the only patients in which no pain is reported to have other symptoms were variously given as the occurred were the youngest infants chief complaints The symptoms of onset tend to differ somewhat from the presenting symp Vomiting toms at the time the infants are seen As seen In all 928% of the children vomited before in Fig 5 evidence of abdominal pain announced treatment was begun In the patients under the the onset of intussusception a little more fre age of tho years vomiting occurred at some time quently than did vomiting 98 out of 199 or in 9166 In the children to years of ige 19º. is compared to 66 out of 199 or 31%. The and over 82 6% vomited As to the relationship appearance of blood per rectum 17s the first of vomiting to the time of onset of symptoms it symptom in only 23 out of 199 or 120 is found that 73% of the infants under to yours might be c«pected pain is increasingly the first of age who lomuted began to somit in the first symptom in sticcessively older age groups while three hours of the disease while in the children blood in the stool is the first recognized symp over two 520 vomited in the first three hours tom almost solely in infants in the first 110 It would appear then that somitin, excurs years of life when the less dramatic symptoms most uniformly in the younger infants and in may not command the motlier s attention thene infants vomiting tends to be carlier in the ·40 I\TUSSUSCEPTIO\ I INFUTS AD CHILDREN course of the disease This early vomiting is of after the onset of symptoms is n negatise sympcourse reflex vomiting The vomiting of intes tom of some importance although it is not un final obstruction is a lite sign which should common for the patient to evacuate lus bonel never been seen in an intussusception which has shortly after the onset of intussusccption been properly handled Diarrhoea The Iceding history of the children after the onset of symptoms is of interest Only nine of Dirrthoca after the probablc onset of intus 112 in whom data are able tool food and susception occurred in 13 or 65% of the 199 retained it but 47 out of 112 took food when it cases Fleren of these turtcen patients were 1175 offered after the onset of symptoms al linder one year of age Thus symptom may oc though they proved to be unable to rerrin it cur when obstruction to the bone is still uncoin plete Two of these il patients did not hic ? Bloodl palpible miss on physical examination Dunn In all blooi was seen in 91% In 93% of the hoea occurs in intussusception with sufficient patients under luo years of age blood had been frequency to make it wise to consider the dig observed on stools or in the rectum but in only nosis of intussuscepuon in infants presenting in 6, of the patients over two years old In 211 atypical clinical picture of dysentery of these 59% of those who showed blood at all nges 13 patients six were actunlly first mistakenly shoncd blood in the first 12 hours and 37% of diagnosed as having dysentery and three died as those showed blood in the first three hours a result of the ensuing delay There appears to be lule difference in the ap I'rolapse of the initussusception through the petrance time of blood in the stool in the two inus occurred in seion children in incidence of 78groups but the younger children are more 35% with no apparent predilection for any one lihely ko slon blood than are the older ones nge (ross and are found six cises of prolapse The blood is prominently mixed with mucus of the intussusception outside of the mus in in the majority of the cases At times the pas their series of 610 In hihics 1951 report of 51 sige consisted almost entirely of mucus which cases prolipse of the intussusception through "15 proxluced with only a slight ndinixture of the antus ltd occurred or no bloxxl and excisionzily with blood detectable Distention 15 1 complaint #76 more bring only under the microscope In soine instances mide only thrçc armes in all each time in in infant I ostlessness drowsiness prostration the passage was a thin milogrny colored fluid I fest hue blood cells sese not uncommonly cre noted by all motliers in 30%, of all cases seen in the surxo) but it was uncommon to see with no rition in listribution in the age In many cases blood is detected groups Only one mother lud felt 7 muss in licr only on the c 1711, fın.cr further emphasiz chulds zbulonin ing the necessity for rectal cx711111711on In FWMIVATION Ihnchers series blocul 7 found in 61% of Feuer thic patients in Cross S Series in 81%. in Thurs ons in 0. There icre 97 children tonder one year of Torden and in hahles in 904 nge in whom there were 16 the temper tuft Cound passage of bloxxl from the lxucl in 899 ture and of these 11 mi of 97 or 1260 117. a of the tinder 110 jeits of and patients age icmperature of 101° or xnç 14 the time of in Yxo of those above the age Admission 29 out of 97 or 29% hid tcmpxera Con tipation mures of 10% IOT OSC and 12 out of 97 or 1.FC In 18 of tlic lud cases coup71101) 375 nola 104 1 or oscr in the one to your ChrOU 157 comprunt tnore commonly in the less articu Sit out of 19 or 320 331h ditiline temptiturna lale younger patients The absence of stools of 101 I or user wil in this grouposchino yaits atul pus ·INTUSSUSCEPTION IN INFANTS AND CHILDREN 21 of age three out of 21 or 14% had a fever of lacking as to prostration Obviously the signs IOI F or over of torpor and depression are indicative of graver Fever is both commoner and higher in the progression of the disease There is no impor younger patients tant variation in the significance of this symp There were so fatal cases (all fatal cases were tom in the three age groups in our additional prior to 1946) in which the admission tempera series of 47 cases 14 were severely prostrited ture was recorded There were 15 children who and interestingly enough the only child in the had temperatures of 103°F or ofer on admission group with an irreducible intussusception was and 11 of these 15 73% died There were four not particularly prostrated who had a temperature of 104°F and these four The appearance of prostration is furly di all died Of the fatal cases 23 out of 35 or rectly related to the duration of symptoms of 66% of the patients had a temperature of 101°F 79 cases of prostration in which data were ade or over Thus the presence of high fever was quateof very grave prognostic significance although 8 instances of prostration occurred in 44 parents in a third of the fatal cases in which there were (19%) who were ill less than 12 hours data the patients had temperatures below 101°F 13 in 35 patients (37%) in the 12 to 24 hour In the records of the patients before the reduc group tion of the intussusception pulse and respira 14 in 31 patients (45%) in the 24 36 hour group tions are not regularly noted and no statistical 10 in 13 patients (77%) in the 36-18 hour group studies could be made In both features the 11 in 24 patients (46%) in the 48 72 hour group trend is toward elevation 11 in 20 patients (55%) in the 72 96 hour group 12 in 26 patients (46%) in the 96 hour and over White Blood Cell Count group Of the 109 cases in which the white blood cell As we shall see in the analysis of the relation count is recorded before treatment the count of duration of symptoms to mortality there also was 12 000 or over in 60% and 13 000 or over in is seen there a steady progress up to 96 hours 53% in 17% the white blood cell count was after which there is a levelling off and a decline 20 000 or over This is explained by the generally earlier plu Of the patients ulio died the leurocyte count cation for treatment of the severe cises and the before traatment is recorded in 21 Of these selective survival of the non strangulating cases 14 out of 21 or 67% liad counts of 12000 or higher but since 51 out of 88 or 50% of the Dehydration survivors with data on white blood cell count Dehydration was found to be marked cnough had counts of 12 000 or over leucocytosis is of to be noted in 51 out of 121 (11%) of cases in no prognostic significance which there were adequate data prior to 1918 Of these 21 or 41% died Ilere 175 no sig Prostration nificant difference between the infants and thic Vany of the prostrated children were cold older chuldren Of the 73 children who were and sneats some unresponsive all of them tor not dehydrated 8,73 (11%) died Adequc pid apathetic knocked out data regarding dehydration were not gu 111 Of the total of 199 cases in our earlier report 14 children who died It seems clear that had the history permitted evaluation of this symp adequate datı been available in this group the tom in 137 of this group 66 or 137 or 48% grave prognostic significance of dehydration presented the appearance of prostration of the would be even more strongly emphasized for 76 showing little or no evidence of prostration as it is only eight patients died in whom the nine dieci Of the G6 noted to be prostrated 28 absence of delıydration was recorded on 70mis or 49% died In si\ of tlie fatal cases data was SION ·I\TUSSUSCEPTION I\ INFANTS AND CHILDREN NCSS 1941ciated Disease complete relaxation of the abdominal wall with It appears noteworthy that at the time of ad 110 resistance or spasm anywhere Some resist mission in 11/190 cases or 21% of the patients ince even though only over the miss was note! in whom there were adequate dari there 175 in 40% Tenderness was noted in 41% of those found citlier otitis media or in upper respin with adequue du In most of these thic ten (ory infection or both on the admission pliysı derness 175 noted directly over the miss IC 01 (lamination A number of authors have will be seen that the figures are almost identi suggested that cnlarged mesenteric nodes muy cul for the incidence of resistance and of tender be associated with upper respiratory infections Presence or absence of clistention is te and in their turn cause intussusception Re marhed vipon in 186 cases In 51/196 or 29% cently we have seen it another hospital in intus 1 rather higher incidence than might be expect silsception in a child with florid chicken pox ed distention 75 present This is a reflection Ftamination of the Abdomen of course of thic durition of the disease and of Ju 1 chuiled with the characteristic picture of the appearance of signs of intestinal obstruction intussusccption the abdomen early in the dis Maaa cise is flat or actually scaphoid The intussus Dur were adequate in 196 cases In 167/196 ception occasionally forms a protuberance which or 85% 2 miss could be felt cither abdominally is visible Typically the abdomen is very soft or rectilly In most cases of 1 recul ms 175 and non tender although the child may ince priprble in abdommal 311755 175 fele 75 well when the moussusception is palpated and in but in ten of the (7505 in which m755 175 felt such instances there may then be felt little it was felt only per rectum In an exccnsional muscular resistance over the mass Palpation patient the allominal miss 175 plaıly visible of the ineussiscepuron is the surest diagnostic Thricher reports 2 palpinic muss 111 8570 Cross sign and one should expect to palpac the tumor in 81%. Thurston 113 72% md hulle in only almost invisibly Parly in tlic progress of 1 59% I miss on palpation was found in 6950 clurn icristic intussusception the mass passes of ordentofts children under ino years of 10 into the heptic flexure behind the right cost?! wd in 73% of the oldeschuldren Snyder et al margin ud under the right lobe of the incr found 1 in7s5 111 only 69% where it my foc difficult or impossible to feel for some time Is time passes the disease pic Periitalans ture is confused by the superimposition of the Vention of presence or absence of usible 11op specifie signs of intestinal obstruction -chis peristalsis 1176 mnde 121 122 anses It #175 torud Intion and intestinal patterns sluch may ob to be present in 21/18, 5750 Or 18% sure the mass In 7 number of instances the m755 175 not definitely palpable unul throun Prolapar into promuchce ley sigorous peristalsis during 1 111 7/199 or 85% of the cases the Intussen op trump 111 illiussuscption palpable before suchi tion presented at the mus er leyonel px ristalsis is fell to lx much firmer 7t such Customers to Nirn 7,7111st mistaken, 1 poro) tinc The mass is usually described as tubuir SOUSO E slapelo clindrical The pull of the lined missusception for a more ferral praline 11 h Docs olajonly die foner unor le Moenite ry on the intussusccptal lost bctnicu passed luctscan the prolapcal lonel me the the lives of wluch it has been don con slicich of the intussurse cption que most from us the cunor to uch in 1 cunc the wide difference in the clinical picture in the Alulominal Resistance Inn conditions Other Series repent a substanti be wo of the parents "cic said to shou all, lovor Bence of proline ·IMTUSSUSCEPTION IN INFANTS AND CHILDREN 23 DURATION Figure 7 shows the relation of Vortality to The age of the pathologic process is an obi the Duration of the Disease before the onset of ous determining factor in the production of definitive treatment The current mortality is necrosis of the bone and other physiologic dis so los (in The Johns Hopkins series-no deaths turbances It is of interest therefore that while 1946 1958) that it is only in the study of our in the last thirty years the promptness with which earlier cases that this sort of information can be children with intussusception are brought to our elicited It is obvious that there is direct rela hospital has indeed changed somewhat for the tion between the duration of disease before the better our hospital mortality for the disease has onset of definitive treatment and mortality un first improved and then been eliminated with til one reaches the group with symptoms of 96 out obvious reference to the modest decrease in hours duration or longer It is apparent that the average duration of symptoms A fess cases many of the children still alive with intussus of more than seven days duration are accepted ception untreated for over four days must have as being typical chronic intussusceptions which had non strangulating obstructions and that might weight the results In the period 1893 these carrying a better prognosis than the ordi 10 1909 patients averaged 56 hours from the nary intussusceptions tended to decrease the onset of symptoms to beginning of definitive mortality in this group Only 4/52 children therapy and in the period 1910 to 1919 the treated in 24 hours or less succumbed a mor time was 54 hours In the next decade 1920 tality (1893 1948) of seven per cent In the 24 1929 there was substantial improvement to 45 hour to 48 hour group 10/37 died or 27% In hours However the periods in 1930 to 1938 the children in the 48 to 96 hour group 20/37 and 1940 to 1948 were still 28 hours and 38 died a mortality of 51% but in children not def hours In the decade 1918 1998 the period from initely treated until 96 hours after the onset of onset of symptoms to institution of treatment symptoms only 7/23 died or 300% Has 25 hours after he excluded from the com putation three cases of chronic intussusception OCCURRENCE OF SPECIFIC LESIONS of 53 22 and 21 days Retained were two of 96 CAUSING INTUSSUSCEPTION hours duration one of 81 hours and three of 54 52 and 50 hours (Fig 6) In our first 152 cases eight specific causative lesions were discovered In five there was 7 DERATION OF SYMPTOMS AT 481005 FRION AND TORTALITY polyp in two there was a Vechels diverticulum IN TITOSE PERIONS in one an ectopic focus of pancreatic tissue 11 the 47 intussusceptions since 1918 we have en (Hours) Mortality countered one small enteric cyst at the alco (631 72 valve causing intussusception three Vechels du verticula and one unusually large discrete puch 1920 1999 of ileal lymphoid (issue leading an scussuscep tion The total for the 199 cases is thus 1 3 such 1939 1919 lesions an incidence of 61/. It is significant 1919 1918 that only three of these pruents were less than Fig 6 One Hundred and \incts nine Intussusceptions one seir old Three were over 1 year old one in the Johns Hopkins Flospital-1899 to 1998 There was 1115 (No sears old one 21, one 3V one I tho a fairly steady decrease in the elapsed time from on et ol and one u 7s 11 seirs old It is of course truc that symptoms to the institution of definitie treatments from in the core of our recent cases in which the intus 1899 (36 hours) to 1939 (28 hours) and a drop in mortal ity from 75 to 390 Since then there has been little siis eption was reduced by Barum cncini alone change in the duration of symptoms but a decrease in le hast had no opportunity to demonstrate the in ortalte from ma to O existence of absence of suci mechanical losions Onset to Treatment Date 56 1899 1909 1910 1919 51 4 41 1940 1939 23 33 94 ·31 I TUSSUSCEPTION INFANTS AND CHILDREN THE JOHNS HOPKINS HOSPITAL INTUSSUSCEPTION 1893 - 1948 RELATION OF MORTALITY TO DURATION OF SYMPTOMS 30 27% MORTALITY 25 RECOVERED DIED 304 % MORTALITY 20 541% MORTALITY NUMBER OF CASES 774 MORTALITY HT. 101214 16 18 20 22 24 36 48 60 72 84 96+ Hig, ONSET TO DEFINITIVE TREATMENT (HOURS) Intussusccption-relation of mortality to duration the appearance at this point of ciscs of nonstringatung of smptoms (1893 1948) The deaths in the group ol 2 Mw3susception in the lonce nil any current tekilalay tients xen in the first 24 hours all occurred more than it is only !! tlic studs of carlier cases that is wort of 3) curs ago The mortality Teses siccpli in the succeeding information can be elected (From Ravicct and Vic hours and drops suddenly alter 96 hours This is due to Cune ] Iedral 37 1930) nor have such lesions if they clisted appeared 1 noxlule of ectopic panctCUIC lissure frac ? 10 (use my difficulty bond resection and died I lie chcrie cyst uns Io lo of the five children who lord polyps successfully resected with the cecum und ich the polyps ucre cxcise in one the type of ml sleum The large is sproud from ars si to not opxnitine prix elure is not described and in one r\cised In general the spxuific locon Trc THC the involved sagenent 1 is reseckd in thn baby 7931 except in the despxrely ill liould be diel (of polyprisis of the care 6741717 maresmal crossed inCouncu 71 epernon Ju oldes (170) ind und dieet on the opening able be children with intusstisception or 11 7) chill fore option could be pxtformer The fuse with a recurrent inhuisstieption the pensionality patients 1) whom 7 Vackels dretchum as mi such a losion inust be consciere found 1 sutusal after reset tion of this dneti lymplu sarcom is the channel (use of 1 culum or of thic segment of the bone from the sx of four stran, latin !!! Cp 1. huich the diverticutum rose Iten month old tion and the dogtenis may 11 times lor veni infant with 10 hour oleh intussily cption due to ture in the procure of 1 cmon initius ·IN TUSSUSCEPTIO IN INFANTS AND CHILDREN 23 I CAECUM AND APPENDIX OF FOETAL TYPE IA INVAGINATION OF APPENDIX TIP INTO PROXIMAL APPENDIX ben Ų Ų w IBINTUSSUSCEPTION OF DISTAL APPENDIX NTO PROXIMAL APPENDIX IC INTUSSUSCEPTION STARTING ALONG LENGTH OF APPENDIX 10 RETROGRADE INTUSSUSCEPTION OF APPENDIX IE COMPLETE VAGINATION OF APPENDIX C 2 EARLY CAECO COUC NTUSSUSCEPTION WITH NVAGINATED APPENDIX AS APEX SIN 3 INTUSSUSCEPTION OF APPENOIX COMPLICATED BY ILEO-CALCAL INTUS SUSCEPTION 4 MUCOCOTLE OF APPENDIX Jula 4 INVAGINATION OF MUCOCOELL OF NPPENDIX INTO CAECUM Tenis 1er rare Fig 8 The \ppendix in Intussusception Intussusception of the appendix a The tip of the by(t) a borc The invaginated appendix Icads the intut appendix forms the intussusception and is invaginated suxeption 3 lleocecal intussusception complicated by into the proximal appendix which forms the intussuscip appendicular intussusception but not led by it 1 The The intussusception consists of only to layers appendix without being turned instde out as invaginated b The invagination starts at the junction of into the cecum as in the called intussuxeption of a the appendix and cecum The appendix forms the intus mucocele of the appendix 5 Not shown) The appendix susception the cecum the intussuscipiens. Thus is the may be drawn into the general mass of any intussusep commonest cope to which almost all appendicular intus tion but prosuded the relationship of the appendix 19 suscepnons belong « The invagination starts at some the cocum is not altered (sec (rontupiece) this does not point along the length of the appendix-no recorded case constitute an intussusctption of the appendix 6 (loc « Retrograde intussusccption-one recorded case e Com shoun) The stump of an amputared apprndıx may be the plete invagination of appendix into cecum from progres apex of an intussusception (From Forshall I Ingunus sion of a borc Compound intussuxeption initiated (option of the Termorm Ippendix Bni J Surg 1952) ·26 I\TUSSUSCEPTIOV IN INFANTS AND CHILDREN tions ccption which resides in the cecum At times ruin etiology rather than 15 cases of intussusccpthe hypertrophed lymphoid patches in the tion The reason for the occurrence of intus terminal ileum which are thought to be respon suisception in the region of the ilcoceral value sible for many cases of intussusception assume is disputed The disproportion between the such tumor like proportions as to invite resec sizes of the ileum and the cecuin in mfancy is tion Chuld and O Sulltı in hue reported such greater than in later life and may perhaps more cises and we describe one above readily inuite intussusception The frequent The vermiform appendix my particip?te in presence of large bodies of submucous lymphord or initiate in intussusception in one of a num tissue in the terminal ileum may also explain ber of ways is Forshall has shown but ordinır the occurrence of some fussusceptions ily it is merely drawn into the spice between No discussion of intussusception is complete intussusceptum and intussuscipiens ind it is without mention of the inatomical runt of there compressed (Fig 8) the normal attachment of the cucum which goes Cross and Wore in analyzing 610 cases of by the name of cecum mobile While it is not intussusception found 1 discernible mechanical necessary to have 7 mobile cecum in order for factor in only 54% of the cases –twenty nine intussusception to occur it is obvious that the instances of Vechels diverticulum four of intes free progression of an intussusception around the cinal polyps two of lymphoma of the bowel and colon and down into the rectum as frequently one duplication of the terminal ileum There occurs would be impossible were the cecum to is no mlysis is to the ages of the children ve firmly freed It is the relatise mobility of involved the cecum in muy mfints which permits the Thurston et al reporting 116 cases from the extensive progression of so many intussuscep- St Iouis Children s Hospital ſound nine intus eptions due to 1 Vleckels diverticulum and BIBLIOGRAPIX (No more in which 7 Vechels diverticulum was Arherren 1 und Pettersson G Intcstmal intus present but not involved in the intussusception susception during the neonatal period Acla chir In illo cases there were adenomit of the sleuin scandinat 107 500 552 1931 and in one duplication cyst of the ileum Bolling R18 Acute intussusception in infants It will be noticed that we have inde no men Ann Surg 78 319 356 1923 tion of the various annonucıl types of intus Close II c Icute intussusception in children Serceptions-ileu cieco-colic ileo ilco-colic alco Cuys Ilosp Rep $1 136-113 1931 (10) Etc The Inc We feel that no purpose is served Court SDV and Jones J DT ment of intussusception in chuldhoxxl Med Illus by mroclucing these terins and that further 69 68 19.3 more by fluoroscopy it is usually impossible to Demison 11 W Acme mtussuscepuron in my separate these and at operation (requently diffi ind childhood Class ou " ) 29 71 80 118 cult Essemurlly it is important to know that Dennison 1 Iersonal communication 1.7 15, of all intussusceptions in infants and chul Fitzwilliams B C I. The patholo) and vertolony dren begin 1 or near the ileo caetal valve ind of intussisception from the study of 1000 (7568 Lancet 1 629-633 1909 It s sub these by and large that we are con Forshall 1 Intussusception of the scriniform 1 cernal Very Icut intussusceptions in children px ndır sith a report of 7 cases includere liri begin in the colon The symptoms in these are Surg 10 50.0-31? 19.3 inclmal to be less cutte ind on the other hind Far It Intussusception-Surgical itement in the small number of intussusceptions which Clon Vorth America 36 1501 150 19 6 Iseg, m lar up in the soll bouch the symptoms Coldman Sa and Imin K Spontaneous solus are fulmiting and the patients usually pro tion of acute intre susception 1.1 chuldren sent 15 oses of intestinal olostruction of uncer Surg 192,9263 1910 S ·INTUSSUSCEPTION IN INFANTS AND CHILDREN 27 Gross R E and Ware PF Intussusception in Nordentoft J M The value of the barium enema childhood experiences from 610 cases New Eng in the diagnosis and treatment of intussusception land ) Med 239 645 652 1918 in children illustrated by about 500 Danish cases Harkins H N Intussusception due to invaginated Acta radiol Supp 51 1943 Mechels diverticulum Ann Surg 98 1070 1095 O Sullivan W D and Child CG III Ileocecal 1933 intussusception caused by lymphoid hyperplasia Hellmer H Intussusception in children diagnosis J Pediat 38 320 324 1951 and therapy with barium enema Acta radiol Packard GB The treatment of intussusception Suppl 65 1918 PP 1 120 in infancy and childhood Pediatrics 15 291 297 Hipsley PL Acute intussusception Brit MJ 1955 2 717 721 1935 Packard GB and Allen RP Results in the treat Hogg B M and Donovan EJ Acute intussuscep ment of intussusception in infants and children tion in infants and children Ann Surg 124 262 Surgery 41 567 575 1957 267 1946 Parkkulainen k V A cause of intestinal atresta Holowach J Thurston D L and McCoy E E Surgery 44 1106 1111 1958 Intussusception due to Mechels diverticulum Perrin W S and Lindsay EC Intussusception A MA Arch Surg 67 699 707 1953 a monograph based on four hundred cases Brit Illingworth CFW and Dick B M A Text Book I Surg 946-71 1921 of Surgical Pathology 5th Ed London Church Rachelson MH Jernigan J P and Jackson W 11 1917 F Intussusception in newborn infant J Pediat, Jeffrey F W Intussusception in newborn Canad 47 87 94 1955 Md / 54 271 272 1946 Ravitch M M Polypoid adenomatosis of the entire Jones J DT Treatment of irreducible intussus gastro-intestinal tract Ann Surg 128 283 298 ception Brit A1 ] 2 1301 1306 1953 Aug 1948 Kahle H R Intussusception in children under two Ravitch MM and McCune RM Jr Intussus years of age Surgery 29 182 195 1951 ception in infants and chuldren J Iediat 37 Kahle H R and Thompson CT Diagnostic and 153 173 1950 therapeutic considerations of intussusception Santulli TV and Ferrer J M Jr Intussuscep Surg Gynec & Obst 97 693 701 1953 tion - an appraisal of present treatment Ann Ladd W E and Gross R E Intussusception in Surg 143 8 17 1956 infancy and childhood Arch Surg 29 365 384 Snyder W H Jr kraus A R and Chaffın L 1934 Intussusception in infants and chuldren a report Ladd WE and Gross R E Abdominal Surgery of 143 consecutive cases Ann Surg 130 200 210 of Infancy and Childhood Philadelphia Saun 1919 ders 1941 Spence j ind Court D Acute intussusception in Leichtenstern 0 Intussusception invagination childhood Brit M 2 920 19,0 and darmernschiebung in Ziemssens Cyclopedia Thatcher DS Intussusception in infants and chil of the Practice of Medicine 7 610 621 1877 dren Ann Surg 140 180 181 1951 Ling J T Intussusception in infants and children I liurston D L Holowach ) and McCoy F F Radiology 62 505 513 1951 Acute intussusception analysis of 116 cascs it St MacFarlane DA and Thomas LP Early recur Louis Chuldren s Hospital AMA Arch Surg rent acute intussusception in children Brit A 67 68 79 1933 | 1 559 560 1951 Troyes F Intestinal Obstruction London Cassell Mac Vahon Brin Data on the etiology of acute & Co 1901 intussusception in childhood Am J Iluman Wakeley CPC and Atkinson I RB Acute Genetics 7430-197 1999 intussusception in childhood Brilſ Clald Dus Mordentoft J V The value of the barium enema 35 211 20 1938 in the dignosis and treatment of intussusception leta The Irute tbdomen in Rhyme London in children Acta radiol 34 481-188 1918 Lens 1955 ·Chapter III CRRORS IN THE DIAGNOSIS OF INTUSSUSCEPTION In periodically rescuing our experience shup here In any cient, the possibility of intus with intussusception we were struck some ycarsstisception may be thought of in 1 child who ago by the fact that fasc dentlis occurred in our sceins inucli sicher than his obuous upper respi experience between 1939 and 1916 all of thescritory infection of history of previous mild der in patients treated primarily by operation f10c? would suggest A few patients have strong What was most disconcerting was the discos and clear histories of previous similar attacks cry that in each of these fise instinccs a serious from which they recovered spontaneously Such dela had occurred in the initiation of defini 7 lustory should slurpen suspicion not allny " till trennent In each instance the delay 175 Diarrhou during the pericxl of intussuscega (resedi by fulure to diagnosc thc intussusception con occurred in 15 or 75% of our entire series upon the patients first visit to the hospuolaltcr of 199 cases and 13 of these 15 patients were the onset of the coudiuon In one child it is under one year of age I huis is of curemic 117 truc intussusception) 75 only in incident in the portice for there is an understandable tenden course of an already established fatal disease cy to assume that in the presence of intusstis but the other four cluldren should not borse died ception there must be compleic mesul ols hund the drgnosis been made promptly This struction of these 15 chukiren the condition cxpcricrice led us to resicts the firstories of the 578 acouilly mist Thants ongttoscd 101 sosest 76 chatldren in whom intussusccpton 17s improp. dysentery and three of them subsequently chcel crh dignoscd 16 The Johns Hopkins Hospital is the result of the delay In thic prroxl 1980 in tlic pcriod 1930 to 1931 in order to illum 1908 121 children with intussusccption were 17e il possibile the more common dignostic treuod a The Jolins llophins llospiri 11 ?? pilulls We nos record 1 further resten 10 of these there *75 TIL l error in de RM18 19,4 mnd combine the in groups sluch affected the treatment and eight of these w By and large mussusception is 7 rcadily d115 19 chiron dluer ill bcfort 110 11th the Boscd disease sath in casily recognized suprom brick focus and berring in 1911 the pattern of galdetul It is well to note that in many chuldren history and physical examination in odurry the symptoms and signs of intitssusception sul (75cs of tritussusccption as olas trasei a koni in fxn ene during a mild illness such as an upper Clupter 11 scinay fororced to an analysis of the respiratory inferuion or 1 ]xollt of non specific cases in which thote 175 7 d:7, nosta crror with dianthoxen 1 liose who feel that the presence 1 significant ensuing delis ly of this of cnlrrged submucosal lymphoid masses pre Lind obtains its chief value from 111 ctamina tion of the clinical characteristics of the 777 dispares to intis susception sectenusal relation $ ·INTUSSUSCEPTION IN INFANIS AND CHILDREN 29 nosis reviewed and does not lend itself to statistical felt and the diagnosis made by barium enema tabulation so that it seems most profitable to It is worth remembering therefore that abdom discuss the cases in groups using the individ inal spasm may be an important feature of ual cases for illustration these cases and may prevent early palpition of Our errors in making the diagnosis have the mass fallen into several categories One instance was Palpation of the intussuscepted bowel should that of a patient who showed all or most of the not be considered a sine qua non for the diag signs of an intussusception which was not recog In the group of 23 cases of delayed dig nized because of the ignorance of the examin nosis 1930 1951 there were nine in huch no ing physician In a second group the diagnosis mass was ever felt by abdominal palpation or was missed because of the rather long duration by rectal palpation and ten cases in which there of the symptoms and the relative well being of was a variable delay before palpation of a muss the child There were five such cases in all of ultimately established the diagnosis In one case them the diagnosis was not entertained because a palpable liver was repeatedly mentioned the history went bach for periods varying from This may well have been the intussusception In a week to as much as 40 days during which the two cases the mass was felt but thought to be a general condition of each child remained good neoplasm or a cyst In some cases the mass Ultimately in each instance admission to the was undoubtedly under the right costul margin hospital was precipitated by the worsening con and therefore not palpable In others it may dition of the child One must ever heep in have been obscured by distention and in still mind the occasional occurrence of chronic others by tenderness and spasm In 7 of the non strangulating incompletely obstructing in 23 cases the intussusception involved the ileum tussusception only In 4 of these no mass 175 ever felt One of the commonest errors was in making The age of the patient was misleading to the the diagnosis of dysentery based upon fever pediatrician in several instances of the total vomiting bloody stools and abdominal pain In group of 23 patients whose condition was ini this series there were seven patients in whom tially misdiagnosed there were 8 patients over the erroneous diagnosis of dysentery was made a year old including 7 over to years and there When one considers low common dysentery is 111s one who was 2 weeks old of the 199 c7scy and hos variable its manifestacions it is small analyzed almost 90% were under ? yeirs old wonder this error was made One can only sug and 57% were 4 11 months of age In this group gest that intussusception must be hept in mind of 23 children 7 or nearly 7 third were over 2 In (no cases there was sufficient spasm rigid One tends to forget the possibility ity and tenderness to simulate an acute abdomi of intussusception in the older age groups as 1 cl nil condition requiring surgery In one a diag 1$ in nens born infants nosis of appendicitis seemed unequivocal with Blood in the stools or currant jelly stools is tenderness und spasın in the right Jouer quad another classic sign of intussusception rant no palpable mass and no bloody stool At may not appear on in appreciable number of operation the appendix was found to be normal cases is evident since it did not appear it all in and intussusception was found In the otlier 10 of our 19 undiagnosed cases Indeel in ses case there was first tenderness in the right upper eral cases the stools were normal or nearly so qurdrint then considerable rigidity and conse and in some others there were repxatel ziety quently the possibility of appendicitis sickle stools In some cases there was occult blocul in cell crisis or other cause of abdominal pain and the stools and in others it was found only by spasm was entertained Eventually after ad rectal examination ministration of secobarbital sodium a mass was In two cases and possibly a third the issue years old I hit it ·30 I\TUSSUSCEI 110\I\INFANTS AND CHILDRE was beclouded because the patients were already of the biruum enema shoned dilated loops ind in the hospital with another disease An addi demonstrated the evistence of 1 mechanical in tional case of this kind was seen recently in in testinal obstruction 7 mandatory indication for infint admitted to mnother hospital with severe operation in itself and flagrant varicella It was thought by some There was one other case of essentially iner observers that all of the symptoms could be cusable diagnostic inaccuracy which fortunate ciplined by intestinal involvement in an enan ly resulted in recovery Wlule cveryone may at them and accurate diagnosis was delayed for times fail to see the obuous 1 lugh index of several hours on that account suspicion in regud to intussusception and ? Occasionally a blatantly typical case is mis sense of urgency in the presence of the possi diagnosed is in the following instance bility of intussusception should reduce the num PG ? ten month old girl was seen in the dis ber of diagnostic errors pensary with a temperature of 101 8 ind a history It is possible in some of the cases to see how of fcver sonuting and constipation for over 24 the examiners were misled! hours In enemr the night before id returned In six cases the duration of the illness was bright red blood The abdomen was distended and there were no fecal misses no tenderness masscs so long and the children in such good condition or spasms Enema return in the dispensary was that the correct diagnosis was not enteritined practically clear except that the water was tinged until late These cases were of very different with light pink Diagnosis were Otitis media types chronic constipation () intussuisception The chuld I he first case was that of a six year old cluld with was sent home to return the next day However the a two year history of anemia abdominal pun ano. CrTor was detected that night by the dispensary chief res and carry stools with occasion vomiting She in 1 rcucu of the day s hustories and the baby was 111d frequent tacks of abdominal pain when a mass found and brouglit in 12 hours after the first dispen *75 visible in the ?blomon Fien though these sary visit The chuid 175 non flaccid ind almost attacks occurred during a hospital hdmission intus completely unresponsive A diag barium en susception seems not to have been considered Lapi ema filled the colon Rocntgenogrims showed nu rotomy #7s finally undertaken and two separate merous loops and flud levels and upon operation intusstisceptions were found with pxolyps in euch 1 short intussusccption was found just above the small bosc ure ilcocecal valve It was not fingrenous but 175 irre This chuld had peculiar pigmentation (llut ducible Rescction and anastomosis were performed chinson Jugliers Vichusıch spots) on the Jups The clulds temperature rose to 101 (1018°F) the significance of wluch as indiciung diffuse She had con ulsions (or six hours ind died I he intestinal polyposis was not then realized I hc Specimen shoncal tlie intuisstisception to loc been due to nodule of nberrant pancreatic tissue chronicity of her complaint and the extensive Tluis child and coming constipation ind blo«l loss clue to the polyps had led 10 (741oss blool in the boucl when first scen ind consid of Mechels diverticulun ulcerative colitis cic eration of intussusception should have been ob In actuality repertori lxouts of intussisception ligatory regardless of the absence of 1 mass are 7 regular feature of the several syndroines which is all that was laching If the mere ?ssoxiated with multiple small intestinal polypas thought of intussusception is entertained a bar Another patient celebrated in the annals of the Ilarriet Lanc ffome nas in the month old 401 som en mu should be administered and only if whose intel (114fx iury 19 #75 on the 11th day the small lxonsel fills readily and there are no of illness I hus had thyun with allomal prin llud levels or dessende loops may the poss and a norinal vacuation follow me whter fusc louis Iolit lic distrisseel It is true that in this in by the passage of bluxxl Slic sumseed oirry day had stunce the intussuxeption 375 entirely in the fuser Mery day and had one of the normal stels small txucl wuch makes for more difficult ochi day until the eles of her first 11 nhien she Framtu2013 sonral clignous me lugher imortality Iloncicr films had a blexxl watery stoot ·INTUSSUSCEPTION IN INFANTS AND CHILDREN 31 SIS dehydration a palpable liver a fluid brown stool elery meal but she had normal stools without any and blood in the rectum She was thought to have blood for the tko days preceding admission She was dysentery and was followed thereafter for 40 days thin dehydrated and crying with frequent spisnis of during which she made 25 dispensary Visits Some abdominal pain There was much audible peristal times she had diarrhoea sometimes not sometimes Hard dry feces lay in the rectum There was she vomited sometimes not sometimes she passed tenderness and muscle spasm in the right upper blood sometimes not She neser failed to have a quadrant and a poorly defined tender muss She was stool but often had bouts of pain The liver was observed for 12 hours for () lead poisoning (1) apusually palpable pendiceal abscess until a diagnostic barium enema She was finally admitted to the hospital where shoned an intussusception at the hepatic flexure after three days a barium enema was given as part Operative reduction was successful of the diagnostic study and was interpreted as nor There seems little justification for the delay mal The next a mass was finally felt Barium in operation although the absence of bleeding enema reduced a typical intussusception from the and distention are extenuating factors and 21 transverse colon to the ileocecal valve and reduction though the mass must have been partly concealed was completed at operation The child had no trou by the Iner and the right costal margin ble thereafter Review of the first roentgenograms The fifth child in this group was a six month old which had been read as normal actually showed a boy with a three month history of cramps and vom typical chronic intussusception (F169) In this instance despite innumerable bloody and never passed blood Three days before admis iting occurring in episodes He had daily stools stools bouts of pain and vomiting the possi sion a tubular non tender mass in the left upper bility of intussusception was ignored because of quadrant was felt and taken to be an enteric cyst the long history and the absence of obstruction Upon operation this mass proved to be an intussus in an eight month old infant who was obviously ception at the splenic flexure When it was reduced not desperately ill a mass at the ileocecal junction was discos cred and Ihe next chull in the group with chronic intus resected and turned out to be a small enteric cyst susception was a one year old girl with vomiting which had led the intussusception and constipation of one week s duration and with The sixth case in tlus group is similar to the fifth a history of ſlechs of blood in an enema and re A five month old boy was seen by his physician 21 peated bouts of periodic abdominal cramps The hours after onset of vomiting and constipation and abdomen was distended a roentgenogram showed haung failed to respond to a change in formula dilated loops and intestinal obstruction was sus was scen at the hospital after another 18 hours Ilc pected but because her condition seemned excepdid not appear alſ was only slightly dehydrated tionally good she was sent home to return the next afebrile A firm round movable miss was ſet in the day! She was then distended there was tenderness right mıd abdomen He was considered for six hours and spasm in the right lower quadrant and the sus to have an abdominal neoplasm before a birium gestion of a mass She was thought to have a los enema was finally administered and the intussuscep intestinal obstruction Barium enema showed an tion in the mid transversc colon cncountered and intussusception in the right louer quadrant for reduced whuch operation was undertalen The intussuscep- The most interesting feature common to all tion was reduced these children is that despite the fact that they In this instance the picture was largely that lind long standing intussusceptions from one or of intestinal obstruction for such admission two days to others arving in duration from ten and operation should have been adı ised in any days to a month or more all survised and none had gangrenous bowel Thus is unlicrent in the The fourth case of delayed diagnosis in a child nature of chronic intusstisception A moments with a long Iustory was that of 124 year old girl ulio fad a ten day history of illness Tlus had reflection will show that precisely thoxe chul begun with sudden severe cramps which px sisted dren will liate chronic intussusception of long at frequent intervals She comited after almost standing whose intussusceptions do not become case ·32 I\TUSSUSCEPTION IN I\FINIS IVD CHILDREN gangrenous ind in thom neither the intestinal inconspicuous or absent canal nor its sascular supply becomes completely A very small group is represented by to chil obstructed One should not insist upon feeling dren who were already in the liospital and scri a mass before resorting to brrium enemi The ously :]] when intussusception superi ened merc fact of a long history in a child who is An 18 month old boy #35 in the hospital dying sull in tolerably good general condition does not of malnutrition is result of diffuse polyposis of the entire intestinal tract This had resulted in cxclude intussusception and the child may con almost constint diarrhoc? In the hard long time tinue to pass stools daily By the same token nter admission he spent a bid night with abdom in these cases bleeding into the bowel may be inal pun and began to pass liquid bloods stools B Chronic Intussusception Tip 9 ( 15 female 8 months old 7 his child was first cinils one or isso occasions in her supercury 19t1 hod Irrought to the hospital 11 days after a bour of alulominal mass been feit She hal appearcel a quinty clull and had par followed by pasuge of bright red blonxl She had generally licen thought to have licpatomegaly Her ad Simuted daily had fever lost appetite but had continued mission diagnosis was dysentery Sie had Ime weight and to banc one to the lonel monicments a day some watery had acier stopped vomiting On admission she as de and with hixul She had lost s funds She was sen on tibed as fasing a sole Iner with mounted cilge Tur) or 2) sparate visit to the hospital On the first sist it was three fingers breadth Lelow the costal margin Ihree days 17 diced that she had what was thought to be a palpable afice admus in the man was identified as being use luct and upper alxlominal fullness lfer sisits were usu shaped and conceivably an intusstieption and a disa ally excavonetleser vomiting diarrhoea and blonuly nostic larium enema nas rezuestel of the Ratif my Ir flachs in the stu. She was finalls admitted to the hou fuartment To surgical connotation *Jsqurused the jutal 3 days alter the firse it for this complaint On (Configurfinnut p-} ·INTUSSUSCEPTION IN INFANTS AND CHILDREN 33 C Fig 9 (Cont) mass apparently disappeared just before the roentgeno diagnosis leading to delay in the treatment of intussuscep gram was taken and the characteristic findings seen in this tion is dysentery film were not appreciated The following day the mass was 4 This was a dugnostic study undertaken when the diag palpated once more and the diagnosis confirmed on surgi nosis of intussusception was not very seriously enter cal consultation Barium enema reduction demonstrated tained Vlthough barium reaches the right loner quad a typical intussusception at the splenic flexure whuch was rant the characteristic coiled spring appearance is seen readıly reduced to the cecum beyond which it could not be from the splenic flexure around to the right lower moved Through a small McBurney incision the cecum quadrant was delivered and less than a centimeter of bowel ap- B With expulsion of some of the barium what is presum peared to be still intussuscepted This was readily reduced ably cecum seems empty and the coiled spring There remained so much edema at this point that the chronic non strangulating non-obstructive intussus bowel was opened found to be normal but for the edema ception is seen in the transierse colon and hepatic and closed The appendix was removed the child left the flexure hospital well eight days later The coiled spring appear ance is typical of a chronic intussusception The edema C Enlargement of B to show the coiled spring more of the non strangulated bowel prexluces the large ning like clearly Gilling defects in the barium which enters between the It is probable that the infussusception moved back and Intussusceptum and the intussuscipiens "The absence of forth for a month or more almos reducing enutely at complete intestinal obstruction does not rule out the pos times passing far around the colon at others (From sibility of intussusception The commonest crroneous Rausch {m} Dis Child & 1952) ·$1 I\TUSSUSCEPTION IN I\FITS I\D CHII DREN ܚܝܝ B Intrissureptum Superpuvesi on Other Busse asc ( B Wale istreen months old (1) C II) Plus finnclith the opinthem of mela and it was hout chuld had les sit at home ſex wel with an upper res bulore a farsumi enema 11 mittakan pirats entectum and the unitats manifestations of The plain film shows humerous dilatal twee of small <schen mit Durm, this peruxl he had somel sescrat bunel and en kwip konfiable * calon The day before acleus son he began ve more to "The colon filled readily safont demonstrating as an and came disetideIchaut luad aluminis il pun DUSHKcprion but a peculiar shunuan se in the It m time (1) (SSTIC <luring this entire neck It the time of small fxnel ('us opposite the bend 153 the gastritulum udmiston lie had she flagra111 rash of chicken pt in 111 the film) on the social cofer *** **tranti Yure of the mu au 13 alul omenal pun indirming it as anul the patient allowed < cuacuate the executoutum med that the ANC ION us dur 20707717senicht of the (Conditucion nraight) 11127 11 letters a use was felt in this rulet uppet were suiken The alulosen *175 saplon! Ihr feire quad 7511 The mess develoxıl madh i uns! Jxrature was 108 (10! the ultime et l* ploter snd found to be an ilcolcai intunut eption came ingantic nu dostudel almost at vixt and The only diel 21 ks after ojxtation fr autant she se in to przys Lyon klexel 133 the steily with alle cure Inti from cardinto anus wis Inunul tr> snurh DUCTES liter 7 houts she was furioulos In seddel sath these phyzx felel anu scker dopie charit, « tlır pre 111 I missith old girl sy admuste nith 1 114 malttium (1x1.3 124 mual bustie wohl werk filters at reus #3377\xal stool kifexxl 1 st [Xiated curuit geldt strusle ! pw nije ratson pir the sixls terct cu and yxiusten toimitil (Tosic ilokal intussen was found ari! ft I lite tillt uprxteste pptu oMINNIle duld story sath o'rtinis * deludsata tlic on and the fontanello In lxyth thetc 11770cm atsax cpt diesel ·INTUSSUSCEPTION IN INFANTS AND CHILDREN 85 A 14 month old boy was admitted to the hospital with obvious chicken pox and abdominal disten tion Seven days before he awakened from a nap like a wet dish rag and vomited He had a normal stool that night but slept poorly For the next three days he ate poorly vomited often and slept a good deal and after three days without a stool passed ? reddish watery movement He began to improve eating better vomiting less when he de cloped a rash and abdominal distention The rash was char acteristic of chicken pox there was 7 soft disten tion of the abdomen and a watery mahogany col ored stool Intussusception was at once thought of but the obvious varicella and the prolonged history in a child still in relatively good condition led to the suggestion that the problem was one of paralytic ileus due to the presence of intestinal enanthems It was 24 hours before a barium enema revealed not only the distended loops of boucl which had been attributed to paralytic ileus but a chu icteristic fill ing defect in the terminal ileum (Fig 10) At operation a gangrenous intussusception of the terminal ileum was resected The specimen does not shox any unusual features Tlie chuld made a rapid recovery Fig 10 ( Co it) In this instance the existence of florid chicken C The colon as seen to be filled completely as well as pox led to the dismissal of a fairly characteris a few inches of termunal eum Proximal to this was tic history of intussusception and the erecuon of the sausage shaped double shadow of an unreduced intussusception Operation was immediately under a labored clinical structure attributing the dis talen An irreducible ileo ileal intussusception was tension to paralytic ileus and visceral chicken resected and primary anastomosis performed pox and the bloody stools to ulcerated enan The child recovered without incident Such radiologic thems Barium enema fortunately outlined in demonstration of an intussusception in the ileum 15 rare The plain films showing dilated small bowel loops and intussusception in the ileun-1 rire event no gas in the colon should have led to operation for The largest group and the most duceptic intestinal obstruction consists of the balies who were first thought oped in a child already seriously ill and in the to have dysentery and finally were found to have intussusception Tliere were eight of these hospital and the diagnosis was delayed because children When the suble character of curly the child was already in the hospital on another account Members of the staff were slow to ap dysentery in infants and children is remem bered this error does not scein so remarkable preciate the significance of the chinge in symp although again it is preferable to conduct bar, tomatology is possible of course that the ium eneina studies on the mere suspicion of second case was one of intussusception from the first although there appeurs to have been a sharp the possibility of an intussusception and sudden change in the clinical picture ten month old balxy s3s admitted to the down I recent case involves another instance of sary with a temperature of 109 11 after 21 lours pre of vomiting lule the stools were normal thic throat existent and coinciding disease seen in another was red the cves sunlcn and the chuld was restes liospital Slie was treated for disentery in the preciarilocal ·36 INTUSSUSCEPTION I INF\TS AND CHII DREN of con stage The next day with a temperature of 106 6°F right upper quadrant Barium cnemu recluced a she was admitted to the hospital Slie was very well typical intussusception to the right colon whence nourished to the point of obesity and seemed fairly reduction was completed at operirion nell 1 here was tenderness and resistance in the The fourth inſant in the dysentery group came to right upper quadrant She was thought to have a the dispensary after 18 hours of vomiting and no paralytic leus of uninown origin Roentgenograms stool Hes as thought to have an acute nutritional slowed dilated loops 1 wo days after admission disturbance he was given fluids intravenously and laparotomy showed a gangrenous intussusception feedings were ordered suchlied Scieral hours later wuch was resected The child died soon after he was brought back to the hospital with colichy In thus instance obesity of the child interfered pin and a right upper quadrant mass there was with abdominal palpation and with accurate blood on the finger after rectal cxamination Barium assessment of the condition There appeared cnimi reduced the intusstisception to thic cccum and from the record to be a constant search for real operation completed the reduction abdominal rigidity in 7 ten month old infant In this case vomiting and the fact that the It is well known that in young infants there child had been one day without a stool sere all inzy be little or no abdominal resistance in there was to arouse suspicion but a barium enema might have been advised becrusc of the acute abdominal lesions The presence question of intestinal obstruction stiprtion distention and vomiting were not The fifth chuld in this group an ciglue year old properly cvaluated boy had a ton lour hustory of sciere cramps with The next child also died He was a six month old somiting and several water, stools with mucus and infant with 1 18 liour lustory of bloodly stools vomit blood Ihe abdomen was rounded and slightly ing and crampy abdominal pun HC 175 in shock distended Rectal eviminzion yıelded a liquid stool bleeding from the rectum and scicrely delydrited with blood mucus and white blood cells The dis Recul examination showed bloody mucus It has nosis upon admission was dysentery but alter scu discovered that the chuld had been oſſerce egg for crul liours a brum cncma was donc lucl shoncu! the first time on the day of onset and thercfore time an intussusception in the descending colon wlucha was taken to test his allerg) to cs albumin wluch uis readily roluced loy hydrostatic pressure proved minimal Roentgenogtams showed dilated 1 he sixth chuld in this group was a scien month loops and after several hours operation was under old girl with a tko cch lustory of vomiting, having talen It operation in alcoilcal intussusception was ten to tucke diarrhocal stools a day fever and discovered and reduceel Ilis temperature rose to norexit Blood ?ppeared in the stools the day 116 C (1068 F) and hic died pxrhaps as a result of Infore her first sisit and on that day she had only scanly supportive treatment having recensed only a three to four stools I lie temperature was 101 1 F little dextrose before the operation and only 100 cc She was irritable toxic and slightly dehydrated and of blood after the operation the ear drums were rei and bulging The funer In this instance 1 delay of 1 feu hours 175 was felt tuo centimeters beloss the costal margin occasioned by neglect of the obvious indications Amiringotomy was done and stic was sent home of intussusception with a cicar clinical picture The next day she was vomiting and trad a look except absence of 1 miss The intussusception purulent stool a tender allomen and a rectal pror. was ilcoile The timne u duch 1175 11 75ted could lapxse She 175 admitted and the following day a barum cnc m7 shoued a normal colon but disten liric been cmployed in vigorous transfusion tion increased and stexols ceasel altoetluct copet therapy ition an ilealal intussuscepition as reduced the Ilic tlurd cluld mistakenly thought to liave dis chuld scooted 10 bx recovering when coton bacillus cntcry was eight months old lle came to the hospital meningites des cloped and shic dic? shortly after living passer four water ellow stools Iler cramps somiting and anxierness Isad! and lasing vomited scieral times lll was obviously acutch ill and was sent home as liaving disenter heen ignored and ul is pxossible that the laser Text das he appeared to be having cramps and load 75 the anttissureption IN1225933xceptions as budi a bloxxis mucous stool There was now a mass in the do not citer the colon are radiologically and ·INTUSSUSCEPTION IN INFANTS AND CHILDREN 37 clinically difficult to diagnose Cramp like pain presence of the intussusception vomiting and distention should have suggested The child marantic and moribund on admis mechanical intestinal obstruction It is infinite sion from its long diarrhoea continued in its ly more costly to delay operation for mechanical previous state for two days and died Autopsy intestinal obstruction until diagnosis is abso showed an extensive and profuse enteritis lutely certain than to operate occasionally for In one child a girl of 29 months an attempt what proves not to have been an obstruction was made to establish the diagnosis of meningitis Ihe seventh child mistakenly thought to have She was admitted to the hospital 18 hours after the dysentery was a five month old girl first seen at onset of vomiting and cramps She was marhedly the hospital a few hours after the sudden onset of distended and intestinal pattern and peristalsis were vomiting and diarrhoea Blood appeared in the stool conspicuous nevertheless in the absence of a mass after her first hospital visit Finally admitted 48 or of blood in the rectum her extreme listlessness hours later she was prostrated weak lethargic de and drowsiness suggested a central nervous system hydrated A mass was felt in the left loner quadrant disorder such as encephalitis or meningitis Lumbar and reduced by barium enema and she recovered puncture was negative After fre hours a barium Her case is described in detail in Chapter V under enema was performed and showed multiple fluid Complications of Barium Fnema Treatment levels a stepladder pattern and a typical intussuscep- The eighth child in this group was an eight month tum at mid transverse colon reduced to the ileru old boy whose illness began with a sudden bloody At operation the leo leal component was reduced diarrhoea Seen soon after he was passing bloody manually The child remained stuporous for days watery yellow stools and although exhibiting pera before recovering and it is not impossible that we odic cramps and vomiting repeatedly was sent home were dealing with intussusception supervening in ? on sugar water On his return the next day he was chuld with encephalitis profoundly prostrated severely dehydrated and acı At least three children suffered a delay in dotic A mass was easily palpable in the left lower diagnosis because of a compound error it was quadrant The intussusception was reduced by or should have been evident that some other barium (nema from the sigmoid to the ascending form of mechanical intestinal obstruction might colon and further reduction completed at operation be present or some other acute abdominal proc A ninth child with diarrhoea six weeks of ess yet the child was not admitted to the hospi age had been followed at the Harriet Lane tal for immediate operative treatment Home and Dispensary for most of its brief life One chuld of six years was seen after 18 hours of with constant diarrhoei and occasional bleeding pertumbilical pain and vomiting with no stool in The child was admitted to the Baltimore City the second 24 hours The laser was thouglit to be Hospital moribund and with a profound marasmus palpable An enema was ineffectual but the child Despite the continuing diarrhoea because there was was sent home He was brought back the next day now blood in the stools a barium enema was ad markedly ill dehydrated and distended with nu vised The plain film showed numerous distended merous dilated intestinal loops It was thought that loops of what appeared to be small bowel with no he might have peritonitis and sleus but operation Tecognizable loops of colon A barom enema was showed a large rleocecal intussusccption which was undertaken and no intussusception was recognized resccted Death followed soon after operation A subsequent review of the films (Fig 11) showed an A four year old boy with a similar luistory was obvious meniscus in the ascending colon with the more fortunate He had a two day lustory of alxlom suggestion of a compound intussusception The final inal cramps was sent home and returned in 21 films showed incomplete filling of the colon al hours having vomited several times I here was a though there was a little dribble of barium into the little spasm in the right upper quadrant and 10111c ileum For this reason operation was insisted upon peristalsis He was sent home again and turned The intussusception was found to have been com the next day with cramps distention and tiglit upper pletely reluced by the barium enema only a ga quadrant tenderness and spasm With the chuld notic annualar ring in the ileum some inches prort under sedation with secobarbital sodium a typical mal to the leo cecal valve indicating the presious intussusception was felt Barium encia roluced it ·I\IUSSUSCEPTIO IN I FINTS AND CHILDREN > A B hg 11 Intussuscepton Visciagnosed Dysenters 1) L. female se scris (3) CJ) This baby B The obseryers do not Noie unsweption under was admitted to thc hospital moribund with a hustory of the fluoroscope but this film shows an oxumus mener darthoca for most of its brich lile ind excasional bleed cus in the ascending colon and suggests alsn that there ing Despite the continuing drarthoca because there was may lose been a compound intussusception with the blooxt in the stonls a barium cnema was adused colnxolic portion in the transierse colon in process of I The plun film shows numerous distended loop The being reduces at this point colon is not recognizable (Continued on next) to the accum and opxration completed the reduction ascending colon and reduction and curc were really In this aristance the boy 175 (ulice sent liome accomplisheel despite rightsided abdominal tenderness and a Intussusception had not lone suspected and Juustory of crumps for wluch admission and opera no barium cnemi was performed butxration fron should huic been dised (roin the first was undertaken without delay and the result 175 By contrast twith these cases there is the fol goxoxl louin, (ise history 1 here 1175 one f1011 case in which we see no 131 caroli wlute hos had 7 tische hour history opportunity for the clignosis 10 litsc foceni of generalueel alxlominal pain nausea and somit macle - in with no stiwal in that time Ilicte icre tender Attock old inunt with diatrlnca tud len ness anu ngutus on the rule foncr quadrane Oper lasın, up to sesen or eight stoms a das since the ation for appre milicitis was prompth undertaken Au second or thuird das of life I hate had Ixon no INption as found to have passed into tlic Sortin, anu no blrxxl in thic stol IIc haul talci ·INTUSSUSCEPTION IN INFANTS AND CHILDREN 39 | с D sobowy Fil 11 (Cori) C & D The colon appeared to fill incompletely and imal to the aleo cecal value indicated that intussusccp although a little barium passed into the ileum there tion had been present was a failure of the ileum to fill freely On this ac The child marantic and moribund on admission from its count after a review of the finis several hours later long diarrhoea continued in its previous state for tho operation was insisted upon The intussusception days and died lutopsy showed an extensiic and chiffuse was found to have been completely reduced and only enteritis a cyanotic annular ring in the sleum some inches prox feedings until four days preceding admission The the high mortality There have been 16 enths abdomen was soft There was no vomiting and no in the 121 cases of intussusception since 1930 distintion At autopsy a gangrenous intussusception und in 8 of these the intussusceptions were in the midileum was found ileoilea! The incidence of intussusceptions be It is worthy of note that in 7 of the 23 cases ginning laugh in the sinall lowel was 10% or less of mis-dingnosed intussusception the intussus in the entire series further emplırsızıng tlic 5px ceptions were definitely oleoileal and had not cial character of such intusstisceptions yet involved the colon This being a dispropor I rrors in dngnosis of intussusception excurrul tionately high figure in vers of the loss inci in at least 24 cases in our hospual since 1930 dence of such intussusceptions in the entire se tliese errors were 15sociated in 22 (150s with ries it must be assumed that there is a direct siguficant delay in treatment In the 29rd case connection between the occurrence of ileoileal appendicitis was thought to be present and upon intrissusception the difficulty in dignosis and operat on the intussuweption was found and re ·10 I\TUSSUSCEPTIO IN INFI\TS AND CHILDREN In ses lieved Errors in diagnosis were based on a 4 birium enemy thich runs into the distal ileum number of misconceptions In some cases a rules out the ordinary "pe of intussusception Iristory of days or wecks of pain vomiting con at the ileocecal valie but does not rule out one stipation etc with relatne well being was not hugher in the ileum The latter will usually recognized as characteristic of chronic non short distended 875 filled loops in the roent strangulating intussusception In 8 cases the genogram Mechanical intestinal obstruction passage of feces even to the point of diarr from any cause requires carly relief by opera loerl stools was enough to lead the examiners tion Alertness to advise early operation for istry is sth the suspicion of dysentery suspected intestinal obstruction will benefit the eral cases intestinal obstruction of uncertain type patients with obstruction for more than it will wis thought to exist but operation was inex harm the occasional patients who will prove to placably not immediately undertaken On the Inve been unobstructed Had this practice been one hand, in many of the cases too much stress followed in the cases reported above it might was laid on failure to feel a mass while on the Inveszed a number of chuldren in whom intus other hand an enlarged liver was polpated susception produced a picture of intestinal ob in several cases and insufficient weight 1175 at struction the importance of which was mim tached to a finding of slight abdominal tender mized ness or resistance In some cases the absence The last death in this group occurred more of currant jelly stools apparently encouraged de thin 12 years ago cudence of 7 trend towards 1ny but in others pink enema returns or a his more accurate diagnosis and more vigorous early tory of blood in the stools fuled to alarm the treatinent observers In threc cases the children had established BIBLIOGRAPITY drgnoses of other disease pneumonia diffuse Jeghers II Mchusıch VA and hau II h Con intestinal polyposis varicella and thus delayed of eralized intestinal polyposis and melının spots the recognition of 1 supervening intussusceporal mucosa lips and digits New Fngland / Mied 211 999 1005 1919 tion Rautch Mark V Polypoid adenomatosis of the if we are to lose no children from intussus entire gastro-intestinal tract Ann Surg 125 283 cepcion curly accurate diagnosis is required 998 1918 This calls for a high measure of suspicion and Rutch Mark V Consideration of errors in the a ready resort to barium enema and plun rocnt diagnosis of intussusception du im ) Dis genograms of the abdomen in doubtful cases Child $4 17 26 192 ·Chapter IV PATHOLOGICAL AND EXPERIMENTAL STUDIES IN INTUSSUSCEPTION Despite widespread interest in the clinical own experimental work with guinea pigs cits aspects of intussusception there have been few and rabbits He found difficulty in producing experimental studies of the problem In 1893 intussusception by means of cathartics and other Nicholas Senn found that manually produced pharmaceuticals Intussusceptions which he intussusceptions in cats would reduce spontan produced manually were usually not dramatic cously if not fixed by sutures He reduced expe in their results for his animals tolernted such rimental intusstisception by insufflation of hy intussusceptions fairly well Nothnagel in 1901 drogen gas and considered this the preferred found in cats and rabbits that steadily mun method of therapy in patients Senn s studies tained faradıc stimulation produced a tetinic are perhaps the only ones before our own deal contraction of bowel which occasionally crusel ing specifically with the mechanism of reduc the bowel to telescope into the segment distal tion of intussusception by gas or fluid pressure to it He was chiefly interested as wis Senn in and aimed at establishing the uulity and safety the mechanism of producing intussusception of this method of therapy He was inclined to Both of them noted that the intussusception think that gas was a good deal safer than fluid developed at the expense of the skieth thc but this may have been due to a certain preju lending point not altering D Ircy Poners in dice held by him in favor of the use of hydro terests were more far reaching and luis olyseri ? gen gas in surgery He had recently demonstrat tions more detailed than those of Nothnigel or ed experimentally in dogs wounded by pistol Senn shot through the abdominal wall that if hydro Watts and Fulton in 1931 reported the pro gen gas were insufflated into the intestine it duction of intussusception in monkeys by fordic would escape from the intestine and out the ab stimuliuon of the pre motor arcı of the cerebral dominal wound where its presence could be demonstrated by lighting it with a match This There are 1 number of observations from thic test Senn recommended for use in clinical in experimental laboratory reporting that does with stances of penetrating wounds of the abdomen one or another type of chronic experimental in order to permit early diagnosis of perfora renal preparation are prone to the desclopment tion of the intestine so as to justify operatie of intussusception Hlouch and his 15exitos Intervention found that 11 out of 36 dogs maintained from D Arcy Power in a magnificently comprehen 6 to 111 days on a low sali diet and peritoneal sie Hunterian lecture in 1897 described his dialysis after a bilateral nephrectomy devel cortes ·I TUSSUSCEI TIOSI INFANTS IND CHILDKE opxel in{tissusception Selye mentions intussus Furthermore some vers ago in performing lys {eptions as frequent complications BB Sery young beracum eous ureterostomics in young proprdogs follon mg 1 contricting ligature on one pics bx bolzenit cun peritonierl operations we ruil urtery found fral intussusceprion 1 common complica (rollman and his collergues found intusstis tion of our studies It seems probable that reni! <<prions sn 11% of 71 bilastrilly nephrectom lesions of the kind oder discussion 1re is XI rzed dogs whether interes or subjected to the sted ssst sitesi1973} hyperperistalsis which leads aruftual hidney In Houck s studies nine of with some frequency to the development of the incussusceptions were single {o were dual Intusstisception fen were forward and one was retrogradie The Igreat mass of client experience has been starsuscepxions excurred from the 2nd to the required over the past 85 years in the trcainks Buth day after nuplırectomy some progressed of mutuisstisception bosh by opxruon and I» fus fingrent in some protruded through the reluction with hydrostatic pressure The bulk In many of the dogs hypereni conges of this material demonstrates adequrely in tas ilon epitheinl humorrhages and edemr in the by prigmouc rest the safety and superiority of mucosa of the miestine appeared 31 were inter primary reduction by hydrostatic pressure Tues prired as the possible causes of intussusception of the griest objections raised to the methox! together with visceral peritone Itintson from are 11134 871grenous bone may be reduced and the drolysis flud This could not be the ex that bowel 137, perforate under pressure doring plannion in Scises and Grollsins ms reduction Some years ago in association with us Clamp removed hom sherlh.3- shenthe then it withdraws leni ing 81739 rod in place Mesentery drawn into inlussus depilon B lleum Marking gulure Fugenmental intus uurjon in Ihre k tofu are stipud cut of their sheath and the calls cut has tx 11331slasells a curtcnc tsam 201 lustre at thien teinudd Woh the plans *} ilst intus unesh " crul afilicet me 14 centimeters from the juncuon multianual !. {rntieiets af the Unix (f the roorst thr ( 1912 The spasta rifien sus tres xsayl hul Ingrethe intustik ipient. 1 uk urut in the marke rus! !xer aliex!! nepus ant insaginas into the deszel benci the lord of the Intusixpm (12 Rauch and Me *with flan xl placed atongude the force the (une Hull fiang Ilog ka llor F* 19*} ·INTUSSUSCEPTION IN INFANTS AND CHILDREN 43 Dr Robert M McCune Jr studies were under mental trauma to the borel with resultint ad taken to determine experimentally the likeli herence of the adjacent coats hood of such mishaps and to observe the path The final procedure was as follous employ ological changes in the clinical course of intus ing adult dogs under general anesthesia and op susception in animals erating with sterile technique The ileum 14 Attempts to produce intussusception were centimeters above the junction with the colon made by painting the ileum with barium chlo was stimulated by a faradıc current from an in ride and then invaginating the contracted bowel duction coil While the bowel was still con with rubber shod clamps In some animals tracted strongly it was seized by rubber shod prostigmine was then injected into the corre forceps and inverted into the distal segment If sponding mesenteric artery The prostigmine the entire intussusception was produced in this produced no obvious effect upon the intussus manner the serosal surfaces were sufficiently ception Intussusceptions Produced in this man traumatized so that firm adhesions developed ner were irreducible by enemas as soon as 7 or within 12 hours making the reduction impossi- 8 hours later This we attributed to the instru ble by hydrostatic pressure and difficult by di Fig 13 Experimental Intussusception in Dogs Cross specimen of RVI 9 dying of irreducible intussuscepuon The intussuscipiens and intussusceptum have both been opened Nose the dilatation of the iluem proximal to the intussusception and the narroi constriction at the proxi mal end of the intussusception The muc w of the inner most layer of the intusstiscptum is well prescried and undiscolored The outer layer of the intussureptum is 11 ollen dixolored and the changes are inorc marked at the tip of the intussusception The outcrmost laser the Intussusipiens is grossly normal ·INTUSSUSCEPTIO\I\I\I\TS ID CHILDREN ܙ ܕܙܢ H11 1 xperimental Intusstieption in Dogs Cross gingenous and the unges conspicuously more advanced sprocinen RI 3! Irreducibile intussusception at 19 at the tip thin proximally (From Rasatch and Vicc une hours The outer layer of the intussukeptum is polainly Bull Johns Ilupkins llosp 82 1918 ) 1:1) Experimental Intussuxeption in Ings. The intusuureptun has ptuslapsed through the anus (V) and 15 gangrenouit wlule within the alxdomen (1) there is on pintanierausli preluced coln-cotic innukeption in the same animal The experimental intussuxeptins produced proknied at least as siete a condition as that wen clinically and pronua a unable test of the puble tiarards of hidrmatic reduction (I rom hantch an! VicCutie Bull Johns lloffins llorp F* 191*)

·INTUSSUSCEPTION IN INFANTS AND CHILDREN
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·16 I\TUSSUSCEPTIO\ IN I\FA\TS I\D CHII DRES The pres rect mumpulation The intusstisception there catheter was placed in the rectum the balloon fore wis only initiated with the forceps (Fig distended and salıne solution permitted to enter 124) the forceps then being replaced by a the rectum from 7 height of 3 (cet smooth glass rod and the intussusception com sure is mutuned for 5 minutes If recluc pleted with this instrument (Fig 12B) which tion was not acheted thic colon 1175 allonci to was readily withdrawn without damage to the et cuite and fier 5 minutes the process 11.38 opposed serosal surfaces Intussusceptions of repented If reduction was sull not achieved 1 some 13 centimeters in length were regularly third attempt is made I huis technique fol produced The level of the distal end of the lowed the clinical technique of hydrostatic pres intussusception was always marked by a silk su sure reduction which we unployed at tilt time ture in the serosa of the intussuscipiens The It later became apparent that it was supler neck of the intussusception was usually it the and more effectne to muntuin Irydrostatic pres ilco colic junction or just proumil to it sure without remission rather than emptying Because the cecum of the dog is firmly filled the bonel repeatedly to the posterior parietes there was usuzlly not If the intussusception is reduced the sero much progression of the intussusception In tio sil surface of the bowel was cultured again this instances the intussusception become compound time at the level of the original apex of the developing 1 colocolic component which by intusstisception In any case the abdoinen was shortening the colon permitted the intussus closed and the dog perinıtted to recover from ception of the ileum to prolapse through the the mesthesii The majority of the dogs whose 21us In tuo instances the intussusception was intusstisceptions were completely reduced by his reduced spontaneously In to others the intus drostiuc pressure had unci cntful recoveries the susceptions did not become gingrenous and the dogs in the 38 hour group experiencing the animals suffered only from parul intestinal greatest difficulty When the clinical signs of obstruction Ill the other unimals gie clini intussusception were present bcfore reduction- (olewdence of intussuisception-nor? som inorexia vomiting listlessness passage of bloox! iting passage of bloody mucus per rectum ind per rectum they disappeared within 21 hours malli death unless the intussusception 175 re nfter recluction Some dogs passed soft 1111 ducci In animals coming to operation the formed stools for a few days alternard Other gross parkolo.cl picture was much like that » use the dogs reinamed entirely norınıl to gross In the human In a number of dogs 6 to 8 obscri 1t10n Six of the 10 dloos with irreduce hours after production of the muursstisception 30 ble intussusception of 48 hours showed a procubic centimeters of castor oil was given by gression of their preoperative signisatoriti, stomach tube in the hope of aggruating the listlessness 17chycardu passage of bloul per intussusccption Untreated animals usually sur rectum and soon becimc unresponsive and mor cd over 18 hours I total of 11 dogs suc abund and did I or 1 days after production of (timbed to unreduced intussusceptions Six of the intussisception Two of the 10 dos sillo these intusstisceptions were produced by the ear irreducible initusstisceprions 11 18 hours hud lier and more triumitic method with an avcrage chrome mcussusceptions and showed little more surull of 71 hours Light others hid intussurs thi cxcisional somuing and constspf10n (eption proxlucel lay the gentler methoxl with though one did shos great weight loss by the the glass roul and surused in crage of 89 end of the uccis no dongs of the 19 hour hours group did under anesthesia ruockers shos \lter imenals of 18 28 38 and 18 hours the 1916 spintaneous reductions at 18 hours and the dogs cre inesthetired with other and the abloy dogs suce essfully reduced a 18 hours REYES men repencul I lie serosal surface of the neck cred tiresentfully Tuo dogs dying in less than of the intussusception was cultured A balloon 18 hours before reduction could be attempel ·P 1 C D Plate I 4 RV 28 Experimental Intussusception in Dogs The scrost (not shown) 15 cilematous and hemorrhagic Intussuscepuon irreducible at 18 hours Dag surired ind infiltrated with a fer politin orphonek ar leikocje Specimen removed at 14 dus The lumen through the among the round cells Intussusceptum is narrou but patent There was 10 I bale I DRVO (112) Experimental Intus aneption in gangrene at this time but the mucns of the intussuscep Dogs Intussusception of u lours duration 1) ug dicu tum lind slou,lied from the returning cont particularly 1 6 hours of intussusception Tuinpad 11 once Ilic near tlic apex photomicroraph sh» s all three Iners of tlus antur its I late 1 1 RV 31 Hyperimental Intussusception in Dags ception at the time of the animal deith 1) died at 43 hours The apex of the intussusceptum 1 Inne in at laver oſ til ukeprunt 571,rennus the remunder licmortliagic and sollen I Returning layer of stussuxeptum The ensheathing intussuscipiens is essentially normal (In hetjung Itur-tlıc intussuu ipien 1 late IC RV 22 (130) Experimental Intus uxception The changes are le sextreme thin 3n RV 3 (ilite II 1) in Dogs Intus uvepuon of 24 hours durion Reduce butine can see cleath the mucru! Picin rhuage and ulcer by enem Seroxal cultures Vi sterile before and after stion and the uniscou) lem nhanc in ile sorunun Touuction The tips of the villi are slou Ining and the Iuer (1) < f the intu! Cflun These (113nges are much ville are engorgeil 11th binos! fibrinous hemorrhagic further advanced and much m te werking than this are meml tanec sets the muma The submucosa ! iremen in the inner er entering laser of thic intus ux cph 11 Die du ciematous and hem hag ind filtrated h utenn > use this intu piens is went te relatiei mund cells The Inngitu linnuuk relata eli a urmat trormat

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·INTUSSUSCEPTION IN I\FATS AND CHILDRE 47 EXPERIMENTAL INTL SSL SCEPTION IN Docs Table of Results Duratiort of Inzagt nation HT Culture Before Reduction Result of Treatment Culture After Reduction Dog Fare RV 16 18 Sterile Reduced I enema Sterile Anesthetic death RV11 18 Sterile Reduced I enema Gram + coca Surused RV 18 18 Sterile Reduced I enema Stenle Survived RV 21 18 Sterile Reduced l enema Sterile Survived RV 19 28 Sterile Sterile Reduced 1 enema Reduced enemas RV 20 28 Gram + cucci Gram + cocci RM 20 8 Sterile Reduced I enema Sterile RV 29 28 E coli Reduced 3 enemas Surused Biopsied at 9 days Survived Biopsied at 7 days Sunived Biopsied at 2 days Sunlied Biopsied at 10 days Survived Biopsied at 8 days Surved Biopsted at 6 days Suruned Bropsted at 4 days Surs used Bropsted at 2 days RV 30 38 Sterile E coli strep fecalıs Strep fecalis Sterile Reduced 2 enemas RV 31 38 Sterile RV 33 38 E coli Reduced 3 enemas Reduced 3 enemas Reduced 3 enemas E coli RM 36 38 Surep salıvarius I roteus vulgaris strep salvarjus sirep equinus Gram-rods RM 88 38 Sterile Reduced 8 enemas RV 4 48 Sterilc RV 2 48 Spont reduction Spont reduction Irreducible Sterile RV 96 48 Gram + COCCI Sacrificed immediately after biopsy Survived Survived Chronic intussusception Sur vsed Biopsied at days Anesthetic death Died at 9 hours Chronic intussusception Sacro ficed at 14 days Anesthetic death Died at 45 hours RV 23 49 Gram + COCCI Irreducible RV 21 48 Gram + COCCI Inreducible Irreducible RV 28 48 Gram + cocci RVI 39 48 Irreducible RM 31 18 To treatment RM 35 48 Diciat 98 hours Jrreduable Reduced 3 enemas RV 37 48 Cultures lost RVI 39 48 Hemolytic Staph albus Salmonella Para B (post mortem) Strep fecalis E coli Cultures lost Strep fecalis E coli Clostridium welchu Strep fecalis Eco), Strep saltsarius Surep salısarius E coli To treatment Sussie Die at 1"14 hours Diod at 3 hours RVE 40 48 Irreduable RUE 41 48 Irreducible Diciat 60 hours RUI 49 48 Irreducible 1) ed at 120 hours RVI 43 48 Irreduable Disl at 111 hours (From Ravitch and McCune Bull Johns Hopkins Hosp 8 1918) Fig 16 Experimental Intussusception in Dogs. Intussus under direct visual control It is of greatest interest that ceptons were produced operatively under sterile condi pathogenic organisms were frequently found on the sur Lions and the abdomens reopened under similar conditions face of the intus uxeptum and even of the intussuxipiens at the stated inten als Cultures were taken of the serosal in many animals with bowel sufficiently valle to survive surlaces of the intussuscipiens before reduction and of even after full thickness biopsy of the Lonel mall and the intussusceptum after reduction by hydrostatic pressure dosure of the defect.

·18 INTUSSUSCEPTIO\I\I\FI\TS ID CUIL DREN . Fig 17 RM 38 (160) Experimental Intussusception in Dogs Intussusception of 38 hours duration reduced by cnema and the dog sacrificed at once Cultures Belore reduction-serile after reduction-gram negatile rol shaped bacıllı In the gross the serou was edemarnus and Leefy The insolied mucosa 1135 darler than normal and sharply delineated Under the microscope one sees cellu (ar infiltration of the well preserved mucosi Collet cells are numerous Both muscle coats show sciere changes scen most plainly in the circulur muscle coat the ability of which is doubtful in some arcas There is fibrin on the scrow Experience with animals allowed to survive woulil indicate that in the face of an intact mucosa and submu cosa the areas of probable necrosis in the muscle layers could be expected to heal (From Ravichand Vcrunc Bull Johns flopkins flosp 82 1918) In no had courses much like the other fil cises de Only 1 of these 13 intussusceptions at 18 fours scribed above 1175 reducıhic by hydrostatic pressure rhus der It will be seen from Figure 16 i tobulition sunned The other 12 were all irraducible by of our animal cyperiments that whencier an & fece of hydrostatic pressure and all 12 element Intussusccption could be reduced by hydrostatic died pressure the animal surused indefinitely (but The cultures taken from the scrosal surf10 for one which died under anesthesia) of the intussusceptions are of spcial interest instance lidd any wil with a reducel intus and are shown in Figure 16 The following or slix cption harc peritonitis abscess fistull or ganisms ucre icienuſted from these culturas 1111 other complication to stilgest that non vabic often suveni from one umil Fsclcriches cols lonel night loc licen reducer In no since alpha Sereptococcus feralis itphız Streptoxantils did bossel raducible or irrelucible rupture in salas armas Costudom weltbu Proteus 1111,7114 the 18 24 md 19 hour periis ile intussuscep aplio Streptoxoxcus quinus licmulver Strips tions were all ralucible and all dogs sunned lococcus albus und Salmonella pri In Instances subsequent full tluluess biops lxc suspected wlule cultures were poflc in ? of the tissusception 175 performeri me fol out of 3 des sitli intussukeptious 24 Hours old! lowol by incicntul recoun) In the 1 hour or less 5 out of 6 of the 34 hour old mottakep group there were 18 yox erchung iko klime finns seldal jxxillic cululat ni 1. out of 1? Myopiwis hari selal punt in cousti of the 18 lour old intussuu eptioni velila pw*** ·INTUSSUSCEPTION I I\FA\TS AND CHILDREN 49 dah Fig 18 RM 99 (60) Experimental Intussusception in Dogs Intussusception of 88 hours duration Reduced Biopsied after 4 days Cultures Before reduction-nega tive after reduction-Escherichia coli The mucosa is injected and hemorrhagic but the villı are tall Goblet cells predominate There is extensive submucosal inlil tration and in this instance both inner and outer muscular coats show changes of moderate degree Changes in this animals intestine are not as marked as in many others (From Ravitch and McCune Bull Johns Hopkins Hosp 82 1918) Fig 19 RV 31 (60) Fxperimental Intussusception in Dogs. Intussusception of 38 hours duration Reduced Biopsied after 6 days Cultures negative The patho logical changes are still striking hemorrhage and engorge ment have regressed but there is a heavy cellular infiltra tion nost marked in the thichened submucosa and in the subserosa Again goblet cells are prominent The internal circular muscle layer stains poorly is heavily infiltrated with round cells and appears degenerated The long, tudinal muscle shows some cellular infiltration but the muscle fibers stand out sharply and the nucles are well preserved (From Ravach and VcCune Bull Johns Hopkins Hosp82 1918) tive cultures These results were anticipated by ately after ready reduction of 1 38 four old D Arcy Power who suggested in 1897 chat We intussusception permitted bacteria to pass do not yet know the exact course taken by the through the wall despite well presened mucosa microorganisms as they pass through the wall and submucosa The clinical significance of of the bowel but there seems to be no these bacteriologic findings is apparent They doubt that microorganisms begin to traverse must account in part for the morbidity after the intestinal wall when a loop of bonel has operative reduction of intussusceptions particu been constricted for a period of from 1 to 18 larly in the pre in biotic cra-high fever (some hours and that the more completely the blood times seen also after non-operalise reduction) supply is arrested the more rapidly they pass abdominal abscesses found infections postop- It is striking that bowel as well preserve as that eratne adhesions with intestinal obstruction seen in Figure 17 of RV 38 sacrificed immed: Several features emerge from the patholer ·50 I\TUSSUSCEPTIO IN INFITS IND CHUJI DRES tion cal study of bonel recovering from intussuscep ception The pressure of edema should be the In these e periments the returning lımlı sime on entering and returning layers but the is regularly found severely damaged even to the circulation of the returning layer is further in point of ingrene 1t 1 time when the bowel in terfered with by the U turns mule at the the entering limb is still viable Under the per of the intiissusception and at the ricch conditions of our experiments and probably in effectively isolating this segment of bone! The intussusception beginning in the terminal ileum frontispiece Figures 14 and 1, and Plate Il in patients the returning limb is cut off from AB illustrate this point The changes caused its circulation by the acute kinking of the bowel by the condition are so severe 15 still pluınly 75 it turns on itself at the per of the intussus to be seen microscopically ten days after reduc Fig 20 RV 20 (60) Experimental Intussusception in Fig 21 RH 19 (60) Experimental Intussusception in DD Intussusccption of 28 hours duration Reduced Dogs Intussusception of 28 hours duration Koulucah 1» enema Biopsied 7 days later Cultures Gram positive Biopsied 9 days later Cultures !! sterile The lonel enxos lxctore and after reduction in the gross the bonel appeared norinal in the gross Under the microscope the was slightly thickened Under the microscope the sillt are epithelium is seen to hasc regenerated and arpras not found engorgeul with bloox! and found cells and a few inal but for increase in the number of goblet cells. The polsentrplonuclear leucocices The mucou u flationed hulle although irregular are all There 11 eremoninus anı ile glands di forted the thickening of the lonel at mund cell antiliration of the subrnutog and numerous this stage is due more to the tremendous cellular infiltra engorged sessels. There are a few polyphonuclear 11 in of the subomucna than in alema The finer circular leucocytes among the m manuclear celle The sulmunul mux le laver again appars glass and inliltaal while lymphud follicies are greatly enlarged and contain a few thic cuternal longitudinal muxle lavet is nell presen el polimorphonuclear cells The wesos no turiened area ulceration is seen but the vil xem thinnail out there are sult a few round cells and plasma celle Thesit 111cte 14 Fulcrale senul alema and mund cell infiltra cular muxlc laser s still abnormal play and infolisin! !!! (from Rauch and McCune Hull Johns Hopkins with many mund «ells (1 rol Rasch and Vir une Ilost 9. 1919) Bull Johns llopkins flouf ! 1918) ·INTUSSUSCEPTION IN INFANTS AND CHILDREN 51 tion (Fig 22 (RM 29)) Hemorrhage and en micrograph of RM 23 (Plate IIA) The inner gorgement disappear first then edema and last circular muscular coat is largely destroyed ind ly cellular infiltration The mucosa is frequent unrecognizable in the thickened returning 17;er ly partially sloughed or eroded but ulcers of the intussusceptum while the outer longitudi through to the submucosa are not seen De nal coat is relatively well preserved morphology spite this fact pathogenic bacteria male their cally way through to the serosal surface There is a Another avenue of investigation has been the striking difference between the surual ability study of the pressure tolerances of the humın of inner circular and outer longitudinal muscu colon This was made necessary by such aduce lar coats as sharply demonstrated in the photo as that given by W E Forest of New York in ? Fig 22 RM 29 (160) Experimental Intussusception in Fig 23 RV 23 (1) Experimental Intussusception in Dogs Intussusception of 38 hours duration Reduced Dogs Intussusception of 48 hours duration Inreducible Biopsted 10 days later Culture Escherichia coli alpha Inimal sacriliced and specimen obtained Scrosal culture Streptococcus fecalis. There is no more evidence of hem Gram positive cocci Only the returning layer of the intus orrhage and engorgement One still sees an abnormal susceptum the middle of the three layers of the intussur number of goblet cells There is some round cell infiltra ception is shown The bowel is almost entirely gangren tion of the submucosa The inner circular muscle is almost ous. The mucosa is unrecognizable The submucosa is hyaline The outer coat shows some degenerative changes tremendously thickened The inner circular muxlc * The serosa is thickened and infiltrated with round cells completely disorganned while the outer longitudinal and polymorphanuclear cells and shows beginning organ layer is startlingly presened in contrast to the general ization Edema has entirely receded (From Ravitch and destruction of the other laser The scroya shows only VcCune Bull Johns Hopkins Hosp 82 1948) adema The vessels do not show clots or thrombı poner photomicrograph shoning a cross section of the entire specimen is seen in Plate 111 A (From Ravich and VcCune Bull Johns llapkins Hosp 89 1918) راد ·52 INTUSSUSCEI TIO IN INFITS IN CUI DREN Fig 21 RV 30 (60) Experimental Intussusception in Dogs Intussusception of 38 hours duration Reduced Biopsied 8 days later Culture alpha Streptococcus feca lis The will still show hernorrhage and an infiltration of mononuclear cells The submucosa us thickened and heauly infiltrated with round cells There 13 once more the usual difference between the muscle coats the outcr being well preserved the inner not (From Ravitch and VcCune Bull Johns Hopkins llospo 82 1918) 1889 lle duised laying the child in the hall May inserting the enemi tube and slowly as cending the sturs cnema bag in hand evercis ing caution after ascending 10 feet ! Vorumer in England injected the colons of fresta cidasers with the ileo cecal valve ligited He found the serosa to begin to crack in some (75Cs with frie feet of pressure in most with cight let and excasional rupture to accur with SI feet of pressure Nordentoft performed sim ilor cyperuments distending the boucl of dead newly born chuldren with the ileum ligued 10 the alco ciccal junction I he boclios hund been cend from 13 10 51 hours Rupture of the hou cl ocurred with pressures of from three to ten mctcts In illo cases in which the resistance of the small bond was tested 175 found to rupture after three and "Men meters of pressure respxoticis Thc 3 or 116 lect of pressure used in patients would appear to provide a sale margin BIBLIOGRAPITY Forest W E Intussusception and the use of injec crons Rec 36 371 1889 Ilouch CR Voore 11 Ellison WB and Gilmer R Intestinal intussusception in chronic nephrectomized dogs maintuneil by peritoneal dulysis Science 119 815 816 19,1 Vostum. ) 1 On the islatment of intussusccp tion by injection or inflation and its dangers Iancel I 1111 1891 Vuirlicad + F (rollmon and Vimatta ) Ilypx rtensic cardiovascular disease ( inalignant HyxStension ) rich Path 50 137 150 19,0 Tordentolt J V Ilie salric of the barium cncmna in tlic diagnosis and treatment of intussurception in chuldru illustrated us alxyut 509 Danish card Arla radiol Suppl si 1913 lotinaci Ilir Diseases of the intoymes and fxritoncini 11 Sotlmgels Imagens india al I sactical Medicine i luladelphia Sunddess ·INTUSSUSCEPTION IN I\FA\TS AND CHILDREN 5$ Power D Arcy The Hunterian lectures on the path 32 550-568 1918 ology and surgery of intussusception Brit Med Selye H Textbook of Endocrinology Icta endo- 1 1 381 493 514 1897 crinol 1917 Power D Arcy Some points in the minute anatomy Senn Vicholas Intestinal Surgery Chicago Il T of intussusception Path & Bact 4 484 1897 heener Co 1893 Rayitch M M and McCune R M Jr Reduction Watts J 11 and Fulton J F Intussusception – of intussusception by hydrostatic pressure an ex relation of cerebral cortex to intestinal motility in perimental study Bull Johns Hopkins Hosp monkey Leu England J Med 210 883-896 1934 ·Chapter 1 TRCATMENT OF INTUSSUSCCPTION The A OPERATIVE and rapidly there is no need to deliver the in tusstisception nor (o question the vibility of he standard treatment of intussusception the bonel The proper mechanism of manual in this country ind the British Isles ind in reduction of an intussusception was clearly de most of Furope is immediate operatic rcduc scribed by Hilton Ingge ud Henry House uon of the intissusception I or a good many of Cuys llospurl in their report in the Vedi cars greit stress was laid upon the necessity cıl Chirurgical I runsactions for 1976 They for operating upon the patients within mo stated the intestine was accordingly drun out ments of their aray) in the hospil ud Doc from the abdominal cality and lion then tor Ladd in particular emphasized the urgent some difficulty was experienced in ruluicing 11 impon171cc of instant operation As time has Pulling 11 the end 17s que meffectul though pissed it luns become generally accepted tlıat thic as much force, as was consulered justifiable #138 immediate need of a child uitli intussusception cierted in this wizy Under n kind of Incading is for inertsenatis fiards or blood for gastric moi cricnt honcier combined with circular ispiration is in any type of intestinal obstruc pressuire upon the furthest intusslisecptal part tion and for the administration of antibioucs of the gut it begin to yield and when once 7s in my other sition in which there is poten started the proxcess went on readily umul the in jcopardy of the vascular supply of the last part of the intestine was reached boucl These measures having been under It will be seen that this method of reilu front taken the abdomen is entered through the sur luch is precisely that user exly is essentially gcons Incision of choice Our own preference one in which tic surgeon is compressing llic 111 Nussusccption in a situation in which the bowel distil to the intusstisccptum INCTORS pxne minipulation may begin in the left the pressure within the lumen of in buone louer quadrint ind end in the right lower qund forcing the intusstisceperon proxemilly in this ramt would be for a loner midline incision Tlus pressure is applied much as in ( lcrurilly our innisstisceptions are almost invat lazdrostatic pressure seduction such an enems sabils relucel to the cecum by the barium cncma but the manual mothexi of reduction is no in that 25% of (750s 111 which cnem reduction sanıly more traumatic At times there my l» is not complete and share a small VicBurney (ncountered a sulten difficulty in Operillic Incision sulficos) The intusstisception is then reluction of u int113stixception in such in wills toward the lonel manipulated in com stances it 15 1571pxortant that thic IISSIIKccption le prosion juist distal to the inttisstisception dra delucted and carefully olisend le presse mn, it proximally If thc bowel reduces castly is facing made distal to it The first 111 ເriາງຄcr 51 ·INTUSSUSCEPTIONIS INFANTS IND CHILDREN 55 of impending danger will be serosal cracking geons interested in the problem as to the proper of the receiving loop of bowel as undue pressure method of procedure when bowel is to be re is exerted upon it by the failure of the intus sected Intestinal resections and anastomosis of suceptum to yield At times the manipulation any kind were fraught with an almost prohibi may be aided by the gentle injection of sterile tive mortality up to the first decade of this cen mineral oil between the coats of the intussus tury It is not surprising that in that day sur ception Attempts to stretch the nech of the geons either refused to operate hoping that the Intussusception with instruments invariably re gangrenous intussusceptum would pass spont? sule in disaster and incision of the neck of the neously or attempted some minor appearing intussusception invites contamination of the procedure rather than a bold resection and anas operative field in any case it will be seldom that tomosis Such a procedure was that of Cushing an intussusception so difficult of reduction as to seen in Figure 25 This type of half way meis require these strenuous methods will prove not to ure is still apparently performed from time to require resection because of gangrene or doubt time but with us little success as it had in Cush ful viability If therefore persistent and gen ing s day tle compression of the bowel distal to the intus Maunsells method of resection of turnors of susception does not reduce the process resection the bowel which is based on the delibernte should be undertaken One can tell in five producuion of an intussusception obviously sug minutes whether the bowel will reduce and gested itself to those operating at the turn of stubborn persistence at manual dısını agination the century and fearful of their ability to suture is to be decried divided bonel after a resection This method is In view of the recognized incidence of recur cited only for historical reasons since unlike rence of intussusception numerous methods have most of the other methods of operation which been undertaken by various surgeons to decrease have ever been proposed for intussusception (see the likelihood of recurrence In general it may Fig 26) it is nou never used In thus ingenious be said that the various attempts at fixation of method the entering and recensing layers of the the cecum and of the terminal ileum have been intussusception were sutured together at the abandoned as not being effective and as being neck of the intussusception The intussuscip potentially harmful A good deal has been writ iens was opened by a longitudinal incision and ten about the advisability or inadvisability of tlie intussusceptum amputated from within the removal of the appendıx at the time of reduc intusstiscipiens A circular suture of the impu tion of an intussusception Although the group tated base of the intussusceptum was followed from the Children s Hospital in Boston former by closure of the incision in the intuissuscipiens ly in eighed strongly against this practice a re As might be supposed this method did not prove view of current writings on intussusception to be very successful despite its ingenuity would suggest that appendectomy is now more The drasings in Figure 26 ustnic the commonly performed than not at the time of modes of treatment of irreducible intussuscepoperative reduction In a revient of our own tion which have been employed These are - material up to the time at which operative re Resecuon of the bowel and creation of a duction became a rarity we found that patients double barrelled ileo colostom in whom the appendix had been removed ac 2 Exceriorization of the bowel with delayed tually had a lower mortality than patichts on division of the bowel (the septic Mikulicz whom yppendectomy had not been performed resection) No complications were atırıbuitable to appendec 3 Primary resection with end to side ilon tomy colostomy the open end of the colon being left Surprisingly enough there remains a substan 25 2 sent tial lack of agreement among the various sur Side to side anastomosis around the intus ·50 INTUSSUSCLI TIO I\I\FIIIS I\D CH111 DRET THE JOHYS HOPKINS HOSPITAL THE JOHNS HOIXINS HOSMTAL profunda Uhr 1 Shop + Short phone hangt that 1.1 O fgan fue rie halong the (h they B FIL, 23 Drinings by Harvey Cushing in History To 10141 The Jolins Hopkins Hospital A Case of Intussuxception A March 2! 1900 Operacion {recisan Exploratory Laparotomy (ushung Reduction of Intussuscption ther Tetorition at per al intussuscipiens Establishunent it thi poim olarul anus (luronic peritonitis Sketch thening toughls the Collapsed trimers colons situation und chariter Serovato SerOST of inittissicption (Tucous membranes in red) Iunien 13 Operation Cushing Sicuchillustrating method of closure after reduction of intussusception I went tool anesthetic ludly plush shocked Ci cthcr chart Situation ( slough and perforation pandex Dustendcu Ilcum Hon superior is a brick and nicely illustratoil note (in I*** colors) like thus to the impersonal formal aspred opera 1110 notes which most of us case todas I he operation of Our was els conceicol The lonel 35 OT scirrely injured to be trusted beneath the alkiominal wall this patient failed to survive and the results of the empty ment of this proxelure which are still reported from time to time basc lcen similarly unutracten (uhing *** ullicienils diutuslici with his coutus on the treatment of infassuxeption that in MM lien a culmith hudra <cphalus on whalie houd attempted a utaraclin II frnical shesite through a metal (mla ducir 1913 uurpa 11 on le alused exsung the chule in the hope that of 1511439 435353 heute! Ixcomne gangen u and * ru!! sl rugh out frontarer uls In that instance ihn dini (ker and the child succumul Imunuxeption in the earli dars of the Jolins Hopkins llopal was a highly tatal disease despite the fact that Ilutchinson had already demonyralal the leasibility of opreration and Ilirxhsprung the lower metality IISKI aind with systematic use of lsdromatic pressure Fancy (mind was all my lift a meticulous anel carciul miller Me old fustories of his patients contain many examples of carclul and lucid illustrations like the present one ·INTUSSUSCEPTION IN INFANTS AND CHILDREN 57 are susception which is left undisturbed 2 The desirability of avoiding the fluid loss 5 Resection and primary anastomosis side es and sound complications attendant upon cre to side end to end or end to side ation of an ileostomy As the mortality of intussusception in general 3 Desirability of immediate restoration of has decreased sharply and the frighteningly high continuity of the alımentary cinal and mortality after resection of a few years ago has 4 The avoidance of staged procedures similarly decreased arguments favoring one or This is to a very considerable extent a mat another method of treatment if based on mor ter of individual experience outlook and phi tality figures alone tend to lose their cogency losophy Those who have had disastrolis results The most important determination to be from attempting resection and primary anasto made at operation is that the bowel is indeed mosis in these profoundly all children with un ron viable or that the intussusception is inte prepared intestine and edematous bonel and ducible If after five minutes of attempts at probably contaminated peritoneal cavity manual reduction the bowel has not begun to understandably prejudiced against such a pro move back one should assume that the intussus cedure On the other hand as progress is made ception is irreducıble and proceed with some in surgery staged operations in one field after type of operation which recognizes this fact A another have been gren up for uinmediate de good deal of experience is required to tell finitive operative procedures For a long time whether the beefy edematous thickened and of course it was thought that infants would not indurated hemorrhagic bowel of a reduced intus support an ileostomy with any degree of success susception is viable or not It is a striking fact Improved methods of management of fluid and that in institutions at which the majority of electrolyte problems have very largely disposed intussusceptions are reduced by barium enema of this objection to a staged procedure the resection rate is far lower than in institu Resection of the bou el in the course of the tions where primary operative treatment is the operation and bringing the bouel ends out rule It is entirely possible that the increased through the wound (Fig 26A and B) is the most resection rate when operation is undertalen in direct and simplest way of dealing with the all cases is occasioned to a considerable extent problem Gross in Boston and Jones in New by the additional trauma to the bonel incurred castle on Tyne have described worthwhile mod as a result of the surgeon s manipulations Fur ifications of this basic plan Gross (Fig 268) ther it seems probable that in a good many disides the mesentery but does not resect the cases bonel which is entirely viable has been mis bowel The loops of bowel immediately prox: takenly resected because of its swollen hemorr mal and distal to the anastomosis are suitured hagic appearance Two examples of the latter together in preparation for the construction of a from our oun experience have been cited and double barrelled leo-colostomy The alcorni are allustrated in Plate TIC and D Needless nal wall us now closed about this double loop to say if there is any doubt about the viability the intussusception itself being entirely exterio of bowel it must be resected although increas rized 111th the abdomen nou completcly ing experience will lead to greater accuracy in closed the proximal and distal limtys are tran this determination There is at present no sected between clamps and a catheter is inscri ready method for operating room determination ed into the proximal lumb for decompression of the ability of possibly compromised bonel I cruslnng clamp is applied to the spur within The choice of an operative method of treat a few days and the enterostomy is closeul wathun of an irreducıble intussusception is Six or seven days Cross reports 11 cases trent swayed by the following factors ed in this way with 11 recoveries a mortality The desire to do as little as possible as of 23% Fleren of these patients were treated npidly as posuble in a profoundly ill infant in the nine years Ivetkeen 1999 and 1918 with ment 1

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·IN TUSSUSCEPTIONI I FANTS AND CHILDRE 59 recovery in ten and a mortality of 9% The ages The chief advantage over primary anastomoof the successfully operated children range from sis would appear to be in the improvement in three days to seven years Jones Writing in the edematous state of the distended proximal 1993 reported 82 intussusceptions reduced by bonel and in the certainty that after 48 hours primary operation with no deaths six sponta any bonel apparently viable had survived the neous reductions and six chronic intussuscep jeopardous period of progressing infarction tions operated upon with no deaths In addi It is not surprising in consequence of the fact tion there were nine instances in which resec that the bonel which presents to view in an tion was required The loop of involved bowel irreducible intussusception is almost always via was brought out through the wound (Fig 26A) ble that surgeons hase from time to time been the bon el loops not being sutured together the tempted to perform anastomoses around the in abdomen was closed and the bonel resected tussusception leaving it in situ Parry in 1909 Forty eight hours later the exteriorized ends of and Rutherford in the same year reported suc the bowel were resected and closed and a side cesses by this method and Montgomery and Vus to side anastomosis performed In these nine sil in 1930 revived the method which is from cases there was a single death He excluded time to time referred to as the Vontgomery opfrom consideration a case in which the entire eration (Fig 26E) White and Dennison at the colon was necrotic and required resection with Royal Hospital for Sich Chldren in Glasgon ultimate fatal outcome A later report by are among the more recent advocates of this Court and Jones adds one more successful case method In four of their case, a simple anisto- This method would appear to have all the mosis was performed around the intussusception advantages of Gross s method and to be moving and all the bowel returned to the abdomen much closer to the primary anastomosis since The subsequent courses of these children dem the reconstitution of the continuity of the bonel onstrated that in two cases the intussuisceptiini is achieved in two days The results could hard sloughed and was passed with satisfactory func ly be improved upon tion of the intestine from the time of operation In one case which subsequently died of len kemia and was autopsied the intussuisception Fug 26 Operative Treatment of Intussuscepuon apparently remained in situ but recanalized A Al and A2-The method of Jones of Newcastle In the 4th case the intusstisception apparently 4-The entire intussusception is brought outside the reduced itself and a barium meal followed its abdomen the abdominal wound closed Al-Both loops are amputated and tubes are tied into normal route Dennison und some of the car the bonel The dotted line indicates the site proposed lier authors in bypassing the intussusception transection of the bowel the edematous exterionized ends ads ise suturing the neck of the intussusception being removed 48 hours after the original operation and to present its further adsance a stde to-side anastomosis performed as in A2 Jones reports ten cases with a single death After Dennison s first report in 1918 White B B1 B2 and B3-The Aseptic Vihulic procedure and Dennison in 1932 reported a total of 16 of Gross patients in whom a primary anastomosis was B-The entire intussusception is exterionized the me in senter duided the afferent and the efferent limbs performed sithout resection of the miss SIY of these the mass was exteriorized at the sutured together and the wound closed hi-Both loops are amputated the proximal limbs time because it was thought to be gangte110115 decompressed by means of a catheter through to the outer coat White and Denni 12-1lathin a few days the spur is crushed by a clamp son male the point that they have never seen and on the sixth or seventh day the remaining enterostomy death from peritonitis in unrecluced intussus wound us closed by an essentially extra peritoneal opera the procedure ception and that death occurs from intestinal Gross reports 11 cases with 11 recoveries and of these obstruction and torcinia For this reason tlicy in the years 1939 to 1918 eleucn cases with ten recoveries. feel that the return of the irreducible mass into

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·INTUSSUSCEPTION IN INFANTS AND CHILDREN 61 the peritoneal cavity after a simple anastomosis Dennison it is important to point out as Jones does not violate surgical principles They also and others have stated that occasionally necrosis emphasize the fact that a substantial number of is found and recognized in the ensheuhing layer the resections are required not because of the and when this is the case quite obviously a sim basic extent of the pathological process at the ple sliort circuiting procedure cannot be per time the patient is brought to the operating formed Whether one would choose then 15 room but because of the damage inflicted by White and Dennison have chosen to perforin attempts at manual reduction Of their 16 an intra abdominal anastomosis with exteriori cases four died Four of the six patients with zation of the bowel and of the intussusccption exteriorized bonel required 2 subsequent hemi without resection is a matter for individual colectomy In one of the patients with ex judgment From the report of White and Den teriorized bouel the intussusception could be re nison it seems that very little is guned by len duced subsequently and was returned into the ing this mass of bonel outside of the abdomen abdomen with success In another such case the for a time It is of mterest in White and Den baby aspirated vomitus and died after the sec nison s pitients that after two months there 1179 ond small operative procedure on the second not in any case any 17diologically deinonstrable day The other three deaths were in children evidence that the short circuiting anastoinosis who had simple anastomoses and are described was functioning and the implication is that the as having been due to bronchial pneumonia to normal channel liad been reconstituted and that shock and to toxemia respectively the anastomosis had ceased to function Ones In connection with the work of White and reaction is that this is an essentilly unsurgical procedure and that one is lonth to lenie 1 一条 potentially gangrenous lesion in place and that C and Cl--Direct resection of the intussusception and in general in intestinal surgery short circuiting performance of a straightforward double barrelled ileo intestinal operations which do not del defum colastomy D-The method of Il vodhall-the intussusception hus tively with the primary lesion ure unsatisfactory been resected Continuity of the bowel has been restored Unfortunately for such a priori judigmcuits the by a side to side anastomosis and the ends of the bonel method does work and the results are entirely have been brought out as clecompressing ents which will acceptable It inny prove that the risks of len close spontaneously or can subsequently be closed by a ing the msolved segment of boucl behind are no E--The procedure of Parry (1909) and of Rutherford greater than the risks assumed m performing (1909) revived by Montgomery (1930) and presently ad more complicated operatic proxedures and vocated by 11hite and Dennison The intussusception is anastomoses left in situ and a side to side anastomosis performed be In order to combine the di antages of remov tween the afferent and eſſerent loops I hite and Denni son report 16 cases with 1 deaths al of the intussusception and restoration of the I Fl and r2-Resection and primary anastomosts continuity of the intestinal tract in one singe either side to side (F) end to-end (FI) or end to side (F2) with the decompressive benefits of the Miku This is the most strai, htforward and definitive procedure licz type of operation Woodhall (hg 261)) ? This is the preferred method of Dennis of Benson and the suggestion of Dean I cuis resected the mtus Sharp of Iackard and Wlen of Zachary of For of Thatcher and others und seems to be becoming estab susceptum perforining 1 side to side w7stomo Iished as the procedure most frequently advocated and Sis bringing out the ends of the trinsecteel performant bowel is temporary vents This had the double Ventioned only for the sake of historical completeness di antage of decompressing thic proximal intes is Vaunsells operation Here the neck of the intussuscep tine und mmınızing thic danger or consequence tion is sutured the intus uxcipiens inced the intussusof leil2,e from in mastomosis 111 clemous ceptum amputated the transected edres of the intus us ceptum and intus uxipienst hipped over and the incision Exme! As the anastomosis begin to fine t1on in the intus uxcipiens then clied these vents closed spontaneously or could be feu sutures

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·INTUSSUSCEPTIONINFANTS AND CHILDREN 61 the peritoneal cavity after a simple anastomosis Dennison it is important to point out as Jones does not violate surgical principles They also and others have stated that occasionally necrosis emphasize the fact that a substantial number of is found and recognized in the ensheathing layer the resections are required not because of the and then this is the case quite obviously a sim basic extent of the pathological process at the ple short circuiting procedure cannot be per time the patient is brought to the operating formed Whether one would choose then 15 room but because of the damage inflicted by White and Dennison have cliosen to perform attempts at manual reduction of their 16 an intra abdominal anastomosis with exteriori cases four died Four of the six patients with zation of the bowel and of the intussusception exteriorized bonel required a subsequent hemi without resection is a matter for individual colectomy In one of the patients with ex judgment from the report of White and Den teriorized bonel the intussusception could be re nison it seems that very little is guned by lear duced subsequently and was returned into the ing this mass of bouel outside of the abdomen abdomen with success In another such case the for a time It is of interest in White and Den baby aspirated vomitus and died after the sec nison s patients that after tho months there 178 ond small operative procedure on the second not in any case any radiologically demonstrable day The other three deaths were in children evidence that the short circuiting wastomosis who had simple anastomoses and are described was functioning and the implication is that the 75 having been due to bronchial pneumonia to normal channel lad been reconstituted and that shock and to toxemia respectively the anastomosis had ceased to function Ones In connection with the work of White and reaction is that this is an essentially unsurgical procedure and that one is lonth to Icie 1 potentially gangrenous lesion in place and that Cand ci-Direct resection of the intussusception and in general in intestinal surgery short circuiting performance of a straightforward double barrelled ileo colostomy intestinal operations which do not deal demi D-The method of Woodhall-the intussusception has tively with the primary lesion are unsısfactory been resected Continuity of the bonel has been restored Unfortunately for such a priori judgments the by a side to side anastomosis and the ends of the bowel method does work and the results are cntirely have been brought out as clecompressing Vents which will acceptable It may prove that the risks of le? close spontaneously or can subsequently be closed by a ing the involved segment of bowel bсhind are no E-The procedure of Parry (1909) and of Rutherford greater than the risks assumed in performing (1909) revved by Montgomery (1990) and presently ad more complicated aperitie procclures and located by White and Dennison The intussusception is nastomoses leſt in situ and a side to-side anastomosis performed be In order to combine the advantages of remos (neen the afferent and ellerent loops White and Denni son report 16 cases with 1 deaths. al of the intusstisception and restoration of the FH and F2-Resection and primary anastomosis continuity of the intestinal tract in one stige either side to side (F) end to-end (FI) or end to-side (F2) with the decompressive benefits of the Vikin This is the most strai, htforward and definitie procedure licz type of operation Woodlial (F., 20D) 70 Tlus is the preferred method of Denms of Benson and the suggestion of Dcan Lewis resected the intus Sharp of Packard and Illen of Zachary of For of Thatcher and others and seems to be becoming estabsusceptum performing 1 side to side wastomo Iished as the procedure most frequentis advocated and Sis bringing out the ends of the transccted performed boucl is temporary vents Tlus had the double Ventioned only for the sake of historical completeness ads intage of decompressin, the proximil intes 15 Vaunsells operation Here the neck of the intussuscep tine and minimizin, the danger or consequence tion is sutured the intusyux ipiens incived the intussus of lerlage from manastomosis in alemttons ceplum amput at the transected edges of the intus us bouch «eptum and intus uxiprens whipped over and the inci son is the stomosis begin to fitnction in the intus uscipiens then closed these rents closed spontaneoush or could I few sutures ·62 INTUSSUSCEI TIO\I\ INFINTS IND CHILDREN closed by 1 small clin? peritoneal operation attributable to the condition of the child at the Finally there is the direct primary anastomo time of operation and to the operation and not sis (Fig 26F) usually end to end which most to loss of fluids from the ileostomy The tho u riters are coming to accept patients operted upon by Woodhall both recou In irreducible or strangulated intussusception ered as did 1 third child with a side to end mas It is self erdent that a one stage resection and tomosis the end of the ulert segment bein primary anastomosis would be the most desir brought out is un ileostomy This fistul? 175 able procedure if it could be safely performed closed seven days later That is actually the direction in which most In the ten years January 1918 to January surgeons reporting their experiences today are 1958 uehre had 52 intussusceptions 21 Tlic tending with the notable exceptions gren Johns Hopkins Hospital and no derths Of above Our own experience with resection is these only iko had boucl resections one in 1919 essentially in old one and so fer resections are in 1 seven month old inſint for an enteric gst non required on our service is to allow no con at the illo caecil valve which had cruised a clusions Our present practice in bowel resection reducible intussusccption and one in 1937 in in infant of four months with an irreducible intus in infunts for other causes is entirely in favor of a primary one stage anastomosis In a revient stisception reachung to the hepatic llevure (Fig of the entire material of The Johns Hopkins performed in both infants without event 27) Primary resection and anastomosis was Hospital from 1889 to 1918 there were 32 opera tre procedures for gingrenous or irreducible The reported moreality of intussusception in those cises which required resection lors bech mtussusccption In mine instinces the bowel was extremely high until very recently and it is resected and in imediate anastomosis per small wonder that surgeons have shed 2017 formed Seion of these patients died the first from primary anastomoses believing that these one being in 1899 of 1 breakdown of the anasto requirei lirger operations 106 longer proxec Vost of the deaths appeared to be of dures in cltremely sick chuldren Benson and shock and infection and not due to z suture Sharp reporting their experience at The Chil line brez donn with the exception of the case dren s Hospital of Vichuguin 100 reported done in 1899 In four cases the intussusception five chuldren with intussusccption resected dur was reduced and an enterostomy performed ing the previous three and a half years witls pri All four of these prtients died In one case the mary wastomosis and 1 single death due to Lowel as extraperitonealized and the pitient mecrosis and lezhgc at the suture linc Some died In seven instances boucl of questionable of their anastomoses were end to cut some couch sability was inverted in order to 1101d the larger to sicle sume side to side I be find case had a Operation of resection Three of these seien side to side nastomosis They feel that sucio WII three of these derths occurred sicle wastomosis is preferible for mfants you in the immednic post operatie period ind all er than four months títer which zge the sue of were apprentis duc to the desperite condition the bose begins to make and to end anastom of the patients at the time of operat101 Light sis feasible and practical Dennts utilis, from patients ricre treated by a Mikulici uspe of resec the t'murersity of Vennesota rewrici ciglit te tton Onc byc fore 1930 with enth scion since sections for intussusception Ixenceu 1910 and 1930 with onc denih Inc of these were of the 1917 15th prinnry end to enu anastomosis il Ile land no deaths ordinary Mikulicz type and three of the eight mng the closed icclique were done by the moslification described by Prchard ! Ille 11 writing from The Demet 11 colhall gun these liso deaths occurred (No Cluidrenis llospall remitt ane srsrutions for to three liours after operation lxcin, apparently intussusccpiron with no deaths l'rimary antas 111051s patients did

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·INTUSSUSCEPTION IN INFANTS AND CHILDRE 6 tomosis was performed in all "There is no diffi the technique described above and had fifteen culty in finding reports usually somewhat ear recoveries lier than these listing prohibitively high mor Lawrence und Ulfelder reported from the talities from resection for intussusception Sny Massachusetts General Hospital in 1932 fre re der Kraus and Chaffin writing from Los sections with anastomosis for irreducible intus Angeles Children s Hospital in 1949 report a susception with one death 66% mortality in patients requiring resection Zachary prefers a generous resection with end Gibbs and Sutton in 1943 reported a 71% mor to end anastomosis by a closed technique ind tality in patients requiring resection In their decries either the aseptic Mikulicz procedure hands resection and primary anastomosis yielded lateral anastomosis to such a procedure accord other Mikulicz procedure or the addition of a a mortality of 43% whereas Mikulicz resection ing to the method used at New castle on Tyne produced a 100% mortality Gibson and asso Fox in 1956 from the Children s Memorial ciates reporting from the Mayo Clinic in 1949 Hospital in Chicago reported ten resections with had a mortality of 50% in patients requiring primary anastomosis and one death resection and primary anastomosis and had one Thatcher reporting from the Vilti tukee Chil survival after a Mikulicz reset tion Hogg and drens Hospital in 1954 reported 15 resections Donovan from Babies Hospital in New York with primary anastomosis since 1917 with one in 1916 reported nme resections for intussuscep death a 66% mortality tion Three out of five with primary resection In no single series is the number of resections and anastomosis succumbed and two out of the required sufficiently large to make a compırı four with Mikulicz resection died McLaughlin son of result statistically significant In the in 1948 reported resection in 21 cases with a small series of resections with which we thus mortality of 50% Gross and Ware writing in have to deal random sampling of a few more 1948 reported 18 cases with primary resection profoundly ill patients in one dimc tiran in in and lateral anastomosis with only three recov other may seriously color the results It wouli eries a mortality of 83% These had all been appear probable that as good results « un loc ob performed more than ten years before the report tyined by primary resection and wastomosis is and these results were the basis for the abandon by ? Mikulicz exteriorization procedure Item ment of primary resection and anastomosis at tainly appears to be established that if 1 Viku the Children s Hospital in Boston In 19.13 licz procedure is to be performed an anastomo Gross Ind performed 18 Mikulicz operations by sis may be performed at the same time by the method of Woodhall leavin, one or both loops of bowel open is sent or the double burrelled I The intact specimen the ileum entering the intussus leostomy may be taken down after 18 hours and ception at the left the exteriorized ends resetted and anastomo I The specimen las been split and the view is that of the sis performed by the inethod of Jones or 1 dou interior of the poruon visible in which has now ble burelled ileocolostomy may be performed been turned over so that the intussuscipiens is at the the spur crushed ud clic bowel nastopiOSCH lelt and the entering ileum at the right Notice the some time later -the methodl of Cross apparent good condition of the proximal ileum and the tremendous thuhening of all coats of the returning 1ll of these methods are apprezabely loss tidy limba of the intussusceptum and the beyinning slough than a direct anastomosis and seem not to pro ol the mud I he intussuscipiens is clustended and duce dernonstrably better results It is to be thinned out but intact the appendix also visible in expected that there will be a gradual trend to E luas ju i begun to be drain into the intussuscep tin and its distal portion shows changes in color wards general adoption of the one sta, defins An end to-end ana tomosis 12performed The child tiic procedure The short circuiting prixclure reciere uneventfully and left the hospital in ten days presently advocated by the Clasgos group also ·66 INTUSSUSCEPTIO IN INFANTS AND CHILDREN represents a less than definitive operation hich had 7 simple operative reduction of a mous does not have the appeal of the primary resec susception and the child who has lid 1 testu tion and anastomosis nor results sufficiently bet tion Gastric suction is maintaille from the ter than reported by the other methods to war time of operation ind the chuld treated as if he rant its adoption had an established intestinal obstruction Above all it must be stressed that children soon as the child has passed 7 stool the suction with intussusception are sich indivduals, that is discontinued and the child begun on oral focal they are suffering from substantial fluud loss ing In the simple reduction of in intussuscsp- Joss of electrolytes and blood into the lumen of tion this will usually be within 21 hours liter the bou el into the bonel 121 and into the resection it may be a mitter of several «ltys peritoneal cavity even before operation has been At all events nothing is given his month unul undertaken and that bacterial trinsmigration the child has demonstrated by the passage of through the bonel wall begins even in a stage Stool that the intestinal cun is open ud func when the bonel is still uable No operative tioning Until this time the fluid bilmce is method will yielu good results of time is not muintuned by the administration of inruienracts tahen first for swift and etficient attention to fluids to the amount of 100 to 150 cc per kilo correcting and counteracting these factors No grm of body weight per dry Hle prefer 1 la chuld rich intussusception should be operated trte salıne glucose solution for ordinary purpumps upon without having at least received intrue This consists of one part 11/6 lactile to partis nous flurds and any child who is at all pros 085% NaCl and three parts 5 glucose in NINET trated sliould recente blood This should be in In profoundly ill chuldren with resections and the amount of 15 cc per kilogrım of body severe fluid losses it may be well to add pounssum weight If blood has not been administered chloride 1 Bgms/1000 cc of solution Blool may and operation discloses the need for resection Occasionally be needed in the post-operisse fle blood transfusion should be begun 11 once all riod in children who ze had 7 resection patients having been matched for transfusion in All such children should be operated B Non Operatise any casc upon with an intraenous drip running As in The first sinccessful operatie reluction of in all operations for intestinal obstruction, most tussusception in an infant 175 repxirted by Jon particularly in infants who strangle so readily on ahin Hutchison n 1873 she puusut lunung vomitus the stomach should be emptied by heen operated upon in 1871 Until thus tinc stomnch tube before operation is begun and the disease and been irental cither experiently suction maintained on the gastric catheter 12sting for fingrene of the intussusception and throughout the operation Antibiotic dininis spontaneous passage of the sloughi or find been tration should be begun before the child is trented by recta) installions taken to the operiting room This series to rlic method of treatment ls recrul instilla counteract the effect of the bacterial ini 7510n tions is older than any opcritis (ilst 11sppet caused by the primary condition the potential rates and I'raxigoris adused forced soiling at operation und prossible pulmonary 11 170cr or air into the intestines mail foris nof lection In the fut moving field of antimicro 1115 Without 1171ing (lescribed intusstueprion bill therapy specific recomiendmons re and a number of muthors 311 the rirls ? likely to have only a flecting nity teenth century Bessed and uses clysters succes Others user} Ixelles cnt preference is for a combination of penicillin fully for Intussusception and streptomycin or connectei lydrogen territoirs mul this set Post-Ogrerattis Theraps tum or aliserted efferiexçue pxənciris 18:{s: the I rerument after operation is gutled essen Kcium or in cried bottles of clicylater cally by the same indices in the chuld who has jesting carbon diozule under prestatte Suillarda of inja 11 Our pres ·o INTUSSUSCEPTION IN INFANTS AND CHILDREN 67 Intussusceptions at The Johns Hopkins Hospital 1939-1957 Position of apex of intussusception O 00 O o Reduced by enema, alone 53/77(69%) O Reduced by enema and operation 24/77 (31%) (5724 operative confirmation) NO DEATHS Anus Fig 28 Seventy seven Cascs of Intussusccption Treated operated upon five were found to have had their intus Primarily by Barium Enema at the Johns Hopkins llos susceptions completely reduced by the birium cnema s pital 1939 1957 Inclusive Note that the position of the that the barium cnema reduced 59/77 Or 75 of thic intussuscepuon when encountered by the barium enema 19 others operated upon in all but onc ile barium cnem has little or nothing to do with reducibility of those cases had reduced the intussusception to the chccuen ers pissed long bougies in the attempt to per reported that his contemporaries seem 10 11 form a direct reduction or stimulated the pro dloubted his conclusions Jie appears to have lapsed intussusceptum with electricity or cried been forced m self defense to publish 1 concise to shrink it with cold water or lypertonic saline account of each of his 107 cases lle presented solution With this background Hirschsprung a 33. mortality in a disease which up to the of Copenhagen i 1876 reported his experi time 135 fatal in over 80% of the cases In 81 cnces with the systematic treatment of intussus patients treated by Ilirschsprung with enemi ception in infants ind children by isdrostatic alone the mortality was 2900 I besc figures pressure By 190) Hirschsprung was able to compare fasoralıly with these from The Jolins report on 107 personal (73s of intussisception Hopkins Hospital lising operatic treatment Ilus results were so superior in any previously only in the period from 1029 to 1978 more ·GS I\TUSSUSCEPTION I INFINTS IND CHII DRES tion than 23 years after Hirschsprung The method eisen here to result in occasional ruputise of thic of reduction by hydrostatic pressure 1175 sys bonel and for this reason that is to be strongly temained by the Danish school Hirsclisprung condemned and luis successors hoch und Otrum and Mon Our ouni esperience with hydro static pressure has been limited cutirely to the nad Ill of these pricticed to varying degrees, 215e of the birtuti enem reduction and dates mmuil dısını agination of the intussusception from 1939 From 1939 to 1916 the use of the through the intact abdominal wall In 1913 birini cnemiz becznie inereisingly ilit in thox! and 1914 the first reports of intussusception ding of choice in the treatment of intussusception at trosed by roentgenography were made by Ladd The Jolins Hopkins Ilospital and since 1916 11 and by I climann In 1927 Olsson and Pallin in luas been universally the method of choice The Siseden Stephens and Retan in the United demonstration that during the period 1939 10 Stres and Pouliquen in Frince all reported 1947 there were 21 primary opxsmic reduc reductions of intussusception by barium enemy tions with fre deaths 1 mortality of 2106 under fluoroscopic control Clubbe of Sydney 27 primary enemii reductions with no mortality the greu lustrylıın student of intussusception Ind a good deal to do with influencing the prac whule favoring operative reduction of incussus tice of the surgical service Prior to that time ception in his cirly ciscs used an injection of selection of method depended upon my person u7rm oil muntaining that it always reduces success in persuading the indusidural surgeon in alte atitissusception to a certain extent and in the charge of 78110n case Since thint time it has best and gentlest possible way In this way it been standud practice to institute burtum cne lessens the shock of the coming operation be mr in all cases suspected of lizing intussusccp) cause less mumpulation of the intestines is need The Johns Hopkins series consists of 77 cd It is especully useful in cases in whuch we ciscs of intussusception in infants and chuldre find the intussusception in the rectum because trerted primarily by brruum nema from 1934 of we do not use it we may find some difficulty to 1958 We linic lind no dentis ! the series in getting our fingers belon tlic tumor to begi During the three years 1932 19,5 11 the Mount the squeezing process Hipsley also of Sydney Smu Hospital in New York wlien zum chem luseriler dissatisfied with 1 mortality of 8% reduction of intuisstisception 1175 the incidaxl of 11th the operative treatment of intussuscepcion choice there 1757 single cicath This ISIU begin the regulir treatment of intussusce ption chilil 111 skom tlı mussusception could not be by lycrostatic pressure #athi normal salune solu rclucl by brruum (nicht und in whom opuri tion In 1926 Hipsley reported luis first series von » 75 resorted to without delay It as par of 100 cases so treued with the spectacularly ant from the record that the musstisception to los mortality rate for that time of 5% Since reduced uith some difficulty 11 (Jx rition 2014 that tunc use of sine cncinis luns continued to 1110 1011 33ble lonuci 175 judged to lx nilik I stundard 111 7 number of Sustralın cus and left behind The patient s condition sicud but the rise of bom chicmi has been popular y sorsened and the pricht died sithout rc in Scancu17111 2016 in South Americ1 In this pxration I jutops the bowel wish for country and in Ingland and Cermm thic tise of ixen nolied in the stuernsstrept!017 1115 fond Irvalroseatic pressure has never been widels ne frankly neurotic It the Baltimore (its tapi 17}s sliere battuta etc ani teeluidex3 mf mfusu cepce although in recent years there have been Brot cake some concessions in its direction by lption is nou standard pr11 fue suscylor those who previously reporteri solely to open lix! <xc eleuh n i child in te los e ne nuit poti many This is 11111131111c mint sal weeks I le nedition to hydrostatic pressure reulic of age kho hudhud hopi vihje falecil 1901 of fuampulution through the intact 15 in for 5330xt of its brief life and to in til foreni doni) 1 7]} lits bu norai in Copx nlungen und se !!! {« tlit Cus Hospitals u 7 moribund state tion ·INTUSSUSCEPTIOIIFA\TS AND CHILDREN 69 + А B Fig 29 Reduction by Barium Enema Alone Female sixteen months old This inſant auahened at 400 a m crying with pain drawing up her legs and began passing bloody stools shortis afterwards at the same time that she began to somit Seen nineteen hours after the onset she was vigorous not prostrated There was resistance in the right upper quadrant where a sausage shaped mass could be felt extending across the epigas trium There was blood mucus in the rectum Shons the intussusceptum encountered in the trans verse colon to the left of the vertebral column The meniscoid e fect proxluced by the filling defect of the intussusceptum and the extension of the horns of the meniscus up into the space berncen the intussuscep tum and the intu suscipiens are beauu ully shown B The intussusception has begun its reduction and has been displaced almost to the vertebral column (Continud on next page) It had diarrhoea distention tracheo bronchitis suisception was almost agonal in an infant 21 and bilateral pneumonia Despite the continu rendy moribund and was so ripally reduced that ing diarrhoea after two days because there 1175 the original observers doulted its (listence a good deal of blood in the stools a burium ene Autopy showed an extensisc and sucre enteri ma is advised This was interpreted is shors tis involving all the intestine 15 well 75 1 sovert ing no intussusception The revers of the films bilateral pneumonia and 1 diffuse trichco loron shonied poor filling of about three inches of the chitis small bonel and an intussusception originally Technique of Barrum Enema Recluction present in the colon (Fig 1?) Operation was is oon as the diagnosis of intussus cption is undertaken at once To intussusception was suspected the operating room is notified and found In annular cyinotic mark thought the patient formallı panter for operation In probably to have been caused by the neck of an most cases the intussusception has been re intussusccption was found about two feet aboss duced before the operatin, rexom las 11d time the ileo cernl ile There was no hemorrhage to send for the patient Intravenous flud d or edema ministration is begun at once in almost all clul "The baby continued in its marantic and mori dren Is in any type of intotinal obstruction bund state and died the days later Thus intus the stomach is emptied and the gastric tube left

·. tua
D
The 91 on)
Clic concue filling defect lins almost csippered 15
the intussusccpton has moved across the crtebral
column and
D The meniscus is rc formmg once more to the right of
the screbral column
WA
F
E
}
1
Nie braun lise secil loro mithir Ingatur flur
and on
Ilic int sikeption has lxen teslukel alment to the
liep asic flexure and the menus as if forming om
trofe

·IN TUSSUSCEPTION IN INFANTS 41D CHILDREN 71 H $11 Fig 9 (Conl) G Begins to fill the ascending colon but no barium us loops of small bowel which lud been alled With 1 seen in the ileum and the cpcum is certainly not com Iittle care actuall, one loop of small bonch can be pletely filled seen lateral to the mid ascending colon and scieral 11 The abdomen is so completely obscured by barium loops of small bouclcnn be seen immediately beneath that it might be difficult to be certain that there were the muddle of the transverse colon in place Although it has not occurred in our was begun In thus mstance upon mature re experience the vomiting and aspiration of flection it was decided to use general anestle vomitus by an infant in the dark of the fluoro The barium is permitted to run into the scopic room which mught otherwise occur could rectum uninterruptedly although at times the pose a serious problem in the more severely flous may be momentarıly lilted while yxit shocked children blood is matched and blood films are exposed The barum will usually be transfusions begun actually in the fluoroscopic seen in tun rapidly into the rectum and colon room An tingreased 45 cc Foley bag catheter until the head of the burium column molts llic is inserted into the rectum the balloon inflated point of the intussusception At thus print the fully and the buttochs strapped tightly cogether rounded lead of the advancing barium column uitli adhesive It is remarkable to see how suddenly becomes concase forming a quierlists large a bulloon a tiny Infant cin evpxl if it round the head of the intussusception much 75 struggles The catheter is connected to an am would a column of barium in the ima out ple reservoir of bariuin at a height of between lining the envir lor purposes of dxument three feet and three feet si inchies above the tion We usually obtain a film of the intuisusep table We do not employ anesthesia or sedation tion when first encountered and 70 let one In a single instince the patient was a six seir more to shou complete reduction Is the hidrom old girl who bıt the nuthor is the manipuliuon tatx pressure of the column of lyrict Stypx 15

·72
I\TUSSUSCEPTIO IN INFA\15 4WD CHII DREN
J
tag *9(Cont)
I show that with progressive contine of the
barium after the ball mot catheter 1135 licen remoncul
U ind k) burnum bike loops (I still I melain
more clearls and concluich demonstrated
Ilie entire proxes of reduction saapureel ten minutes
I lie chill left the It »spital ell in three dalk (Hand if
instillel n the sound finmnedoch, after thic latiuit
caicmi reduction as ICCoSered at the stolthins
luss
K

·INTUSSUSCEPTION IN INFANTS AND CHILDREN 73 B ? A Fig 30 Reduction by Irkum Enema Alone PC firm in consistency On barium enema the intussuscep Female 334 years old This child entered the hospital tion was met to the left side of the transverse colon and 14 hours after the onset of abdominal pain and somitin, readily reduced with free filling of the ilcum within 15 She had vomited repeatedly no stool had been passed minutes She was prostrated and listless dehydrated with markedly A The characteristic billing defect in the head of the sunken eyes the odor of aretone on her breath and three barium column is seen just proximal to the splenic plus acetone in her urine The abdomen was soft and a flexure transverse sausage shaped mass as visible and palpable 1 The meniscus is found flattened as the barium reduces in the epigastrium measuring about 83 centimeters and I to the right of the vertebral columns sion is muntamed the meniscus lengthens the cum does not full freely one should operate at horns extending proximally around the intus once even though the intussusccption has appar susceptum until suddenly the intussusception 15 ently been reduced through the ilco coal valve displaced and the meniscus flattens out again and the cecum fills without any defect 1 tlc This process is repeated sometimes with ex harm is done by a VicBurney incision which dis treme rapidity until the intussusception is re closes that the intussusception has been in fact duced to the cecum and through the ileo cecal completely reduced and real barm may result valic In the transierse and ascending colon il complete reduction of meussusception is in the intussusception frequently fits loosely correctly diagnosed At times when in intus cnough in the larger caliber incussuscipiens so susception rests entirely within the small bowel that baruum seeps between the intussusceptum it can be demonstrid lny brum refluxın. and the intussuscipicns producing the coiled through the ideo cecil vale up to the intussus spring appearance cien in acute intussuscep ceptum (Fig 10) This is not depxendable and tions One should take care to see that the In any case one miles maticmpt in roluce barium flous freely into the ileum If the u infussusceptions at thus level by brum coema

·I\TUSSUSCE RIO II\FI\TS IND CHII DRE
с
Fig 10 (Cont)
C Barum las reached the hepatic ſexure between the
Intussuscipicns and the intussusceptum although the
latter is still almost 7 the right vertebral border
D) Shows the hepatic flexure filled and burium sceping
between the intussusceptum and the larger cabler
ascending colon
ܟܐ
6
1 Shows free filling of mans lonps of small bonel
11hen the barium as expelled the returns here colored
polis blowxI
1 i fulm talent with the colon less distended after paruul
cxpuluon of the loantin XTINH) Cuser differential !
between the large lxinel and the wall fwnc frare!
by the parzially emptieil coston
I he chill paseo a untancota sfowl and flatus withun
fouts and was dixharged well on the oth day

·INTUSSUSCEPTION IN INFANTS AND CHILDREN 75 A FI 31 Reduction by Barium Enema Alone C G Female 6 months old This child was brought to the hospital 6 hours after the onset of abdominal pain and vomiting She had been passing bloody mucus for 6 hours before admission A large tubular mass was felt In the left side of the abdomen and thought to be the intussusception The child s general condition was good Idmintstration of intravenous glucose and salıne was begun and a barium enema undertaken 1 catheter was placed in the stomach as in all these patients to prevent vomiting and aspiration in the dark of the Nuoroscopy room A balloon catheter i 15 inserted into the recruit and distended The plain film shou s the gastric catheter in place and the rectal balloon inflated number of delitel loops of small bouel are seen in the left upper quadrant B Demonstrates the barium outlining the one of the intussusceptum in the rectum immediately abone the balloon although ic had not like the intussuscytum on rectal examination (( oniinirl on next > Intussusceptions entirely limited to the small of less than five suconds In 7110ther instance bowel will usually present the picture of intesti an expericuced pediatrician called to say he was nal obstruction and in such patients if barium sending in an infant with intussusception AN enemz shows no intussusception in the colon was made ready the body was met at the door Operation sliould be undertaken at once the intusstisception whichi 175 encountered at the There is great variation in the speed with mid transierse colon was completely seduceed 313 such reduction can be achieved In one infint tko to three minutes and the baby was on his Withi in intussusception of the transverse colon way to thic ward within ten minutes of the time motion pictures were taken of the entire reduc he passed throu, h the hospital gale At other The continuous film strip cosers a period umes reduction may be extremely stubber tion

·78
I TUSSUSCEP710\I\I\I\IS AND CUTII DREN
)
se inauxcptum has been reducest is the sigmox
and chest is a shop nic nixord doc ta hic advancing
bruni collan len the intus disceprum futs the
intussurspicas eghely very fue furtun is alle 10
axend ben een die tuo frospys and one geis meniscus
of this character 11 her the st is less snug a goxxl deal
barum mn as bccuees se 3x preklucing the
micul spring appearance is the boom concentrates
beineen the cicmous laid at low at the sun
time that the end of the lotususe plum produces a
large round filling dcfcct frequently thic menu od
sltaclos S SOCIS the left colon and as the stonen
LINN ex fcclused the adults i prature of the intussur
"pron changes fou ard the right colon
D The antsuvoptron las been reled me up in
the dcxenaz colon (i onunur I on now)
W rarely there will be 3 MOI}{}{75) pause redation for as long as 13 $35 (5 393 hour
Wote ih mussusccpuion is Countered the su long as steny prosess so bxan mode 17e
sttuls refut 1087 ) the splcu ile vura Dulay nkelrent Te recording intrischen Blunck or
*the splenue lleure may be fulfonath by ropa bowl is nccded during the proxidic and she
Stilintion to the hepatit Bi xurt where there Hochtigen (4xUTC 18 only fracional 19 iner
11171 1.3333 I want dels Tilin, of the LC 51373
Once it is Obious that there is liceu
is often slum md the serisms my drstend quite monolul attail of the Lord olim for (co
marhaalls ix katt 1 dan rush of bird to UUTICs « so st. 11 fr le meil lor firs
the il le dentes complexe reluction 315111 and operation should lic procula sith
Hcline in hou aan 1 toniting with the The principi delliculet 19 le ile of tlu

·INTUSSUSCEPTIO\I\I\FAITS AND CHILDREN 77 3 E F Fig 31 (Cont) E The reduction has progressed around the bend of the splenic flexure F Although the barium has reached the right colon and the filling defect of the original intussusception is still seen in the ascending colon there is an abnormality in the left transverse colon Inspection shows the column of barium going through the middle of another intry susceptum and outlining a colocolic intussuxeption 1 buch is only incompletely reduced method are likely to inolve a leakage of barium ascending colon and in the last case ircited from the rectum beciuse of failure to strap the the intussusception which proved it operation buttocks together ti, htly or plugging of the to be irreducible could not be reduced by the tubing or catheter by lumpy barium mixture barium eneina beyond the hepatic flexure If there is any doubt that there has been a free It is of the utmost importance to lre (crtu flow of baritim into the bowel with maintained that there is free filling of many loops of small pressure the child may be allowed to evacuate bonel with barium The distenda atau and and the procedure repeated the sigmoid if redundant my overlap and lx It is our present practice to rely in general tween them obscure the field so that it is dill upon one continuous sustained injection The cult to see the ileum In such instances of the intussusception if not completely reduced is al child is turned upon the abdomen its own most intariably reduced to the cecum although weight may separate these tho loops of Ixouct in a fex cases. It has gone no further than the and permit one to see the ileum between them ·78 INTUSSUSCEPTION I INFI\TS IND CHILDREN 11 The colo colic intussusccption is completels recheid and the scending colon progressively hills with Thur Fug 31 Cont) G This intussusception is suill further rcduced slule the transverse colon is filling and one sees the original intusstisccption more slutpls in the ascending colon I hic position of the meni cus of the colo-colic intussus ception in Find ( is such as 10 suggest that this second intussusception was actually a retrograde intussuscep tion Under no circumstances so we crer manipulate Hely after the completion of the reduction parte the abdomen honcser great the temptation dered churcoil is kepxxital in the 201011 I nder no circumstances de la rusc thc (701111s stomach through the tube afraidy in place ter of lorruum luglier than three fect si inches lours Inter m (1141117 is administraders trout about the cable Neglect of these precautions the churcorl and prove loc yonil doubt the select 111CS tupeute of bowel or reluction of 3711 of obstruction I hus method textured in Il mon bonel 15 a number of reports testify Luxley assuttes one that thic obstruction las If the hixlomen becomes se distended witli bir Ixen reliescil but does not r16 (373ly (111011 Tuun that it is difficult or imuxsible to tic cer serute that the intussusception 1175 buc (13 otaff tan tunt locups of stull exense have filled the reduced Mlinics mahull.itse of the collisesta (ntheter is rumored the chuld allowed to (incu tton tort fluid bunch rolures to thicaletim na and then fluoros opel once more The not 1» promptls cyx iled 111 7stres the girls of lewens of all truel filled with burnum will the children lxfore and ofter 3 tane orius asually be seen fromert ly the colon Iminicah il the lxlominal orth Terms guloseinually

·INTUSSUSCEPTION IN INFANTS AND CHILDREN
79
I
Fig 31 (Cont)
Vote how the overdistended signod encroaches upon
the shadow of the cecum so that it is difficult to tell
hcther the small l>o cls filling or not
J Shows apparently complete filling of the son but the
possibility of overlap beticen an averelissendte sig
moid and in incompletely filled accum cannot be
excluded It is probable that some of the shadows
due to Imps of small houel but onc cannot state this
unequivocally
In this instance it a little more filling new In
verse lung loops cross beti eun tic i wypis of colon and
are obuously I wops rf small Inel In ciu4t1on1
film frequent slions loups (I small bud framed by
the partially empts colon (5cc h 30 F)

·80 INTUSSUSCEPTIOIN INFANTS AND CITII DREN 1 increased after expulsion of the enemy le 10 them little distress and it is scarcely necessary cepts this is cuidence of free passage of the fluid to restrain them If restruint is required las into the ileum und hence of reduction of the in tic bundlages holding the extended joined hands cussusception While hus results line been er and the extended fect will decrease the peces trordinarily goodl we prefer the certainty of sity for e posing 75sistants In some of the older direct fluoroscopic observat on and the opportui children it is necessary for properly projecte ility that this affords for objective documenti 19sistants to restruin the hands in fect tion on the film of the existence of wintus In only a single instance Inc we had what susccption and of its reduction might be considered in itoward TON 10 The successful reduction of in inttissuscep this trcitment This 175 in 1 five month old tion is indicated by the following criterii - colored female in{int who had been brought to The free flow of barium rell into the the hospital because of somitig und 1 frank small bon cl This is the sine qui non of com upper respiratory mfection Howser her som plete reduction and must be insisted upon in all cases which are not to linic an immediate Fig 32 (pages 81 82 83) Reduction lay B trium Fremy llone operation The remaining criterii are merely IB ale three vers cight nionths old thus chill was seen frie hours after the muset of severe nulamı confirmatory nal pun There was I trusserse cpigastric ims flix 2 The return of the varrim nith feces or condition 117s good Barrun flowed freely up the devenil uit flatus This is not helpful in the occi ing colon and around the splenic flexure to meet an sional chuld who is incompletely obstructed but obstruction in most cluldren with intussusception are com 1 the transverse colon flise proximal to thc left of the mdline pletely obstructed and we emptied the colon 1 The filling deloc slowly and progressively moncs across (listni to the intussusception so thirt appearance the transieric colon to the right of the milline of focus is on them acceptable proof of reddiction C More barium is beginning to pass betwecut the intus Disappearance of the mass At times ] stisccptum anel ile intussuscipiens There is a large 277755 ay still palpable in a child in whom there Cilling <Icfect in the barium column and the beginning of oral rings of bom in the folds of the celcmatnus is positive radiologic cudence of complete redur intussusceptum r1on of the intussusception Thic miss in such D&As the burium rerchics thic hepatic flexure the line Cases is the swollen oderous boucl previously mich texnxr and a good deal more bitum *cp" forming the intussusccptum 'The enlarged mes betu.cen the friers of the intussusccption prexuding the strkung filling eclect and the could spring appear anteric lymph nolcs winch regularly accompany in intussusception may form part of such i pol I lhe hepatic (lexite is filling more completely lout the prible post reduction mass On the other hud ? Sling defect persists. very small intussusccption still persisting in the The right colon hul hepatic flexure hasc fified cus region of thic ilca cecal alıc m?) no longer be pletels and the filling defect is nos visible down in the ascending cnlon palpable though stil present and significant The avending colon is very largely filled and the out Clinical improrement of the chuld who line of the team can be sen but it is not lillel com often falls into a natural sleep I hus is dri plech although there is no es un filling defest 11tic and furly const 10 is orientoft She cachm non app us to have filled ar drauch And there is nmle birus neilt 10% it wuch 11 le points ont incomplete reduction frequently re in the sth all lonel Isenes symptoms temporarily so that this sigui į With a ru limons lewypus of small temel biste fillest aruf sok is merely confraríory thic cocum a fire in lae hilled comptech31. li Subsrzuruli srcolor) m the stool of the h detulit the small Ixonel trwy shows no atural charcoal given by mouth of the opporncc of 1. lior withdrawal of the Gullonin Catheter and with 2 Ilexxl free to expulsion of met the Israust nurelt hilal Jw of Stosst of the clufiren are so listless and 17 small wnel are xen dixitte for in the luer inimine thictic that the birium cncmit seems to cause Ilie chukit Jele the lingual dl in the days ncc 1 1 its and

·I\TUSSUSCEPTION IN INFANTS 1D CHILDREN
81
--
А
B
1

·89
1\TUSSUSCEPTIO\\ INFINTS IND CUILDRE
M
3
+
E
F
or
Fig 1 (conl)

·INTUSSUSCEPTION IN INFANTS AND CHILDREN
83
میه
مم
سمة
امیر
محروم
K
Fig? (Cont)
1

·81 INTUSSUSCEPTION FIVIS ID CHILDREN B Fig 33 Reduction Harum Incm Vlone T1 Female 8 months old 1 lus child developed dorthoc? and abominal cramps 18 hours before coming to the hospital begin to pus bloxxl mucus 21 hours bclore admission to the hospital had somited two or three times on the lorst day of simptoms but loud alon and retsmed sme (ccdmgs She was apathouc quiet and prostrane Ilie 1xcomen was relince There was a fullness on the loner abdomen and these has an easily palpabile cursed firm in mouble mass attending Iron the umbilicus int) nasal 15 iung Innd come on coucidentally with an al ble cuiss in the kit louer qudrant The bar 1764 of domnil pam during wluch she had mim cncmz encountered the massusception in drun lier legs op cried and vomited In spite the descendin, colon ( 111) LICINE II *15 of thus comicing pun and ? Ilirgy ideich 125 xissly sederer ses che splenic fk vare me nored in the records she 175 sent bonit drag of fac mmates and to the hepatic fk xne 113 in cute nutritional disturbance In another ten minutes I lucre " 15 tlich no chan, she iso wa boll bouts shoxh bd 1873 pused for 30 193wirs of study pressure It is quite sitice the sct of her illness she lid not pusserl Obuous that at this prompt the child stil huse blocxl and curll no bloxxi 1975 passed umul slie buen rikun to the opxriting som 1101 cir lund lucca hartis almost ken hauts more She (ko subsequent tud fuely deliberate attempo soas fmally brought to the Propul A lours isere made i reduction by form one and altcr thc onset of the nos tocit fc #175 on thic hard tral scime rrent w3sch In -111 prostrial cludotel and fa! 7 casily palgat into the excida, colon gud cccam Strecht ·INTUSSUSCEPTIOV IN INFANTS AND CHILDREN 8p Fig 33 (Cont) the left lower quadrant and easily palpable rectally as the intussusceptun and intussuscipiens The outline of well Barium enema at once showed an intussusception in the distended recta) balloon is sharpis susible in the the rectum Is seen in A the intussusceptum reached concase meniscus of barium is scen to have reached the low into the rectum Barium has begun to pass between sigmoid and in the ascending colon In loth D and did not fill the ileum the child was ordered to enema alone in incidence of 69. (I ! 28) On the operating room Before she could get there the 24 patients who were operated upon there she developed generalized tonic and clonic con were fue in which the reduction had been vulsions and had two subsequent seizures of the achieved by the barium cnem so that the opx 17 The operation was postponed for tion 1175 merely confırınttory The lirium chema several hours on this account but when it was therefore completely reduced the intuisstisception finally undertaken the intussusception was in 38 of the 77 cases or 70. Thicre lure been found completely reduced The child ier) no deaths slowly recovered from the effects of these con Recurrence vulsions the cause and nature of whach re We have liad three recurrences in the 77 mained uncertain cases The first recurtce was in a 19 month Results old colorid malc first sech two necks after thic In the 77 intussusceptions treated by barsum onset of abdominal pain and somitin, with con cnema 53 have been reduced by the barjum stipation anoreva and cramps lic had craft same type ·86 I\TUSSUSCLI TIO IT INFIIS ID CHILDREN E F and intussuscipiens to outline the viene flexure in Hlutule bizumi 1173 pissed betsseen the intussusceptum and I the pleine flexure fills progreusch berry colored stools 115 moderately prostrated 111, of the deum althout llicre remuned a full markalı alt hydried and lud a large mass in 11, defect in the accum Operittom discloscat the cpisirium rhic burun (nem? encount in intussilsception of the appendix anscht (*cc ered the diseal end of the antussusceprion 11 lsg 8) le secints p**sihle that the initiusep the splenic flexure tience it was promptly TC tion of the appxenda persisted after the first chuced into the lenin uch filled well Char Tosuction but lind 1100 been observed pluripriscop coll galen by stomul tube 175 TLCoS cred file olly 73 11 lied in the second seduction Ilie hours later in 19xaneous soul ind tlie sol cluld remained ucll ſtor terection of the px ! loxill, mornin, le passed a formal simol felt lisad part of the accum nell had to palpable muss Ile the remained The second recurrence 1761 bol scien 7mptoms 16 19 hours after the ticini tion monitis in whom 101 insesserace parton huil rendu 0101 wlien die somuted tice and stories pret maisha borelt tulncer is 011111111 menunt ! fict futsseel 1 (urrait jelly stool ud ind 7 months tycfore when stic Ret 1720x33pis old conubiy mas pulpoisic in the left loser un The second intussuu cpeirsti 14 111!31 13) it! iant (standing up to the left tipus quadr1118 <<Catefully rexluced by burnum en 1117 mu nchins the tidlinc Bi brum ene 13 thic The chun u BITUICO 1175 inch intusukopin 75 once more tcdical sah lill 7 iusiikeption of six lout unch * 13 ct

·INTUSSUSCEPTIOV IN INFANTS AND CHILDREN
87
I
G
116 33 (C)
In G and t[ the intussusceptutn 15 secn moving ir um
to the hepatic flexure Here there 7 lela Ilic
small but definite progress from to!! justified per
5stence in the recluction
This numerus 1 xips of small boy clucth bonum
-prof I complete reduction Intravenous Guds hul
bren begun before the fluorocopy an Iran continuous
during the procedure The Otal recluction willene liour
of stend progress sith the bariutn expelled and redunt
isteretuie Charcoal was instalked in the stomach at
the conclu son of the por xedure an 11 recensereel six
frours later by chemi Ilic chuld it fiu all the next
m ming Discharge from the li puls delssel hs thr
dieselpnicht (1 ut med an acclluittis to mulku
tane fluid huchi ere gurn the first night

·89 I\TUSSUSCEPTIOI INFI\TS I\D CHII DLEX whe countered at the mid transierse colon and readily reduced mto the small bowel Charcoal admin istered through a stomach tube was recovered by enemy some hours later and thic chuld had normal stools und begin thing fluids Sixty liours inter shic developed crumps und begin vomiting am Inotlier intussusccption was found and this time the intussusception was reduced to the ileum but the illum itself could not be filled Thie zbxlomen was explored and the intusslisception found ctuilly to huse been completely reduced The appendix 178 remoued The chill lras had no subsequent difficulty Confırmatory Operation There u ere four other patients in uliom oper ation undertaken after an apprrently incom plete reduction by birium enemy served simply A to prove that the intussusception hund indeed been completely reduced The second such con firmatory operation 1 is undertalen in 1 tlo ind 1 lull year old white girl adınitted to the liospi tal wuth 1 ten dzy lusstory of abdominal cramps and restlessness with frequent vomiting and only occasional retention of feedings She was prostried quite markedly delydrued acidotic and there 1 75 7 palpable mass in the right upper quadrant A brium enein? encountered an in tussusception at the hepatic flexure 1175 trented in 1912 when ne assumed that 7 This case (Text coifmuel on pare (0) hag 31 Koduction by Barium Fncma Vonc 6.0 Icmnic 4 months oll 1111s child was seen 151 houts after the onset of symptoms marked by somong fol Slooks the charactCTIVIC mpnix 115 of the advancing Joi ad by culenccs of abxlominal pain She had been 123r11in column alieuds duplaced fast eie oleme fun castor oil an hours after the onset of symptoms lleture The Nis urf bon sedexced * quals that passcallowsh a stwo! She had been lethargic ill day Ith vugh the flok of wom sicut wt operulett! Exfore the alixt of frant symptoms ile alloment was 371!!!*** Tp113 outlined in the coftim tlir grafisk soft tietc wi wone ionerness and citance in the left Bon proceed to the solemnc flexure lx're a false fones quadrant nfiere the mass could ixe felt quite te while could by walan The mas as caut palpable on rectal examination as 13 in the salucun proxect in the m 1 1531 Intranches fluids acte administered through a rix col >n with a litlu leicus in the lunar luna uleteau (ut slowty Guxit by the lead if ile inutiko

·I\TUSSUSCI PTION IN I\FA\TS AND CHILDRE
89
с
D
C Shows the filling defect even more plaints in the right
side of the transierse colon
D Shon, the barium filling the ascending colon
IF
E. One can see incomplete filling of the cecum at the
same time that the appendix is nicely outlined Reduc
tion to this point had been extremels rapid but at this
point barium began to escape from the rectum The
catheter was 1 ithdrain the child allowed to expel the
barium the catheter reinserted strapped in place and
the flow of batium resumed
F Shons the filling of the many loops of small towel
which curred with dramatic rapid.rs
It is possible for the alxdi meni to luccmpletely I landed
out by overlapping of a distended and and a distende !
right nlon nithout filling Inps of small towel tre
thus season the barium wascsacuate thru hr il e cathers

·90 I\TUSSUSCEPTIO\ I INFI\TS I\D CHILDREN man H. Gviny loops of small boucl are quite distinctly visible Chacool was deposited through ilus tube and appeareal 11 The catheter was removed and after further exacua In a spontaneous stool Inc hours liter The chuld fell tion there is no question of the adequacy of the sleep at the conclusion of the procedure faut when twal reduction (ned was a good deal more alert thun previous 1 mill Tote the histric tulc visible in I In all cases the philcbantis ne the site of her cut down lepe hier in the stomach is cmptied before the manipulation is begun hospuol for 6 dass Fig 34 Reduction by Baruum Enemi llone RI Female # meynths old I his child had hind dirrhoc? ind a half 'The chill was largic on lins in and for 1 heurs such bad ceased alout 8 hours before during the procedure became normally reactise and admission to the lost I She had been sonuting for $ (ranks and the presusly found nn si to tigrejat hours I cor admis son The chuld 175 t particularls poble The child was in the host putat for $1 un all the alxdomen was soft a tubular mis was cn ily felt I Shus the initusvuiseptin (1?(1911ntered in the trans kung tanserschiabic the umbilicus Onlium ent ma crx colon immcincts to the left the chical the intussex Cphon 75 encountered at the mid transserie cofunm Ilie nierucco edo if the namesti bilan colon keduciron prixccled rapidly to the mud ending Calum as punls sen culou lien thc (athcicr 135 (yxelled On the second B in bolique vies a les nenes later shen the mal artemit the reduction prixecclel to the (t cum licni un ITJUST Cimith shup and clear firmw114 clic cathetet is cypellal On lic iurd atteinpt the small ( Shus the lato o 1o the intus uxojn 1x el filled freely The encuicts require an four 11 the firpatic texte

·91
INTUSSUSCEPTIO\\ NF4\TS 4WD CHILDREN
A
(Continued on ne 1 )

·94 INTUSSUSCEPTIO IN INFANTS I\D CHII DRES 2 Fig 37 Reduction by Barium Enema Alone I allowed to flou uninterrupteilly from a licight of 3 fece Vale 8 years old This boy came to the hospital (Mt above the operating talle without any manipulation of SII) 46 hours after the onset of intermittent colich) the barium or of the alxlominal 11 alxlominal pain lle was known to have cystic fibrosis of A Thic intussusception la progresse once more and the pancreas He had not somited and had not passed was non encountered just beyond the liepatic lleture blood flis general condition was gool and ar casily pal producing the typical filling delect in the tratum pable rounded solt mass was fell in the right loner quad column Vote the apparent double memikus shrowing We were called in consultation on this patient that the monisoid pattern is caused in part by the because a barium cncma had demonstrated the intussus procrision of the intussiscptum into the intussuu ception and had reduced it from the transserse colon to jens and in part by barium filling the caleniatmu lokets the cecum but no further and the attempt had been of the intussuxeptum abandoned and operation was contemplates! Examina 1 Reduction proceele rapidly to the axending out on tion showed the patient still in good condition with an which filial well casılı pulpabic mass in the right loner quadrant The C. I'he cecum fillal poly as a had originalls and an catheter was reinserted and strapped in place and barium inicgular filling delas apixared rant

·INTUSSUSCEPTIONI I FUTS AD CHILDREN
2
34

·96
INTUSSUSCEPTIO\ IN IVISTS AND CHILDREN
D
4
D) Is the brum 15 niloned to ſlow the cecum progres
Schilled with brium
Although there is still an obvious filling defect in the
crum there is 11 leust one transverse lying loop of what
must be ileum filled with lyrium It is important to con
inue the flous of brum 16 thus point
I false diagnosis
»f reduction may be made of a bottle birui Slips into the
leum past in incompletely reluce«l intussuscption
E Shows complete filling of the cecum ind of many foops
of mulj bxond The abulouen fiad filled w7 compleeels
with barium before this film had been taken that it
had not liceu puble to be certain that the opacity
Ws (nucul !» ul lxnd Ilus Ilm talon afic
clactatin ol some of the barium shu free filling
of mums ( xips of small towel
On class for a toprat laruum cnem nas printmed le
cause in huldren of this age calytic lessons ate more
omnli Gound than in infants uch lesson 13+
temonstratcut
E

·INTUSSUSCEPTION IN INF INTS AND CHILDREN
97
B
A
B
Fig 38 Reduction by Barium Enema Alone DB
Female 8 months old
I his patient was admitted to the
hospital 21 hours after the onset of vomiting Her mother
stated that the child was constipated and seemed to be
having abdominal pain
The child had had an upper
respiratory infection for several days She was extremely
prostrated and dehydrated and passing bloody mucus per
There was tesistance in the right upper quad
rant where a mass was thought to be palpable On barium
enemt the intusstiseption #75 encountcred on the left
ide of the transierse colon anii wis rapidly and com
pletely reduced sith free filling of the small boucl
Shows the lipical meniscus encountered in the in
verse colon just to the left of the vertebral column
P The intussureptun his been reduced a little Wunt
ing the horns of the meniscus
Tectum

·98
I\TUSSUSCEPTION IN INFANTS AND CHILDREN
C lhe intussuscepuon is found to be reduced to the
hopitic flexurclerc as the boucl becomes of linger
caliber and there is more space beseen the intussus
ccptum and clic intussuscipiens uc begin to see numer
ous coil like shadows of barium passing between the
intusuvepinm and the insmaprene
D Vuincrous loops of small luc arc son to lase hulle
and the colon is completely outlined and wilica
Ilic chull left the hospital net in the oth das

·INTUSSUSCEPTION IN INFANTS AND (HILDREN 99 A B Fig 39 Reduction by Barium Enema Alone BA Female 7 months old "This infant was seen 3 hours after she awakened screaming with pain and doubling up her thighs A few moments later she had a normal bowel evacuation and began to vomit The paroxysms of pain and vomiting recurred at 10 to 15 minute interals She was lethargic but not shocked There was a firm sausage shaped mass lying transversely across the abdomen just above the umbilicus The intussusception nas reduced by barium enema in a matter of seconds In order to obtain the roentgenograms the flow of barium was momentarily interrupted for each exposure Charcoal deposited in the stomach appeared in a spontaneous stool 5 hours later Feedings were started the next morning and the child discharged in 6 days "The Intussusception was encountered at the splenic flexure where there s NIY ible in A The large falling defect caused by the intussusceptum and the long horns of the meniscus as the barium slips between the inner and outer coils preparatory to Te ducing the intussusception B Shons filling of the colon and many loops of small bowel The pattern of the barium in the moderane verse colon is suggestise ol a second colocolic intuy suxepuion apparently retrograde but may be duc 10 persistent edema The child had no further difficulty ·100 INTUSSUSCLITION IN INFTS AND CHILDRE\ 1 chronic intussusception of ilus durition wonki (lig 41) Igun in thus instince the terminal not yield to a barium enema and the barium ileum was seen to all only for four inches and cnema which was undertaken was meant to be operition was undertaken on the suspicion that purely diagnostic It was undertaken by the the intussusception had not bxc en completely re radiologists who sud that there was no tendency duced It operation the musstisception *78 for the intussusccption to reduce Operation found to have been completely reduced and the 175 proceeded with although the mass seemed appendix 17s removed less definite than it had before It operation there was no intussusception but the entire is Complelion of Reduction by Operation cending colon and an inch or two of the term The wisdom of the exploratory operations nai aleum were edematous thickened and cou performed in the last tno cises because of in cred with fibrin The child had no subsequent complete filling of the sleum is demonstrated difficulty by another patient one of the two m whom an Tlıc third purely confirmatory operation 175 incorrect dingnosis of complete reduction *78 performed in a ten month old white inale ulio mizle Tlus 76 7 four year old girl with 1 *as seen 12 hours after the onset of bloody rec 21 hour intussisccption such 175 encountered tal discharge ind abdominal prin He had 1 7t the hepitic flexure and reduce mo tlic miss in the right mid abdomen and barium terminal ilcuin It was noted that only six or enema showed the intussisccption in the mud seien inches of the terminal alcun filled but clic transscrse colon The cecum did not appear to child 17s alloned to return to the word Shie {}]] although the mussusceptiOn 1128 least begin to somit zgun several hours later parully reduced and operuon k?s undertalen mass ?s once more palpable and it was 1871 With the abdomen open there is seen only demonstrated on barium cnema to be an intus stisception cdomitous ind injected termmul ielum ina It is reduced to the accum but cctum sith no reinuming intussusception no further Operation 11 is undertaken ind after the remainder of the intussusception had been The fourth confirmatory reduction 175 1 2 reduced uumurily there is disclosed ? Mechels child of six months who had come to the hospi diverticulum 15 inches proximal to the skvacil 11 rnclic hours after he had suddenly begun to valve The Viachels discrticulum was rescue scream kith pun lle uns passing bloodly rer and the chuki did well tal discharge me lind 7 sausage slipped miss lying transiersely in the epigastrium On bar him enem (lig 10) the intussusception 175 Fig 10 Operatase Confirmation of Complete Raluction by Barum ncmi 6 months old Ilus chikt first lex alized discal to the splenic flexure in cime te the liospital 1. lours after he had affenly the upper part of the descuridung colon It it? began to wrcam nith pain Je was pissing a blwly frcial slowly reduced through the splenic flexure dicchirge ind land a sausage shaped mus lying lansicruely He was knocked out and dehy trusierse colon lepi ſtesure and ascending Match and at the same time scatiess. I lie alx! men nas colon to the certim The terminal ilcum 175 xaphord and completely relased Ihc luge share then usarlized lyn, to the right of the cecutin ina's was casals leit lung transicisely alxne the umbilicts and lilled for fons inches only For this re 15013 Iliere was dark bloxxl in the rectum 13thum nema 25 undertaken at once operation 175 undertilen but the intussusccp I The intus liv option as inet zust clustal in the picnic tson found to be completely reduced the tlerite in the upper part of ilic devetding coln it xucl licin. simply someu 1171 cdc matolls 33 slomli and trustly displaces groximally III. 9:n thic splenue lleture filled and the menix 118 Ile last micrcly confirmatory opx 1110 1115 aduncing into the transicik color the performed on thic fre month old child pre 1) I)e menix 13s tras llattenril snit as the iniu itief! ! viously mentioned bernurse of the comulsions has been mall further scalucoth acims the institv (of in IX Cutting alter the bariuin enema saluction

·IN TUSSUSCFIMON IN INFANTS AND CHILDREN
101
A
ALG
WWW
D
LJ

·E
F
G
H
1 FAC
Sh yw the progres ise filling of the transserte
colon and ficpatic flexure
Il Shows a sudden billing of the axending colon with
barsum deginning in outline the filling defect in the
J Hons a Irwp of terminal teuin quite clearly bolled an!
ling lateral to the colon an uncommon Ixation
for the iciminal alcum Their actually similar
cancel to the upper end of the larium or lumin an!
thus was e 110th interprete I as a memikih in dator
Incomplete resłuction
(Continud anda)
(CCU
1 shows the corum very largely filled and with no sharp
fulling defect in the wall of the coeum but the terminal
oleum has not fulla!

·L TM INTUSSUSCEPTION IN INFANTS AND CHILDREN mund luaughi Velutiily 11 t1 ton te kun found to be edcinituus ant the small bowcl 10 bx ty hom with no intussuscep 1101 prestilt Thiu appendix a Ruoved and the ctuld left the hospital wel on the teuth (1) I hechuld be a blend course and there is no indication in the record of the reason for the long hos pitaliz 1100 11 horteser there is doubt a to the completeness of reduction or whenever 15 m this use batiuni is clearly seen to enter the small bowel and then to delay operation should be under the Under no circumstances should the child le siten a trial by labor and allowed to demonstrate clinically whether reduction has been complete or not We inuch prefer to operate and find the intussusception reduced rather than to delay and run the risk that an intussusceptton fias been is completely reducci small Mc Burney incision alloss for adexuale exploration of the terminal ileum reduction of the persist pirtion of the intussusception if one is found and removal of the appendix Ilthough the procalare had tourel one and a half kirits progress lund been steady and the chitis ( mon Mas cucllent Berouse one cannot depend upon reducing intu surpcursus which have come irably ley!!! well proximal 10 the ileoxecal valve it Hus Kehte 17 puerice to alsanten luumutalic pressure and resort at once to operation #braciet there is an obvious telas in the terminal levr 35 was esdenced in this case In an nilance with that practice this child was taken to the opxruling room It operation 109 ·101 INTUSSUSCEI (101 I\I\I\IS ID CIUINAE 116 11 Operative Confirmation of Complete keduction ? currint jelly stocsl barium cncm 75 begun shortly by Bruum I nomi с 1 Icmile 5 months of age after the child is admitted to the hopital and it was 7 las childs treatment represented unwise and stublorn record on ille chant thit the inilisti ception encountercal persistence in use of the barium enem which we feel to in the descending coton was only reduced to alıc splenic have been quite improjxt despite the ultimately success flestire in ne mimates to the hepatic fic ure in ten ful outcoNIC She child was seen in the Out patient mutes ubere there as no change for the next thirty Department two hours after the onset of abdominal pain 12111utes secopil wal is made after the cluld was wluch caused fier to dran her legs up with each spam She had somitu kierul times and had an obssous upper GHICI 1 briel reut und in tuents me fminutes again no I third trial was music at once and progress 1121 made respiratory Infection She was sent lume dignoscil as thus tittie zier tilteen minus snc Varium ny seen in ule nutritional disturbance and instructed to Teturn the neus in The child was not brought back the axending onion and ccruin for further progress Being midle after another thurs minutes the effort was utan until two days later 52 hours after the onset of fict symptoms in the meantime she hund licen somiting te done and the chuld uns dipuclicii 10 the oxy011 pearcells and fuad lxccome leurgic and had passed bluxxels 1 \umerman diluted Imps in the fun film oli usly material from her rectum indicate an intestinal oltrict of mr character She was prostrated and dehis cratcil and a mass measuring 1 x 1 centimeters was casily one of the latcıl i wps are identlable as cofrin felt in the lelt lower quadrant in the sectum there was (conftaurton natif) an du may be of interest to see the stars of the thic et LITT The 1pxnd filled out only a little Mustik PHAN 1 OxTmn in the other cases bumum entered the sleum (Im 14) Ilround 7 Incompletely reduced by the litum quema Burnicy (19000 1 ml uls of ileumi 1 74 In a six inonth old nile in un intus Todel from the resumn and the prodhin IC Silkeption of 30 jours 175 chicoutical at the money licure flexiitc and refused to brinum enemy to In 7 ICN 11h old palc 111 ESTS 2 3 ·I\IUSSUSCEPTION IS VISTS AND CHILDRE 'B B The injusstiscepuon is met in the distal tran serse colon fluoroscopically it was first seen in the descend ing colon ( In this oblique ven of the transserse colon one sccs the barium infiltrating between the layers of the intus suxception the intus isceptum ptrælucing a spherical filling defect (Contrued on next fen) ception of 27 hours was encountered distal to the splenic flexure The cecum filled but the sleutn did not Evght hours later cramps re curred and on a repeat enema the ceciim be gan to fill but the ileum did not This is the scienth case in our barium enema series out only other mistaken diagnosis of complete reduc tion and was one of those which convinced us that operacion must be undertaken at once if the ileum fails to fill freely At operation an leuileal intussusception which had passed into the recum 17s found and reduced the leading point of the intussuse eption 12 centimeters from the alerxecal valie was cyanotic ind a segment to or three cenumeters in length 15 resccica and an anastomosis performed Microscope studies showed this to be perfectly wable boucl (Plate ID) The chuld did sell + In a child of eight months in intissitsep tion of eight frotirs was encountered on bruin enem at the splenic flexure and *75 recurred to the ileocecal salic without film, of the ileujn It operation about one inch of scum 175 gently pressed out of the cecum tirou, 7 VicBurmes incision In 1 Si month old infant with a 131 2 ·1 E F . G D) Shons the intussusccption nearing the liepatic flexure and snollen and laci obuously been included in the intusand stixeption There were numerous cnlarged sticculent Shou s the hepatic flexure filled lymph nodes in the neighborhoral of the encroal sale F Shows the barium passing down into the axending the child did not analen for sine hours after anesthesia colon and the cocum and but thereafter madle a grwal 1CONCT) and was taling One sees the cecum still further filled This is the fluss by myth on the thin das She was dischargeu last film which was talen There is a suggestion in the 1 ell on the fifteenth day Ihc inal crros in the des middle of the field of loops of small lonel huch hase Kur *as the result of an inadequately tough indeur lxcen filled cien though there is still a filling defect sucion The onls leads from interpti in the in the accum Johns Hopkins lliutat on the last 19 years (the last onc Before she could get to the operating room the child had 12 vejty as ") were in children in hun sie diagn will the first of three severe generalized on and comic con Ixon similih missed at the hospital in the prevent in vuluon nhwul delated operation for 2 px12x! ol xeral stance the shuts blenprolall us in sur e the fourt. When axration has finalls undertaken the intus met rigorous and perustant attempts at Frilucts o lleve Hikepun mail rund to fuse been completels sceluca! Cank nifact) * flere minneration ballen Train cither lis the larium cnemis or subsequent to that the Cven lxci se trifti in la! bren allemand anscum een inches of di tal ileum the cocurn and the formal reduction lung linallı lxen achuria iru) ?> *J!!! arending it were engorgail with 11 ww! edemarnus anuntatt som tar II) ·INTUSSUSCEPTIOIIVIIVIS ID CHILDKL 107 + } 7 3 5 B Fig4" Operative Completion of Incomplete Reduct in Ett feels ld must has now palpable in the region of by Barum Enema WA Vale 6y month old This the cerum irr the Urst time It operation through a night child came to the hospital 30 hours after the onset of Ve Burney incest in a small nubbin of sleum was found imitability abdominal pain and vomiting He 78 sila byc procruding into the cecum and was easily re passed bloody clots following a rectal examination in the luced in appendectomi was performed and the chile hopital but had been vomiting up to the time of admis Ich b) pral well on the 8th day son although he had been able to take a little water Shou s the filling defect of the barium column just to There was slight resistance in the right upper quadrant the left of the hepatic (lexure with the characteristic but no mass could definitely be felt Upon barium coems meniscus and osallilling defect fluoroscopy the cussusception was encountered with its B The intussuxeption has been further reduceul toward aper at the hepatic flexure it was readily reduced to the the hepauc flexure one can see a few rings of barrum cecum and could not apprrently be reduced further The around the negatie shadow of the intussusceptam as bartum was obsered to pass freely into the appendix and the barium seeps verneen the intussusceptim and the some barium passed into the sleum but the ileum did not intu syurycipiens (Conu vuelon n alpage susception of 28 hours duration an intussuscep with some difficulty the reduction was com tion filling the ascending colon st as rapidly and pleted This child did well bust sellised siste almost instantaneously reduced to the celum months later and was opcrated upon for Kitc but without filling of the small bonel It op mechanical intestinal obstruction du touinc eration a nubbin of ileum was reduced through sions and had one further out of obstruction a the ileo cecal value and the appendix removed month later which ssas treated without afxration 6 In a male of tinee months in intussuscep The note was made it the original ofkricion de tion of over 96 hours Juraison was encountered the muscularis and serosa of the avendim, colon in med sigmoid and reduced to the ascendin; were badly dimaged thongh the nel nas colon with the brilum encm2 It operation considered sable as it in fact porouud ta lic Sequired One is justified in maintaining hydro rand Pressure upon the bouels long as there as persistent and sieads reduction of the intussuscepun slon though it may be 11 so progress made the pauent should be sent to the operaung room hicle has been held in readiness Srubixin deicominat n to actuele a cure Inium enema has no place in a ratı xal therapeutik * 1117 is the onls instance in lucha Mchane ke muls mat in asyn sato in with inter uurt rolurert i brum eficia ·109 I\TUSSUSCEPTIO\I\I\I\IS I\D CHILDRE 1 . . C (Shons the intussuxeption reduced to the axending colon wth ng xxl cal of barium passing now letucen the intussuscptum and the lonels fitting intussus. cipicns 1) The final olm. there is seen some barium in the appendix and some in the terminal sleum but an Obsous persistent filling defect in the cecum The D appirent Golling (Icfect lugh in the nxending colon is of course 1 pcristaluc wie Is in this case operation must be undertaken promptly unless there is free billing of the alcun with barium und without any persistent del prmits of the cerum (trotul Kasach and V.Cunc inn Surg 19 1918) Sont of the children who we had reduction I he child and normal stools yppx rrect perfectly of mtussusccpton I barnum enemy zlone linic well without a palpable mass wd 175 sump Inul salacquent tricks of mechanical intestinal tonttic tatil 18 hours after the rouluctuoint sulent obstruction and thus is the only one of the chul the symptoms of intussuiseption raurtul dren tsith reduction completed by operation sho I lucre 1751 1755 in the left loner quadrant hund such testnil obstruction The intussusception is reduced from the de 7 Ilus thirteen month old male is men soudug colon or sigmor to the incum where I tronce under recurrence of intussuscepron ifter small fillons difett Chine! A oprition Dum cncm reduction in intussuscption the only intussuse pron rumm, 75 lexumd to of 11 dass durison with 1 typical lustors 1975 He thrit of the 11 fx ods hxl * 1 semaid (> chcountered at the splenic flomme IL #TC Acther with its borse of cal 11 all The child cut duced to the cum ind the small lwnie could hell Ixe son fillin, nell Chroenl bilen bus stom 8 In 11 month old male in intuitiv oplote nchi tulx 175 pussel bi rectum fue hours later of 27 hours duration 11.25 crcountered on br10111 ·transverse colon Tlie cecum did not fil com > oft і It 1 1 1 1 ! the remainder of the missusception was readily desi lo primary lesion was found in the lonel the last bit of the intussusception was flicked out of the cecum and the appendix bas removed 10 in a seven year old boy 12th a fne hour basyurt crema reduced the intussusception to Intussusception Teaching the hepatic flexure the ferminzl ilcoin for three or four inches and the IN1 USSUSCII J10 mema in the Icft trinsicrse colon ind rei, through the cocum up into the laten inches of ilcum fillol 78 dicu 1 tsk!! effect could be seen in the Ilcum through a Vchurncy MCISION 1 small is intusçusception is reduced without dels and the appendi uis removed In intussuisception of 53 lays duri an eight momh old child 1 as reducou ! splenic flexure to the accum le of burton of vleum in the cocum *75 {{t he 10 In miussusception of 12 hours ou in an 31 montı old female uits encouns the left side of the transierse colon and re tn 21 to the cecum (Fig 43) At operation im did nubbin of ileum nas casily poppeul bu }} in thit the bonel and the appendix removed 11 thumb 11 in a 29 month old female in prsteun apathy with an 18 hour intussusception drum € 1100$suscep enema rapidly reduced the intussuscepti in ti " (1 Thus was the midtransverse colon to the cerum mich 1.1 hour incus small bone did not full readily 1114'!lur the splenic flexure 14 inches more of intussusception was!! !!e hepatu flere in 30 min disclosing a Vechels dnerticulum hun ud icmuitos 7) but could not be Tesected further redu! Operation was undertaken at 12 An incussusception of 28 hours in an once thc kayset Retical reduction and 3 resection eight month old child was reduced from the and pumar and 10 end anastomosis *75 per sigmoid to the ascending colon Ac operation formed The curd left the hospital well in ten an additional sase listed as requiring opx57 13 This was a four year old child with a si hour old tussusception presenting in the left susccptun of only se hours durinion in a los no scars and four months old was encountered pletely and at operation the tiny remaming in the mid transierse colon and complcicly and Tic portion of the intussusception at the leo cecah readily reduced by the brruum enems wahe reduced just as it is as being demonstrated barnum entered the small brossel freely the mus Mith a sponge stick in the abdomen was no longer palpable and nothin six hours ! In a child of 15 months a 46 hour old the child possed charcoal and stol lie seemed mahu susception presenting at the recto sigmoid quite uril sn and a half hours after reduction has reduced to the cecum in 30 minutes of steady se dei cloped crumplike Ixdominał gaun und e S. The sleum did not full At opertion began to pass blood and mucus together will lo miss reappeared and after 21 hours when a aque mass w7s ſelt and 11 was thou hr liat he had a recurrence It operation thic cecum md proumal ascending colon veic tre At operation thelle inendously thcene and indurated and it was reduced stool the cecum but no further ·108 INTUSSUSCEPTIOI IN INFIN15 AND CHILDREN 9 1 с Shows the intussuscepnon reduced to the ascending colon with a good deal of brum passing nou between the intussusceptum and the loosely fitting intussus apiens The final him there is seen some barium in the aprendi and some in the terminal sleur but an out fous persistent filling delect in the cecum The D apparent filling defect high in the ascending colon is of course a peristaltic wave is in this case operation must be undertaken promptly tnless there is free filling of the sleum with barium and without any passistent deformity of the cecum (From Rauch und VcCune san Surg 128 1918) Vond of the children who hait hnd reduction The chuld had normal stools appeared perfectly of intussusccption by brum enemy alone have well without a priprble muss und was issmp frid subsequent attacks of mechanici intestinal tomic until 18 hours after the reduction 71 olistruction and this is the only one of the chil the symptoms of intussusception recurred dren with reduction complexed In operruon who Thure s7s a mass in the left Ioner quadrun Innd such intestinal obstruction The intussusception 375 reduced from the de 7 This thirteen month old male is men scending colon or sigmoid to the accoum where ? 110ned under recurrence of intissusception after small filling defect remained At operatii? brum cnem reduction An intussisception the only intusstisception remu, was found to of 11 dts durion with 7 pical fustory #25 be thrzt of the appendıs shuchi 175 remos er to encountered at the splenic flevare It 1125 re gether it is lase of cert 1 }} I lc ciuild duc duced to the cerum ind the small bosci could well be keen filling kell Charcoal given his stom 9 In 11% inonth old mrle in tissusception Ich tube x7s passed by recium fne hours liter of 27 hours dura11011 1 15 encountered on huum ·I\TUSSUSCEI TION INFANTS AND CHILDREN 109 not full The enemy in the left transverse colon and reduced inches of ileum was reduced and the appendix through the cecum up into the ileum Several removed inches of ileum filled and then a typical filling 16 In a three and a half year old box 11th 7 effect could be seen in the sleum At operation 14 hour intussusception at the hepatic flexure through 1 VcBurney incision 7 small ileoiler! the intussusception was reduced into the alcum intussusception was reduced without difficulty which fuiled to full freely It operation the and the appendix was removed intussuscepuon was found to extend for prou An intussusception of 53 days duration in mally into the ileum and to have arisen in 1 an eight month old child was reduced from the large lymphoid patch about three fuct proumal splenic flexure to the cecum It operation a to the ileocecal value Reduction is easil 10 button of ileum in the cecum was flicked out complished and the appendix removed 10 An intussusception of 12 hours duration 17 In a three year old box in intussuscep in an 11 month old female was encountered in tion of six hours duration had reached the left the left side of the transierse colon and reduced side of the transierse colon The burnum en mi to the cecum (Fig 43) At operation a small reduced it quickly to the cecum The ileum did nubbın of ileum was easily popped back into At operation a button of iluum in the the bowel and the appendix removed cecum was readily pushed back with the thumb In a 29 month old female in profound and forefinger apathy with an 18 hour intussusception barium 18 In only a single case 1175 the intussissep enema rapidly reduced the intussusception from tion irreducible and bonel resected the midtransierse colon to the cecum in a fue month old female with 7?1 hour intus small bowel did not fill readily At operation susception which had reached the splenic flesta 14 inches more of intussusception was reduced It was reduced to the hepatic flexure in 30 mln disclosing a Mechels diverticulum which was utes by barium enema (Fig 27) but could not be resected further reduced Operation was undertaken ? 12 An intussusception of 28 hours in an once the bon el defied reduction and a rescation eight month old chuld was reduced from the and primary end to end anastomosis was per sigmoid to the ascending colon At operation formed The child left the hospital well in ten the remainder of the intussusception was readily days No primary lesion was found in the boucl reduced In an additional case listed as reqmring oper? 13 This was a four year old child with a 57 tion in addition to the burium encmi un intus hour old intussusception presenting in the left susception of only five hours duration in a bos transverse colon The cecum did not fill com (No years and four months old was encountered pletely and at operation the tiny remaining in the mid transierse colon and completely and portion of the intussusception at the ileo cecal readily reduced by the barium cnem Thic value reduced just as it was being demonstrated barium entered the small bowel freely the m74 with a sponge suck in the abdomen was no longer palpable and sthin sıx hours In a child of 15 months a 46 hour old the child passed charcoal and stool le scenci Inttissusception presenting at the recto sigmoid quite sell Six and a half hours after reduction was reduced to the cecum in 30 minutes of steady he developed crumplile rlxlominal pain and progress The ileum did not full It operation began to pass blood and mucus progether with the last bit of the intussusception was flicked out stoo! lo mass reappeared until after 21 hours of the cecum and the appendix was remoi ed when a vzgue mis has felt ind 11 175 thu,ht 15 In a seven year old boy with a five hour that he had a recurrence It ofxration thic intussusception reaching the hepatic flexure the terminal ileum for three or four inches and the barium enema reduced the intussusception to cecum and proximal ascending colon CIC IIC the cecum but no further It operation inche mendousls thiciened and indurated and it was ·110 INTUSSUSCEPTION IN INFANTS AND CHILDREN eralia VOTT B Tig 13 Operative Completion of Incomplete Reduction well nourished child in good condition "The abdomen by Borium Enema IC Fenizle 11 months old This 175 Tery soft and relaxed There was an casily visible and chuld was seen 12 hours after the onset of spasms of palpable sausage shaped mass in the right upper quad periodic abdominal pain She vomited immediately after rint four by three centimeters in diameter There was the onset and repeatedly thereafter She took ſeedings a little renderness over the mass when offered but was unable to retain them She was a (Continued on next page) thought that it miglit be the site of 1 tumor per hours duration At operation the interssuscep haps a lymphosarcom For this reason the ter tion 1178 rerdily polpred in the sigmoid colon minal ileum and the right colon were resected A Foley big catheter had been placed in the rec and in unstomosis performed Plate IIC of the tum the balloon distended and the cithcter con specimen shons merely the changes consistent nected to a bottle of intricuous siline solution with vible bowel at this period after reduction This is allowed to run into the boucl wlic the of an intussusception The chuid dick well al operitor and first assistant eich muintiineri 1 though he returned subsequently with 1 mechan ſinger on opposite sides of the intusstisception in ical obstruction due to adhesions which required the abdomen At the end of fac minutes when operation neither observer had noticed any change in the In (No other cises listed as requiring oper? position or tenseness of the intussusception thic tson and very curly in the series the operators attempt was discontinued the lands removed agreed to the performance of hydrostitic pres and the bowel erimined To our surprise the sure reduction on the operating table with the intussuisception had reduced completely and this open zlxlomen The first of these was 1 sis hid all been accomplished so swiftly smoothly month old female with an intussusception of 15 un gently tiszt our fingers holding the Inttise ·INTUSSUSCEPTION IN INFILTS I\D CHILDREN 111 COM VOIT C A. The intussusception was encountered at the distal B C and D Shot progression of the reduction across the transverse colon but the first film talen shows that it tran verse colon has already been reduced to the mid transverse colon (Continued on rugace) ception had not percened the change in tension convince us that if manurl pressure is nodod as the intussusception 117s reduced and the bonel and of the barium canmister no higlier than filled with saline solution The same procedure three and a half feet above the operating cable kas employed in an eight months old mile with ingrenous bowel will not be reduced and pxerlo an intussusception of 36 hours durnon This rition of the intestine will not xcur We live intussusceprion had reached the descendin, seen children in such a degree of collapse that it color and as similarly reduced very rapidly to seemed almost certain that the bowel must byc the cecum The final portion of the intusstiscep gangrenous who live ser had intusstisceptions tion could not be reduced unul sterile mineral reduced while blonxl 78 being administerul and oil had been introduced between the inyers of the hile not requirei operuuon It is scarcely pos intussusception and very firm innurl pressuire ble 10 malc in absolute duguiy of gingrene made on the cecum just distal to the incussuscep of an intussusception 11th accuracy without tton "This chuld also did well To tine is kint by the use of the bar He feel stron is that burium enema ca and uuin enema since the opxracın. Troms is licin, should be administered to evers cluid with in fritten in readiness and the chuid is having a (118susception regardless of the durituon of the Ostric spinion and supptic intrucnous disease or the chulds condition I revenu mnt Dud therapy of transfusioj) 11 the home time Preusous experience and experimental studies furthermore even if the intukux pron should ingether with the great mass of reported cases prenc to lie ilicumplicly reduceri i baritime erition ·112 INTUSSUSCEPTION IN INFANTS AND CHILDREN IT 8th day E The splenic flexure has been passed and barium is nubbın of ileum was found in the cectim and through pissing round the intussusceptum in the ascending the small McBurney incision was readily reduced with colon pressure of the thumb The appendix was removed F The transverse colon and ascending colon and cecum and the child was discharged from the hospital on the are filled However there is still a partial filling defect in the cecum and no barium has proceeded into the Thuis was an early case If the catheter is kept in place small boucl It is obvious that the balloon catheter without leakage such intussusceptions will usually reduce has been expelled and that there is leakage of barium completely without operation If the catheter is expelled on the sheets The operator did not reinsert the cath reinsertion in such case with another flow of larium will eter into the rectum and attempt another enem but usually bring success. proceeded at once to operation At operation a small enem? the more of the intussusccption that is sions occurring subsequent to operative comple reduced by the enemi the less remains to be tion of reduction 179 in one of the earlicr cases done in the operating room The problem of where i vertical right rectus retricting lower reducing an intussusception found at operation abdominal incision was employed to be in the right colon or in the cecum is Vost reports of extensic clinicıl experience quite znother one from that of reducing an intus s3th intussusception mention the occurrence of susception from the rectum or sigmoid entirely mechanical intestinal obstruction due to adhe around the colon sions some time after operative reduction of Fıcept for the first few cases most of the intussusception In vient of the formal lnpirot incisions in cases requiring operatise comple omy required and the extensive Innalling of tion of the reduction have been right Joser the already traumatized bowel his is small quadrant VicBurncy or lateral transierse inci wonder and marks 7 slurp difference from thic Sious wuch expose little more of the peritoneal experience of clinics employing primary hydro cauty than the cocum and terininrl ileum The static pressure reduction one case of intestinal obstruction due to dhe Packard reports to such ist wices of subsc ·INTUSSUSCEI TIO IN INFANTS AND CHILDLE 119 O 88 cases quent mechanical intestinal obstruction in 43 medium which results in accuracy of diagnosts in children previously treated for intussusception essentially all cases and thich is curune in 70% by primary operation Thurston Holow ich und to 75% of cases and enormously simplifies the McCoy in 109 operations foi intussusception ru tash of the surgeon in the remuning 2510 30 pore 7 cases of mechanical obstruction due to Our own interest in intussusception was adhesive bands occurring from two months to uroused in 1933 by the paper of Dr E H Viller three and one hulf years post operamels hahle of Chicago who described his dissatisfaction with reports 4 such obstructions 2 of them fatal in hi oun poor results (47% mortality in 20 cases) We reported in 1950 12 cases of me vid referred to the remarkable results of Hips chanical intestinal obstruction (3 of them fatal) jev in Au tralia with reduction of intussusccp developing weels months or years after opera tun by hydrostatic pressure In reviewing the the reduction in the early series at the Johns literature we were struck by the interesting Hoplins Hospital fact that Surgeons reporting in 1930 and 1910 Tlus is therefore a serious complication and moitalities of 20% and 30% for the treatment of the deaths should fairly be attributable to the intussusception scorned the non-operative meth treatment of intussusception by the operative ods which had a lower mortality in 1890 and method in 1900 and which in 1926 gave a mortality a Although we are convinced that all children low as 5% in 100 consecule cases trered by with intussusception deserve a trial at barium Hipsley enema and expect that between 70 and 750 of paper of Hipsley s published in 1995 is them will be cured by the barium enema ve partirular interest He reported on this occa are emphatic that the barium enema should not Sion 486 cases of intussusception treated by sa be stubbornly persisted in If at any point Surgeons with an over all mortality of 11% absolutely no progress is made for ten or fifteen Shree of the ten surgeons always attempted minutes the attempt should be abandoned and preliminary reduction by salıne enemi and b operation proceeded with On the other hand! a mortality of 98% The other ses en sulo so long as there is any progress however slots operated on all patients without in attempt the attempt should be persisted in hydrostatic pressure reduction and hurd 1 117 It is our feeling that the barium enema reduc mortality This is a significant difference 131 tion of an intussusception is as much a surgical large series of patients treated in the procedure as the manipulative reduction of a period of time and at the same hospital fracture or the cystoscopic removal of a ureter Today there is essentially no mortality fr The barium enema should be under intussusception treated in the best pediatric sti The control of the surgeon who will make the gical clinics except in the case of children decision when and of operation is to be per rady irretrievably moribund at the timer formed and who will perform the operation admission A comparative study of current As close cooperation with pediatricians and ra tality statistics is therefore of little value Suc diologists as can be achieved is desirable but the a study published by us ten years 7,9 * surgeon should be present at all such manipula mortality from intuisstisccption 175 not so tions and responsible for their conduct Any showed a striking difference in tlic results other course is certain to result in delays the clinics employing operative reluction prin only interpretation which can be placed on some and clinics employing lıydrostatic pressure series of hydrostatic pressure reductions which tion primarily with the balance lieasily fast have presented a significant mortality is that a of the latter policy of hydrostatic pressure reduction at all Nordentoft and llinsen Wie compiled in costs was in force The barium enema should results of a colossal Dinish experience with be considered as a diagnostic and therapeutic tussuscepuon based on 1012 cases treated! al stone ·132 I\TUSSUSCEPTIOVINFANTS AND CHILDREN E FIhe splenic flexure has been passed and barium 15 nubbin of ileum was found in the secum and through passin, around the intussusceptum in the ascending the small VcBurney incision was readily reduced with culen pressure of the thumb The appendix 175 Temnyed F 7 lic transscrse colon and ascending color and cecum and the child was discharged from the hospital on the are fitted llonever there is sulla partial filling defect 8th day in the cocum and no barium has proceeded into the This was an early case 1f the catheter is kept in place smit fou el it is obvious that the balloon catheter without Icalage such intussusccptions will usually reduce has been expelled and that there is leakage of barium completely without operation If the catheter is expelled on the sheets. The operator did not reinsert the cath reinseruion in such case with anoilier flow of barium will cter into the rectum a nuempi another enemi but usually bring success. proceeded it once to operation It operation a small ancul the more of the intussusception that is sions occurring subsequent to operate comple reduced by the enemi the less remins to be tion of reduction was in one of the earlier cases dient in the operating room The problem of where a vertical right rectus retracting lower reducing an intussusception found it operition abdominal incision was employer? 10 lc in the right colon or in the acum 1 Vost reports of extensive clinical experience quite unoilier one from tnt of reducing an intus with intussusception mention the occurrence of suist oprion from the rectum or sigmoid enurely mechanical intestinal obstruction due to the round the colon sions some tuine after operative reduction of Ixccpt for the first fex cises inost of the Intussisccption 111 vies of the formal lipirot INCIsons in (ises requiring operative comple omny required and the extensisc branding of nion of the reduction 1111e been right loser the sends traumatized lonci his is suit quadrant VicBurncy or $11cral transierse inci wonder and marks a sharp difference from the Sions wheypore Juile more of the peritoncil cyperience of clinics employing primary fusdro cavity than the cicum and terminal ileum rhe static pressure reduction one case of internal olostrucnon due to adhe Pickard reports two such instances of sulise ·IN TUSSUSCLI TION IN INFI\TS IND CHILDREN 113 0 8S cases quent mechanical intestinal obstruction in 43 medium thich results in accuracy of diagnosts in children previously treated for intussusception essentially all cises and which is curative in 70% by prmry operation Thurston Holowach and 107 of cises and enormously sınıplifies the VicCoy in 109 operations for musstisccption re t35h of the surgeon in the remuning 20 to 300 port 7 (78cs of mechanicıl obstruction due to Our own interest in intussusception was adhestie binds occurring from two months to proused in 1933 by the paper of Dr E H Viller three and one lulf years post operunchs hable of Chicago who described his dissatisfaction with reports | such obstructions of them frtal in his own poor results (43%, mortality in 20 cases) We reported in 1950 12 cases of me and referred to the remarkable results of Hips chanıcıl mutestinal obstruction (3 of them fatal) les in Australia with reduction of intussuscep developing weeks months or years after opery non bi hydrostatic pressure In reviewing the the reduction m the early series at the Johns lite ime we were struck by the interesting Hopkins Hospital fact that surgeons reporting in 1930 and 1910 This is therefore 7 serious complu wion und mortalities of 20% and 30% for the treatment of the deaths should fairly be attribuible to the intussus eption scorned the non-operative meth treatment of intussusception by the operrune ods which had a lower mortality in 1890 and method in 1900 and which in 1926 give ? mortality as Although we are convinced that all children lou 73 74 in 100 consecutive cases treated by Mith intussusception deserve a trial at barum Hipsles enema and e\pect that between 70 and 70's of paper of Hipsley s published in 1993 is of them will be cured by the barium enema "le particular interest He reported on this occa are emphatic that the barium enemi should not sion ton cases of intussusception treated by ten be stubbornly persisted in If 16 any point surgeons within over all mortality of 11% absolutely no progress is made for ten or fifteen Ihree of the ten surgeons always attempted 1 minutes the attempt should be abandoned and preliminary reduction by salıne enema and had operation proceeded with On the other hand a mortality of 98% The other seven surgeons so long as there is any progress however slow operated on all patients without an attempt at the attempt should be persisted in hydrostuic pressure reduction and had a 14% It is our feeling that the barjum enema reduc mortality This is a significant difference in a con of an intussusception is as much a surgical furge series of patients treated in the same procedure as the manipulative reduction of a period of uime and at the same liospital fracture or the cystoscopic removal of a ureter Today there is essentially no mortality from 'I he barium enem 1 should be under intussusception treated in the best pediatric sur the control of the surgeon who will make the giral clinics except in the case of children al decision when and it operation is to be per rendi irretrievably moribund at the time of formed and who will perform the operation admission comparatie studi of current mor As close cooperation with pediturns and ra ity statistics is therefore of little value Such diologists as can be achieved is desirable but the 7 studi published by us ten years ago when surgeon should be present at all such mampula mortality from intussusception was not so rare tions and responsible for their conduct \my shoned a striking difference in the results of other course is certain to result in delays The clinics employing operatise reduction primarily only interpretation which can be placed on some and clinics employing hidrostatic pressure reduc series of hidrostatic pressure reductions wluch tion primarils with the balance heavily in favor Hate presented a significant mortality is that 1 of the latter polics of hydrostati pressure reduction at all Vondentoft and Hansen have compiled the Coses was in force The barium enema should results of a colossal Danish experience with in be considered as a diagnostic and therapeutic tussuscepuon based on 1012 cases treated be al stone ·INTUSSUSCEPTION INFANTS AND CHILDREN Ineen 1928 and 1935 and 796 cases between for this treatment and thus muy quite nuturally 1914 and 1949 In the first period ordentoft lead to dier vigorous persistence ili enemt mi collected 419 cases of intussusception 201 were nipulation From Vorsientoft s 1935 paper one treated by barium enema alone and of these gathers that m 1134 brrium cnemi reductions there were 12 derths Tho hundred and fif four cases of rupture of the bowel occurred teen had 1 secondary operation 16 of lucht all events Nordentofts und Hinsen s results are Here merely confirmatory and 45 of these chil good for their time comprre fuoribly with re dren died There were thus 57 deaths out of ports from other clinics but are not quite as good 119 cases a mortality of 13 6% in 1928 1935 ? 75 one hould hater right to expect result outstanding for the time In 450 pri Helmer reports 130 cises of intussusccption mary operations there were 116 deaths or 1 reduced with barnum encm? (over 80%) with 258% mortality The remainder of the patients no deaths In 30 additional cases in which were treated by a water enema or by trins laparotomy lud to be resorted to 1 70dinion abdominal inanipulation In Hansen s supple there were nine deaths 1 mortality of 56% for mentary report there were 413 cases treated only the whole material In the last three and 1 by burium enemz with to deaths and 302 half years of the study that is to say from 1911 cases secondarily operated upon (in 53 cises to 1947 there were mine cases operated upon the operation was merely conformitory) with 50 one liith 1 resection with no cenths This is deaths There were thus 52 deaths in 715 c15e considered to be due to improved mesthesia 1 mortality of 73% The mortality during the ind post operative care sime period out of 71 cases operated upon pri Recently Packard and Allen from the Den marily was 18 9%-14 deaths The remainder of ver Childrens Hospital and hable from the the patients were apparently undiagnosed and Charity Hospital in New Orleans live appar died without treatment Once more the mos ently begun to use the burium enemy with in tility 73% was better than most American clin creasing frequency On the other land Denn ics ucre reporting m 1919 The cruse of the son of Closgon after 1 ton) hos gusen 1 pp 18 deaths is only very briefly discussed In the uns itisiictory carler paper Nordercoft states unong oclter Voore appirently attempted barnum enemir things that while the pressure used is generally reduction in 17 cases and had only tuo successes that of 1 to 12 meters it is never to go above in addition to one u fuch 128 confirmed at oper 2 meters that is to say six feet! 1 buch 17 7t1on He had one denth foiioning Test ction great deal more than we think is safe Nor in bis total of 19 cases and 5 deaths without dentoft states, if there is doubt about the re reset tion The results scem unsatisfactory with duction-lucli there will always be if the enemna all forms of treatment in this series does not pass into the snall bowel-an immedi Trincis and Triedmin report from 1993 1955 ne final treatment will be indicated In early 38 cases treated by primary operation with four rises 7 brif delay to and developments will resections and tho dentis In 7 cases baru be arranted but should on no account exceed enemu is as employed-four with complete reduc 1 tery fets lours This le consider 1o be don Lion and three requiring operatic completion If there is any doubt about re As a result they ads ise birium cnemby the sur (uction immediate operation should be under geons is the first step in treatment taler I reading of Lorentoft s sest kould Santullt und Ferrer from the Blues Ilospa printry borut suggest that iſ reduction is not achieved repeated 11 10 lex loch recently used enemy reduction in 30 cases aith complete se utempts 1re made during the first ind usu ally only roentgen crimination It would ir duction lition operation mil complete reduction in Sittore confirmed at opx r11101 pear from ordentoft s statements that the pr atelits are tlie patients of the rdiolo,ic service that is to say 606 in 111 Incluiry Slickliche Lerouls duce ·IN TUSSUSCEI TION IN INFANTS IND CHILDREN 115 eration after initial resistance fias finally tried the bar inexperienced may reduce an intussusception um enem and has been successful in 33 cases without recognizing it certainly but no one can out of 54 He points out the hus incidence of fail to diagnose an intuissusception in the large success has been highest in the intussusceptions intestine which does not reduce Intussuscepunder 24 hours and in babies older than six tions still in the ileum cannot usually be dem months Combining these two fertures he re onstried Honever they present as cases of duced 23 out of 28 or 82% of intussusceptions mechanical intestinal obstruction and if enemi of less than 24 hours duration in infants older does not disclose an intussusception the history than six months Hiller in Australia reporting the course and the fluoroscopic finding of dis from the Royal Children s Hospital in Mel tended loops will require operation Further bourne has been employing the burium enema more whereas most cases of intussusception are in early cises of intussusception and in 41 such diagnosed clinically a few actually require bar intussusceptions out of 1 total of 60 succeeded in ium enema for definituie diagnosis In many reducing 24 all of the rest of them having been at clinics in which the barium enema is not used least partly reduced Giordany Bass and Grier therapeutically a good many intussusceptions of Pittsburgh treated 27 cases of intussusception have been inadvertently reduced in the course by birium enemu and redured 22 or 81 They of what was meant to be a purely diagnostic had one death in spite of complete reduction barium enema Furthermore human nature Twith viable bowel in 1 child who had convul being what it is pediatricians are much more $ions and died with aspiration pneumonia which likely to make a tentative diagnosis of intussus may have been due to aspiration of the barium ception before they are absolutely certain when in the fluoroscopic room this involves merely an enemy rather than in op- What are the reasons for the resistance among As a pedagogic point we perform a surgeons to a form of treatment which in so barium enema whenever the question of intus many hands has given results superior to those susception is raised however confident we may achieved by primary operation: The objections be in a given instance that the suggestion is buse commonly raised are these - less The result we believe is substantially The original diagnosis may be uncertain earlier definitive treatment 2 It is difficult to be sure of reduction 2 Accuracy of diagnosis of complete reduc Will not the recurrence rate be higher- tion is high We have made an erroneous ding 4 Polyps and other tumors cause many in nosis of complete reduction tune in the 77 tussusceptions and will not be found The second of these was nine yeirs ago 5 In the unsuccessful cases a dangerous delay Once we adopted it as iron clad policy that op will have been caused eration would be performed in every case in 6 The bowel may rupture which there was not free fulling of many loops Non viable bowel may be reduced of small bowel te hue had no ferr of mis To answer these objections taken diagnosis of complete reduction On the 1 To be sure in most forms of non-opera other hand as indicated in a previous section tive treatment of acute abdominal conditions as ne have in fuse instances been knsure that rcduc in acute cholecystitis acute pancreatitis per tion was complete only to discover it operation forated duodenal ulcer the first problem is that that it was of diagnosis and the fact that in such conditions Even if we were to insist on operative conſirm this cannot be made with absolute accuracy is ation of every enemi reduction the procedure an automatic disadvantage However in intus would still be safer and casier than operative susception the diagnosis by fluoroscopy is fairly reduction alone The use of hydrostatic pressure simple the criteria are characteristic and expert is safer quicker and less traumatic in the reduc ness in their recognition is soon acquired The tion of intussusception than is the manual 3 cases 7 ·116 INTUSSUSCEPTION IN INFANTS AND CHILDREN 1 squeezing pulling and huling of operative hydrostatic pressure and religiously rustuin from reduction mmipulation of the bowel There have been a 3 As to the rate of recurrence we have had fell instances in Scrindinius of rupture from only three in the 77 cases This mte of recur minual reduction through the intact abdominal rence is about that which is reported from series wall with or without enema of primıry operative reductions 7 As for reducing non uable bonel it would As concerns the possibility of failing to appear that with 7 pressure of three feet six discover such a tumor by barium enema alone inches one cannot reduce gangrenous bouel Ir the incidence of specific causative lesions in our reducibility of an intussusception as indicated series has been only 13 în 199 cases of intussus by our experiments and the previous state ception a total incidence of 6% These oc ments of others is determined by adhesions be curred practically all in the children over two tween the sheaths and by the degree of edemı years of age Furthermore the tumors which Both factors increase with time and become more cause intussusception are rarely dangerous of elfective in preventing reduction is the damage themselves Mechels diverticula occur in per to bowel increases By the time the constric baps 1% of the population and in addition it tion is so severe as to have produced gangrene would appear from our experience that intus the moderate pressure employed will not reduce susceptions caused by Mechels ducrticuli arc the bone and it is important to note thit the not usually completely reducible and will come stress of this pressure is borne by the outer to operation Polyps in children may be the sheath the intussuscipiens which usually re cause of repeated intussusceptions or may cause mains viable to the end anemia from bleeding but are not dangerous if An advantage of the barium enemi reduction not found at once Large lymphoid patches will so obvious as scarcely to need mention lies in usually cruse no further trouble and such rare the fact that 70% or more of the children will lesions as the occasional small enteric cyst or have escaped an anesthetic and a laparotomy focus of ectopic pancreatic tissue are of little con with whatcver risks are tahen to attend these sequence except as they cause intussusception Turthermore although we insist that cich lica 5 As for the delay which might be caused by reduction is obviously complete all children 20 (successful attempt to reduction by enema should be liospitalized and placed on itibiouc it usually requires less than half an hour from therapy of the enteric poorly absorballe type start to finish to reduce an intussusception by to decrease the likelihood of a specific enteritis this means It is our practice to call the operat occurring in the injured bowel these periods of ing room as soon as the dignosis is made and hospitalization are appreciably shorter than in we have usually finished the reduction in time patients who are operated upon The 11 erige to cincel the operation before preparations in duration of stay in the hospital for otir last 15 the operating room have been completed This pacients trerted primarily by irarum cicmi 178 titne in any case is employed for Iwage of the little more than four and a half days with many stomach administration of intrni enous fluds of the chuidren leasing the hospital !! Ino or and antibiotics and so long as the procedure is three days under the control of the surgeon from the out It is as well to sc-emphasize again the fact set no time will be lost that this method is not a substitute for opera It is 15 Rupture of the bone can occur with hy nor an escape from operation drostatic pressure as well as 111th manual reduc much a surgical procedure 75 ss reluction of 1 tion during operation Horcier it is much less fructure by tricuion The surgeon should be as lilcl; to occur with enemi since less force is em ready to perform 1 laparotomy of it proves nec ployed and that force is diffuscly distributed essary is the orthopedlist is to perform an open recluction The treatment should be corried out lle employ three feet to three feet six inches t10n ·INTUSSUSCEPTION IN INFANTS AND CHILDREN 117 by 1 surgeon and in a hospital It is not an tion from Charity Hospital of Louisiana at New office procedure nor 1 litchen table remedy Orleans Am J Surg 52 215 224 1941 Lidd WE and Gross R E Intussusception in infancy and childhood Arch Surg 29 365 384 BIBLIOGRAPHIY 1934 (a) Ladd WE and Gross R E Abdominal Surgery of Infancy and Childhood Philadelphia Siun Benson CD and Sharpe H R Jr Recent expe ders 1911 riences with intestinal resection in infants and Laurence GH and Ulfelder HIntussusception children Arch Surg 61 822 833 1950 Close HG Acute intussusception in children Vew England J Med 247 499 502 1932 Guys Hosp Rep 81 436 143 1931 Mayo C l and Woodruff R Acute intussuscep- Court SDM and Jones J DT The manage tion Arch Surg 43 583 587 1941 ment of intussusception in childhood Med Illus McLaughlin C W Jr Surgical management of ir 9 63 68 1955 reducible intussusception Arch Surg 56 1857 Dennis C Resection and primary anastomosis in 1948 treatment of gangrenous or non reducible intus Montgomery 4 H and Mussil J J The treat susceptions in children Ann Surg 126 788 796 ment of irreducible intussusception in children 1947 A study clinical and experimental Surg Gynec Dennison WM Intussusception in infancy and do Obst 51 415 419 1930 childhood Glasgou M ] 29 71 80 1948 Moore TC Management of intussusception in Dennison W M Personal communication 1997 infants and children -a report of 43 cases Ann Fange CH and House H G A case of intussus Surg 135 184 192 1922 ception in an adult without symptoms of strangu Packard GB and Allen RP Results in the treat lation treated successfully by abdominal section ment of intussusception in infants and children Aledico Chir TT 59 85 98 1876 Surgery 41 567 579 1937 Francis WW and Triedman L J Intussuscep The treatment of irreducible intussus tion in infancy and childhood Rhode Island MI I 39 560 562 1956 ception by lateral anastomosis Proc Roy Soc Med 2 Pt 1 271 274 1909 Gibbs EW and Sutton PW Intussusception Peterson EW and Carter RF Icute intuisstis Surgery 14 708 718 1913 Gibson R H Dockerty M B and Dixon C F ception in infancy and childhood Ann Surg 90 94 97 1932 Intussusception in infants and children s Clin North America 26 1141 1151 1919 Rutherford H Irreducible intussusception in the Goldenberg I S Intussusception Surgery 36 732 infant treated by ileo-colic anastomosis Brut 739 1954 Child Dis 6 501 510 1909 Gordon EF Intussusception - review of 42 cases Snyder W H Jr hraus A R and Chalkın L from files of New Haven Hospital Arch Pediat Intussusception in infants and chuldren Report 57 585 591 1910 of 113 consecutive cases Ann Surg 130 200 210 Gross RE and Ware PF 1919 Intussusception in childhood experiences from 610 cases Aew Eng Thatcher DS Intussusception in infants and land i Aled 239 615 652 1948 cluldren Ann Surg 140 180 181 1951 Gross R E The Surgery of Infancy and Childhood White and Dennison WM Irrcducible intus Philadelphia Saunders 1953 susception in infants Bril | Surg 10 137 110 Hogg B M and Donovan EJ Acute intussuscep 1932 tion in infants and children Ann Surg 124 262 Woodhall B Vodified double enterostomy (Volu 267 1916 Licz) in radical surgical treatment of intussusccp- Jones J DT Treatment of irreducible intussus. tion in children Arch Surg 36 989 1938 ception Brt A1 ) 2 1301 1306 1993 Zachary RB Acute Intussusception in childhood Kahle HR Analysis of 151 cases of intussuscep Arch Dis Childhood 30 34 36 19,5 Parry RH Y ·118 INTUSSUSCEPTIOV IN INFANTS AND CHILDREN Acute intussusception Ann Surg, Re BIBLIOGRAPIY Miller E MI (b) 9$ 706 712 1933 Vionrad S Acute invagination of the intestine in Clubbe CPB The Diagnosis and Treatment of small children Acta paediat 6 31 52 1926 Intussusception 2nd Ed London Hodder & Voore TC Management of intuisstisception in Stoughton 1921 infants and children - report of 43 cases inn Giordany B R Bass L W and Grier G W Surg 135 181 192 1992 duction of ileocecal intussusception by hydrostatic Nelson TI Place of hydrostatic pressure in the pressure Radiology 60 518 526 1953 treatment of intussusception A) Australia 1 Helliner H Roentgenologic diagnosis and treat 823 827 1919 ment of intussusception in children Acta radiol Nordentoft J M The value of the barnum enema 24 235 2.8 1913 in the diagnosis and treatment of intusstisception Hellmer H Intussusception in children diagnosis in cluldren Acta radiol 24 481 188 1913 and therapy with barvum enema Acta radiol Nordentoft J M The value of the burun enem? Suppl LWV 1 120 1918 in the diagnosis and treatment of intusstisception Hiller HG Barium enema reduction of intussus in children illustrated by about 500 Danish cases ception in infancy M J Australia 2 157 1955 Acta radiol Suppl 51 1913 Hipsley P I Intussusception and its treatment by Nordcntoft J M and Hansen H I rentment of hydrostatic pressure Based on an analysis of 100 intussusception in chuldren -a brick survey based consecutive cases so treated M I Australia 2 on 1 838 Danish cases Surgery 38 311 319 1935 201 206 1926 Nyborg S Intussusception in chuldren study based Hipsley PL Treatment of intussusception M ] on 108 075CS data chur scandinav (Supp! Australia 2 696 697 1934 LIIT) 89 1 219 1913 Hipsley P L Intussusception Brit A1 ) 2 717 Olsson I and Pallin Uber das bild der akuten 721 1935 darminvagination bci Rontgenuntersuchung und Hipslcy PL Treatment of intussusception Sur uber desint igination mit hilfe von lontrastlase ger) 1 825 837 1937 ments Acta chir scandinav 61 371 383 1927 Hirschsprung H 107 Falle von durmint igination Pichard GB and Allen R Phosults in the trcat bei Kindern behandelt im Lonigin Louisen hin ment of IntusSUSception in inlants and children derhospital in Kopenhagen thrend der Jahre Surgery 11 567 57. 1997 1871 1901 A1111 Grenzgeb Med Chir 14 555 Pouliquen M et DclaMarnierre Indication du 1903 11icment bismuthé dans certaines formes d mag Hutchinson Jonathan successful case of abdom 11itions intestinalcs Bullet Mem Soc Xat inal section for intussusception Medico Chur Ir Chirurgie 53 1016 1021 1927 I ondon 57 31 1871 Rasitch Vird V and VcCune RW Jr Keduc hahle II R and Thompson CT Dingnostic and tion of intussusception by barılın enemi ann therapeutic considerations of intussusception Surg 139 901917 1918 Surg (inec Obst 97 693 701 1953 Raslich Vark Mind Vorgm R } Reduction koch 1 ind Ocrum HP 1 Intussusception in of intussusception by frium cnemia Ann Surg chuldren Four hundred Danish cists rdınburgh 135 996 601 1951 X1227 211 1912 Rasitch Var. V Reduction of 1991ussuisception by Ladd 1 F Progress in the dignosis and treat birum cneina Surg Cyner Obst 90 131 132 1991 ment of initissiisception Boston VESI 165 519 1913 Raunch Varh v The non-operunc treatment of Lehmunc Tin ball von ini aginatio ilcocrccalus intuisstisce ption-lıydrostatic pressure reduction by barium (neina Surg Clin lorth Imerica fra am Rontgenbilde Cortschr Ceb Röntgenstrah len 117 561 191 13. 1936 Viddlem65 Intussusception in childhood Rausch Vlak ll Intussusception in infancy and radiological appearances on plain radiography childhood Tea Ingland J Med 259 10,8 1061 19,9 Brit / Radio! 25 237 263 1913 ·INTUSSUSCEPTION IN INFANTS AND CHILDREN 119 Retan GM Non operative treatment of intussus Stephens V R Ileocecal intussusception in infants ception Am J Dis Chuld 33 762 770 1927 with special reference to fluoroscopic findings Santull. T V and Ferrer J M Jr Intussuscep Surg Gynec Obst +7 698 700 \or 1927 tion an appraisal of present treatment inn Surg 143 8 17 1936 Stephens IR Acute intussusception-manipula Sjostrom PM Ober unblutige desinvagination tive reduction under fluoroscopic control im von darmınvaginationsfallen mit hilfe von lons Dis Child 3, 61 61 1928 trast einlauf unter roentgendurclıleuchtung Der Zachary R B Acute intussusception in childhood Chirurg 6 706 714 1934 Arch Dis Childhood 30 32 36 1933

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·AUTHOR INDEX Allen RT 13 61 62 11" 114 Ithinson FR 16 Aurelianus Caclius 3 Oerum HP T 68 Ohle GH 6 Olsson G 10 69 O Sullilan 11 D 6 Bailette P 36 B: $ L. 115 Benson CD 61 62 Bollin R 16 Hippocrates 3 66 Hipsley PI 18 10 14 19 16 69 78 113 Hirschsprung Hit 7 10 16 1 6/ Flogy BV 16 63 Holowach11 19 20 26 113 Holt I E5 Houck CR 41 19 House HG51 Hunter J x 3 Hutchinson J 5 7 30 66 Chaffin L 13 14 20 6) Child CG 26 Close H G 16 Clubbe CPB 1x 10 68 Collinson F1 10 Court SDV 14 18 59 Custung H 18 50 56 Packard GB 13 61 6 11 111 Pallin G 10 68 Party RH 59 61 Perrin S14 1 16 Pever J C3 Pirogoff I 7 Pouliquen V10 64 Power DAX 41 49 Praxagoras 3 66 Illingsworth Cr 17 J ghers H 30 Jones J DT 18 57 59 61 6) Rachelson VH 15 18 19 Retan (10 68 Rohitansky k Rutherford H 9 61 hable H R 13 14 18 19 0 22 113 Dennis C 61 62 Dennison WV 14 15 17 59 61 114 Dich B V 17 Donovan E J 16 65 Dowd CN 10 hoch A 68 Kraus AR 13 14 22 67 Ellison WB 41 Ellman R 17 Ladd WE 8 10 54 68 Lawrence GH 65 Lebmann C 9 10 68 Leichtenstern O 3 4 7 Lewis D D1 61 Lind ay FC 14 15 16 Ling JT 13 Suntulli T 14 18 114 Selye H4 Senn N 115 41 Sharp HR 61 62 Smith JL 5 Snyder 1 H Jr 13 14 2 65 Soranus 3 Spence j1 Stephens IR 10 68 Sutton P l 65 Fagge CH 54 Ferrer J M 14 114 Fiedler FA 6 Fitzwilliams B 16 Forest E51 Forshall E 25 26 fox P F 14 18 61 65 Francis W 1 114 Fuchsius C6 Fulton J F 41 Tay | | Thatcher DS 13 20 22 61 6 Thomas Li Thompson 1 1 6 Thurston DL 14 18 20 22 26 113 Treyes I 18 Treuman L J 111 Llfeldier 11 6 MacFarlane DA 18 Vac\fahon B 14 15 16 Maunsell S E 55 61 VcCoy LE 14 18 20 113 McCune RM 343 Vicku ich Y A 30 Vcl auglılın C Jr 65 Viller EH 113 Mitchell S4 Monrad S 69 Vontgomery 1 H 59 61 Voore A11 Voore T 11+ Vortimer J D 57 Vurhead EE 42 Vassil J J 59 Gerson C6 Gibbs E W 65 Gibson RH 65 Gilmer R 41 Gordany BR 115 Goldman L 17 Grer G W 115 Grollman A 49 Gross RE 13 19 20 20 26 57 59 65 Tanatla J 12 Hakci CIG 16 Ware 1 F 19 20 22 26 65 Hatts J 1 11 Tells S 7 Ilhile V9 GI Wilson JRG 11 ilson J16 11 oodhall B G1 (6) Flachmann LN 6 Haenisch F 9 10 Haller A6 Hansen 1 113 114 Helmer 11 14 114 Hiller H1 G 115 Tordentoft J V 14 19 20 52 80 113 114 Tothnagel H1 x 11 Tuck 1., 6 11 Zachar RR G1 ( Icta IS 121

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