HX641 38224 
 RC862 .F76 Intussusception in c 
 
 . 
 
 RECAP 
 
 INTUSSUSCEPTION IN CHILDREN. 
 
 W. E. FOKEST, M.D., 
 
 New York. 
 
 Reprinted from The American Journal of Obstetrics and Diseases 
 of Women and Children; Vol. XIX., July, 1886. 
 
 COLUMBIA UNIVERSITY 
 
 DEPARTMENT OF PHYSIOLOGY 
 
 College of Physicians and Surgeons 
 4s7 west fifty ninth street 
 
 NEW YORK 
 
 NEW YORK: 
 WILLIAM WOOD & COMPANY, 56 & 58 LAFAYETTE PLACE. 
 
 1886. 
 
££I6Jl 
 
 £u 
 
 Columbia (Bntoergftp 
 
 mtijeCttpoOtogork 
 
 College of iPfjpstctang and burgeons; 
 library 
 
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INTUSSUSCEPTION IN CHILDREN 
 
 BY 
 
 W. E. FOEEST, M.D., 
 
 New York. 
 
 Reprinted from the American Journal of Obstetrics and Diseases of 
 Women and Children, Vol. XIX., July, 1886. 
 
 NEW YOEK : 
 WILLIAM WOOD & COMPANY, 56 & 58 LAFAYETTE PLACE. 
 
 1886. 
 
"KG £6.2. 
 
 Fig 
 
INTUSSUSCEPTION IN CHILDREN. 
 
 Case I. — In July, 1880, a child eight months old was brought 
 to me for treatment for diarrhea. It was much reduced in flesh and 
 strength. I saw the child one afternoon, and recommended the 
 mother to take it to the sea-shore the next morning, and remain 
 on the beach during the day. The same evening the mother 
 noticed a lump in the right hypochondriac region that moved at 
 times towards the left side. 
 
 The child passed a restless night, occasionally screaming, and 
 the diarrheal discharges gave place to bloody passages, accom- 
 panied with tenesmus. In the morning, without seeing me or 
 notifying me of the new symptoms, the child was taken to the 
 sea-shore. The mother had already noticed that, after violent 
 expulsive efforts, what she called the child's "body " came down. 
 During the day the child had occasional attacks of screaming and 
 straining, accompanied by the same bloody discharges. In the 
 evening I was called in, this being about twenty-four hours after 
 symptoms of intussusception had become prominent. Found the 
 little patient with a rapid pulse, eyes sunken, cold, and vomiting. 
 No tympanites. 
 
 An oblong tumor could be felt in the left iliac region. When 
 the abdomen was manipulated, the child made expulsive efforts 
 which forced out about two inches of the invaginated intestine. 
 
 The diagnosis was readily made. I at once attempted to 
 remedy the difficulty. The patient was held in a reclining posi- 
 tion, with head and shoulders lower than the hips, and attempts 
 were made to force back the invaginated intestine by means of in- 
 jections of warm water through a Davidson's syringe. The 
 sphincter ani was so markedly relaxed that two fingers passed 
 through without difficulty, and, owing to this relaxation, it was 
 impossible to confine the injections in the bowel. As soon as 
 
4: Forest: Intussusception in Children. 
 
 three or four ounces had been thrown in, an expulsive effort 
 would drive out every particle of the liquid at the side of the 
 nozzle of the syringe, and force the intestinal tumor down upon 
 the syringe nozzle with considerable force. 
 
 Finding my efforts unavailing, I called in a neighboring physi- 
 cian to assist me. The child was suspended for a few minutes 
 with its head downwards. The assisting physician held the 
 nozzle of the syringe in the anus and supported the relaxed 
 sphincter with his hands, while I attempted to inject warm sweet 
 oil. In spite of the position of the child and every endeavor on 
 the part of my assistant to constrict the anus and retain the in- 
 jection, it was expelled repeatedly. The expulsive force of the 
 abdomen in this weak child was almost incredible. After inter- 
 mittent attempts for more than two hours, we were compelled to give 
 up these efforts and to propose the operation of abdominal section. 
 To this the parents would by no means consent, and so, it being 
 nearly midnight, we left the case for the night. On my way 
 home I thought of a measure that might perhaps be of service. 
 I stepped into a drug store, and procured an old-fashioned glass 
 vaginal syringe, one inch in diameter and six inches in length, 
 with a rounded end, perforated by a number of small openings. 
 From the syringe I removed the piston and fitted a cork in the 
 open end, with a hole in the cork just large enough to receive the 
 nozzle of a Davidson's syringe. I removed the rubber tube 
 with the nozzle in front of the bulb of the syringe and passed 
 the nozzle through the hole in the cork. A little melted sealing- 
 wax dropped on the cork held the nozzle in place firmly, and 
 made the joints air-tight. The other end of the rubber tube 
 was then slipped over the nozzle of a siphon of Vichy water and 
 fastened. I then made a shoulder on the glass vaginal syringe 
 about an inch from the perforated end, by winding a roller band- 
 age tightly around it. This bandage was wound so as to make a 
 firm shoulder an inch in thickness all around the tube, and made 
 slightly cone shape. My apparatus consisted, then, of a siphon of 
 Vichy water warmed to the temperature of the body, a small 
 rubber tube about two feet in length connecting the siphon with 
 a glass tube one inch in diameter and six inches in length. The 
 end of the glass tube that entered the rectum was rounded and 
 perforated with a number of openings. One inch from this ex- 
 tremity was a shoulder formed by a roller bandage. 
 
 The apparatus being complete, 1 proceeded to put it to the test. 
 The glass syringe was inserted in the anus until the shoulder on 
 it pressed firmly up against the parts about the sphincter ani and 
 thus supported them. Then I cautiously depressed the cock on 
 the siphon. Not till this moment did the completeness, and (if 
 I may be allowed the expression) the beauty of the apparatus 
 appear. 
 
 Whereas with the ordinary method of injection, two physicians 
 had found themselves totally unable to force any considerable 
 
Foeest : Intussusception in Children. 5 
 
 amount; of liquid into the intestine, owing to the relaxation of the 
 sphincter and the powerful expulsive efforts of the child, now hy 
 the pressure of one finger upon the cock of the siphon I was en- 
 abled to give an injection without the escape of a drop of the in- 
 jected fluid. With the utmost ease I could bring to bear upon 
 the invaginated intestine an elastic pressure of gas and water that 
 might be increased at will up to almost any amount. Very slowly 
 then, barely a drachm at a time, I allowed the gas and liquid to 
 escape from the siphon into the glass tube and so into the colon. 
 When an expulsive effort came on I at once stopped the injection, 
 when part of the fluid would be driven back into the glass tube 
 
 and there meet with an elastic cushion of carbonic acid gas, that 
 while yielding somewhat to the expulsive force of the abdomen, 
 still kept up a continuous pressure on the tumor and gradually 
 forced it upwards. In twenty minutes I found by abdominal 
 palpation that the tumor had risen somewhat in the left iliac 
 fossa, and that the expulsive efforts of the child were less violent. 
 Thirty minutes later, no marked tumor could be felt in this 
 region, but there was still an obscure swelling in the right hypo- 
 chondriac region. 
 
 I then had the child held in a semi-reclining posture, with the 
 shoulders higher than the nates, so that gas might rise upwards, 
 and inverted the siphon so that carbonic acid gas alone could es- 
 cape from the siphon into the rectum. As the gas rose up 
 through the portion of the colon below the tumor and pressed 
 against it, there was a faint rumbling sound and immediately all 
 signs of an intussusception disappeared. The child was then 
 given an anodyne, and soon fell into a quiet slumber. Two hours 
 later, a natural feculent discharge came from the bowels. 
 
 Case II. — An infant, five months old, in ordinary good health 
 except that it was teething and had a slight diarrhea, was taken 
 in the evening with sudden attacks of crying and screaming. 
 
6 Fokest : Intussusception in Children. 
 
 These attacks were paroxysmal in character. The child vomited 
 occasionally. About 2 a.m. to these symptoms were added dis- 
 charges of blood accompanied by marked tenesmus. The parents 
 then summoned me. I found the symptoms already mentioned. 
 The child was pale, but not yet collapsed. Suspecting what the 
 trouble might be, I at once examined the abdomen and found a 
 tumor in the left hypochondriac region. On passing the finger 
 through the dilated sphincter, and as far as possible into the rec- 
 tum, it came in contact with the end of the invaginated portion 
 of the intestine. 
 
 The diagnosis was plain. Without delay I procured my simple 
 apparatus and the siphon of Vichy, and commenced giving the 
 injection. The tumor was gradually forced upwards. The ex- 
 pulsive efforts of the child became less and less violent as the 
 tumor rose, until at length, before the invagination was reduced, 
 the child fell into a doze. It had had neither opium nor an 
 anesthetic. In one-half hour there was no sign of a tumor pres- 
 ent. There was a faint rumbling sound at the close, much as is 
 heard when a hernia is reduced. I gave the child an opiate. 
 The next day it appeared well and made a good recovery. 
 
 Case III. — In April, 1885, I was called to see a girl of 5 years, 
 who had had intermittent pain in the abdomen for two days. 
 She then began to have well-marked tenesmus with the passing 
 of blood. 
 
 On examining the abdomen, I discovered a tumor in the right 
 hypochondriac region. This tumor was movable slightly and 
 during a pain became somewhat harder, " rose up " under the 
 hand, and moved slightly upwards. The patient, however, was 
 very comfortable between the paroxysms of pain, there was no 
 collapse, no vomiting, and no dangerous symptoms of any kind, 
 such as were present from the first in cases I. and II. Tenesmus 
 was well marked, however. 
 
 In making the differential diagnosis in this case (and I must 
 confess I was a little in doubt at first, owing to the absence of 
 acute symptoms), I had to consider whether the tumor might not 
 be impacted feces. Against this theory was the "feel" of the 
 tumor itself : it did not have the doughy feel that impacted feces 
 are said to have in most cases. The tumor, too, was somewhat 
 erectile, which is said to be characteristic of a tumor due to in- 
 tussusception. Then again, in impacted feces there is rarely 
 marked tenesmus and passing of blood unless the impaction is in 
 the sigmoid flexure, which was not the case here, the tumor being 
 in the region of the ascending colon. 
 
 From these considerations I decided that it was a case of sub- 
 acute intussusception, probably ileo-cecal. Owing to the absence 
 of acute symptoms, I decided to treat the case tentatively, and 
 immediately began to carefully administer opium, and then 
 waited for other indications before commencing active treatment. 
 After a few hours the pain and tenesmus gradually subsided. 
 
Forest : Intussusception in Children. 7 
 
 Fomentations of the abdomen were then added to the other treat- 
 ment. The patient passed a comfortable day and night. 
 
 The next day (twenty-four hours after beginning treatment), 
 the tumor was present, but slightly smaller. A little blood still 
 passed, but tenesmus was absent. I continued the treatment 
 and employed massage to some extent. 
 
 The third day the tumor could not be felt. In the evening 
 the child had a passage of natural consistency and made a speedy 
 recovery. There was no evidence in the passage of hardened, 
 feces. 
 
 Intussusception or invagination of the bowel in children is an 
 affection of great interest to the physician, not so much because 
 of its frequency, though it occurs oftener than is usually sup- 
 posed, but on account of its dangerous tendency unless promptly 
 and carefully treated. 
 
 The varieties of invagination, classified according to situation, 
 are four. 
 
 1st. Invagination confined to the small intestine. 
 
 2d. Ileo-colic : the small intestine passing through the ileo- 
 cecal valve into the colon. 
 
 These two varieties are extremely rare in children under ten 
 years of age, and it is doubted by some writers whether the 
 first ever occurs in small children. 
 
 Bristowe says " jejunal and iliac intussusception (i. e., intus- 
 susception of the small intestine) is met with generally, if not 
 exclusively, in adults." 
 
 3d. Ileo-cecal : the cecum and ileum pass into the colon, but 
 the ileum does not pass through the valve. 
 
 The cecum enters the colon, dragging the ileum with it, the 
 ileo-cecal valve forming the lowest end of the tumor. The 
 cecum and the upper part of the colon are gradually inverted 
 as the tumor descends. 
 
 This variety of invagination forms forty-four per cent of all 
 cases both in adults and children. It probably forms between 
 eighty and ninety per cent of all the cases occurring in child- 
 ren. 
 
 4th. Colic invagination; colon passing into colon. This 
 forms eight per cent of all cases, but probably a larger per cent 
 than this in children. 
 
 From the foregoing it will be seen and must be borne in 
 mind, as it has a practical bearing on the treatment, that, in 
 
8 Forest : Intussusception in Children, 
 
 nearly every case of intussuception in children, the colon alone- 
 forms the sheath or outside layer of the tumor, and that the in- 
 vaginated portion of the intestine can be acted upon by a 
 pressure from an injection thrown into the colon. 
 
 Cause. — The cause of intussusception is given as unknown in. 
 sixty-two per cent of all cases. In eight per cent diarrhea or 
 dysentery is given as a cause. It is probably due in every case 
 in a child (when there is no polypus or malformation of the in- 
 testine) to disturbed nerve action in the intestine ; a want of 
 rhythm of action between the circular fibres of contiguous parts 
 of the intestine. The experiments of Nothnagel are interesting 
 in this connection. He exposed the intestines and mesentery in a 
 living animal, and applied the faradic electric current to a small 
 area of the mesentery. A portion of the intestine a few inches 
 in length, connected with the part of the mesentery acted upon, 
 contracted firmly into a dense cord-like condition. The intes- 
 tine just below this portion, not being acted upon by the elec- 
 tric current, and hence retaining its natural calibre, gradually 
 rose up around the contracted intestine and inclosed it, thus 
 forming a perfect intussusception. Now apply this view of the 
 cause of intussusception to the human subject. A child, from 
 some one of the many possible causes, has the nervous action of 
 the intestine disturbed ; it has a colic in fact, a wave of spasmodic 
 contraction and relaxation either commences near or travels, 
 down to the lower end of the ileum. 
 
 The cecum, the beginning of the large intestine, is large, and 
 in the child very movable. As the ileum near the valve con- 
 tracts spasmodically, the larger cecum slips up around it and 
 the intussusception is commenced. Now every paroxysm of pain 
 tends to increase this condition by pushing the ileum further and 
 further into the colon, turning the upper part of the colon 
 inside out, until at length, in severe cases, perhaps in a few 
 hours, the extremity of the ileum, with the ileo-cecal valve, will 
 protrude from one to six inches outside of the anus. The usual 
 cause of intussusception then must be some disturbance of nerve 
 action in the intestine. However interesting this theory of the 
 cause of intussusception may be from a scientific standpoint, it 
 has no practical bearing whatever. There te no method of 
 knowing when the child is in danger of an attack of intus- 
 susception, for in many cases it comes on apparently in a mo- 
 
Forest : Intussusception in Children. 9 
 
 ment, in children that seem perfectly healthy. Weakly chil- 
 dren, and those subject to intestinal troubles, are probably more 
 liable to it than others. 
 
 Diagnosis. — The diagnosis is a subject of the greatest im- 
 portance. In reading histories of cases of intussusception as we 
 find them given from time to time in the medical journals, one 
 is struck with the fact that in a majority of the cases an errone- 
 ous diagnosis is made at first, and a wrong course of treatment 
 pursued. 
 
 Either the case is thought to be one of obstinate constipation 
 and is treated for a time by purgatives, such as croton oil, calo- 
 mel, jalap, liquid mercury, or bird-shot, much to the detriment 
 of the patient ; or, on the other hand, it is thought to be a case 
 of severe wind- colic or dysentery, and is treated with opium. 
 
 After a clay or two of such treatment, the physician either 
 discovers his mistake, or some one is called in who recognizes 
 the true state of the case. 
 
 Now there is no inherent difficulty in making a diagnosis of 
 this affection in children, in the majority of cases. Mistakes 
 are made, because the physician is not on the lookout for this 
 condition, and because the symptoms resemble somewhat cer- 
 tain minor affections. 
 
 The characteristic symptoms are four : pain, bloody dis- 
 charges, tenesmus, and a tumor. The pain in acute cases is 
 paroxysmal in character, is sharp and cutting, and causes the 
 child to scream. In itself this is not characteristic, but taken 
 with the next symptom it becomes of great importance. A. 
 discharge of blood is one of the most important symptoms. It 
 appears a few hours after the attacks of pain, and is almost in- 
 variably present during the course of the disease. There are 
 but three affections in children that, so far as I know, give rise 
 to bloody discharges from the anus. These are dysentery, mu- 
 cous polypi, and intussusception. 
 
 Polypi need never be confounded with intussusception, be- 
 cause the symptoms are not acute, and they are not accompanied 
 with cramp-like pains, and constitutional disturbances. 
 
 The diagnosis between intussusception and acute dysentery is 
 a little more difficult. Dr. J. Lewis Smith says that, in most of 
 the cases of intussusception where he has been called in con- 
 sultation, he lias found the patient under treatment for dysen- 
 terv. 
 
10 Forest: Intussusception in Children. 
 
 The points of difference are that there is more blood and 
 little, if any, slime in intussusception, while in dysentery there 
 are slimy, foul-smelling discharges, tinged with blood. In in- 
 tussusception the attack is generally more acute than in dysen- 
 tery, the pain is greater, and more like colic ; finally, there is a 
 tumor that may usually be found by a careful examination. 
 
 Blood is always present in these cases in young children, but 
 in children over ten years of age, and in adults, it may be ab- 
 sent. 
 
 The tumor is the characteristic sign. This is present and can 
 be found in about eighty per cent of all cases, and in children 
 probably in a much greater percentage of cases. In the search 
 for the tumor, if the child is very fleshy, or the abdominal wall 
 resisting, the patient may be safely put under the influence of 
 ether or chloroform. 
 
 Generally the tumor will be found in the left hypochondriac 
 region. The location, however, is not constant by any means, 
 and it may be found in any region of the abdomen. 
 
 The tumor is oblong in shape ; it is movable, changes its 
 position during an attack of pain, and is erectile to a certain 
 extent when the child strains. 
 
 Not infrequently the tumor appears at the anus, or may be 
 reached by passing the finger into the rectum. 
 
 Is it possible to mistake a tumor of this character, when asso- 
 ciated with some or all of the symptoms previously mentioned, 
 for anything but an invagination ? The pain, the blood, the 
 constitutional reaction, the throes and strainings of the child 
 without passing feces, and the erectile tumor are the practical 
 signs. Not all of them may be present in every case, but some 
 of them must be. 
 
 There are other symptoms of intussusception, but they are by 
 no means so characteristic as those just given. Yomiting is 
 usually present, but this is so frequently present in children's 
 diseases that it is no guide for the diagnosis of intussusception. 
 
 In the cases I have seen, there was a marked relaxation of 
 the sphincter ani : in children less than a year old, two fingers 
 passed easily into the rectum. 
 
 This symptom points to some affection of the large intestine. 
 
 With many or all these symptoms present, there will be little 
 trouble in making a diagnosis, if the physician is ready to ap- 
 preciate the meaning of them. 
 
Forest : Intussusception in Children. 11 
 
 In subacute and chronic cases, these symptoms mentioned 
 above are not so prominent. There may not be great pain ; a 
 paroxysm not very severe is succeeded by a long interval of 
 ease ; constipation may not be present for some time ; blood 
 will appear at the anus after a time, and careful search will dis- 
 cover a tumor somewhere in the abdomen. But on account of 
 the comparative rarity of the disease, and the lack of urgency 
 in the symptoms, a careful examination of the abdomen may not 
 be made," and hence a mistaken diagnosis is held for severa 
 days. The only way to avoid these mistakes is, in every case of 
 colic or bloody discharges in a child, to make a very careful 
 manipulation of the abdomen for the possible presence of a 
 tumor. The importance of making an early diagnosis in this 
 affection must be evident. 
 
 Treatment. — In the treatment of this affection drugs play an 
 altogether secondary part. Cathartics, of course, are contra-in- 
 dicated. 
 
 The English authors speak of belladonna and opium as being 
 useful, the belladonna to relax the intestinal spasm and to re- 
 store the rhythmical action of the unstriped muscular fibre; the 
 opium to relieve pain and prevent shock. The uncertainty as 
 to how much opium may be given with safety to a child makes 
 me afraid to use it to any extent in this affection, though I 
 should certainly give it. It will require a poisonous dose to re- 
 lieve the pain of intussusception, and if the tumor should be 
 reduced while the opiate is yet in the system, death might occur 
 from opium poisoning. A small dose frequently repeated, to 
 counteract shock and quiet intestinal action, may be safely 
 given, but for the relief of pain and spasm during attempts at 
 reduction, chloroform or ether will be safer and more servicea- 
 ble than opium. 
 
 Spontaneous cure by sloughing of the invaginated portion of 
 the intestines is hardly worth considering in the case of chil- 
 dren under five years of age. Bristowe speaks somewhat doubt- 
 fully of the value of active treatment in this affection, and says 
 that we may well give the child the chance of recovery by sponta- 
 neous cure. But he likewise says that if the invagination oc- 
 curs in the large intestine, recovery by sloughing almost never 
 takes place ; and in another connection he says that intussuscep- 
 tion in children rarely, if ever, occurs, except in the large in- 
 testines. 
 
12 Forest : Intussusce2)tio?i in Children. 
 
 Putting these statements together, it becomes plain that 
 chilclen, unlike adults, can rarely recover spontoneously. 
 
 Treves' statistics show that spontaneous elimination of the 
 invaginated intestine in children under two years of age takes 
 place in only tico per cent of the cases. Even in the cases of 
 spontaneous elimination the child very rarely recovers, but dies 
 from peritonitis or exhaustion. Between two and five years of 
 age, spontaneous elimination (not cure) takes place in only six 
 per cent of the cases ; between six and ten years of age in 
 thirty-eight per cent. Hence, active treatment of some kind is 
 indicated. Bearing in mind what has been said previously as 
 to the usual location of the disease in children, it will at once be 
 plain that pressure on the tumor by injections through the colon 
 will be a reasonable method of treatment. This treatment is 
 as old as Hippocrates. 
 
 There are several things to be considered before giving an 
 injection for intussusception. 
 
 1st. When does adhesion between the coats of the invagi- 
 nated intestine take place ; for, obviously, it would not be safe to 
 try to force back the tumor after adhesion and sloughing 
 had commenced. The very shortest time on record when 
 adhesions had taken place between the coats of the invagi- 
 nated intestine is three days. The average length of time is. 
 five to seven days. Even then these recent adhesions are soft 
 and yield to pressure, and are not a bar to careful attempts at 
 reduction. 
 
 2d. When does softening and sloughing of the bowel com- 
 mence in these cases? This very important question cannot be 
 definitely answered. The time varies remarkably. In the ultra 
 acute cases (which happily are very rare) sloughing may com- 
 mence in twenty-four hours. In the ordinary acute cases three 
 days would be about the minimum time. In subacute cases a 
 week or more may pass before sloughing takes place. 
 
 3d. What form of injection is the best : liquid, or gas, or a 
 combination of them both ; and how shall the injection be best 
 administered ? 
 
 In answer to this I can say that I found the siphon arrange- 
 ment I have described very convenient and effective in the 
 cases in which I used it. Certain facts about these siphons 
 should be borne in mind before employing them. They contain 
 either saline or pure water charged with carbonic acid gas- 
 
Forest : Intussusception in Children. 13 
 
 Thev are charged under a pressure of from one hundred to one 
 hundred and twenty pounds to the square inch. Each cubic 
 inch of water under this pressure absorbs about five cubic 
 inches of gas, four inches of which will be liberated as soon as 
 the water escapes from the pressure within the siphon. Hence 
 when one cubic inch of water has escaped from the siphon into 
 the bowel we have in reality given a volume of gas and liquid 
 that occupies space equivalent to five cubic inches. Hence 
 the liquid should be allowed to escape very slowly, barely a 
 drachm or two at a time ; we must bear in mind that we have 
 a force in the bottle sufficient to rupture the intestine instantly 
 if employed carelessly. Another caution to be observed in the 
 use of the siphon is to avoid exposing it to any considerable 
 heat in warming it, for fear of an explosion. 
 
 It may be said that the siphon cannot always be obtained 
 when needed, especially in country districts. If the siphon is 
 not at hand, one can be improvised in fifteen minutes in the 
 following manner : Take a strong bottle or jug holding a pint 
 of water. Fill it and then put in two ounces of bicarbonate of 
 soda and an ounce and a half of tartaric acid. Cork instantly, 
 tie in the cork, cover with melted sealing-wax, and then screw a 
 champagne faucet through the cork. By slipping the rubber 
 tube over the faucet and inverting the bottle we have a siphon 
 that answers every purpose. 
 
 Ziemssen speaks very highly of carbonic acid gas in the treat- 
 ment of intussusception. He seems to think it has some specific 
 effect on the coats of the intestine that favors the reduction of 
 the invagination. 
 
 He recommends a measure in the use of it that cannot be 
 employed with safety, in children at least. He says that 
 twenty grains of bicarbonate of soda may be dissolved and in- 
 jected into the rectum. Then fifteen grains of tartaric acid 
 in solution may be injected. The chemical union of the two 
 will set free a large volume of carbonic acid gas within the colon. 
 
 4th. What syringe should he used f After a careful con- 
 sideration of the subject and many experiments, I have become 
 satisfied that we should use the fountain syringe only in treating 
 these cases. 
 
 The surgeon should know exactly how much force he is 
 exerting on the walls of the intestine every moment. If accu- 
 racy is important in any surgical operation, it is important in this 
 
14 Forest: Intussusception in Children. 
 
 one. The danger is not greater in using too much force than in 
 using too little. In the former case, the intestine is ruptured 
 and death ensues ; in the latter, the injection having been tried 
 with too little force, the tumor is wrongly declared irreducible 
 by injection, and the child is left to die unaided, or it is at once 
 decided that an operation by laparotomy is the only resource. 
 
 To illustrate how absurdly injections are often given in these 
 cases, let me give the outlines of a case reported in the Mary- 
 land Med. Journal for December, 1884 : 
 
 A surgeon was called in consultation in a case of intussuscep- 
 tion in a child two years of age. He says that in attempting to 
 reduce the invagination by injections, the child was inverted and 
 a funnel inserted into the rectum and water poured into this. 
 This method failing to reduce the tumor, and the parents not con- 
 senting to the operation of laparotomy, the child was left alone. 
 At length the parents consented to the operation ; the abdomen 
 was opened and the tumor easily reduced. The child, however,, 
 died from exhaustion and shock. 
 
 The surgeon reporting the case draws the moral that the 
 operation of laparatomy should be resorted to early in these, 
 cases. It does not occur to him that a pressure from within 
 the colon against the tumor by liquid or gas injected with 
 sufficient force might have done in the beginning what his fin- 
 gers in the abdominal cavity did two days later, namely, reduced 
 the non-adherent tumor. A force of possibly a half pound pres- 
 sure to the square inch was employed by his injection, when he 
 might have used with safety, and should have tried at least, a 
 pressure of five or six pounds to the square inch, before deciding 
 that injections were useless. 
 
 Another case was reported in the JV. Y. Med. Journal a few 
 years ago. The physician says : " I at once suspected it to be a 
 case of intussusception" (the tumor was present and every 
 symptom needed to make a positive diagnosis) " and ordered an 
 enema of tepid soap and water to be repeated every two or three 
 hours until a fecal discharge should be obtained. On my return 
 next morning I was informed that no passage had been pro- 
 duced." Injections thus administered do not tend to force back the; 
 invagination, but to increase it. The colon is stimulated to make 
 expulsive efforts and thus drive the intestinal tumor further 
 down. 
 
 The Davidson 's syringe, the usual means used in giving injec- 
 tions for the cure of intussusception, is a wholly untrustworthy; 
 
Forest : Intussusception in Children. 15* 
 
 instrument and should never be used if the fountain syringe can 
 be obtained. The amount of force evolved by compressing the 
 bulb of the Davidson syringe depends on the muscular power of 
 the operator, and cannot be even approximately measured. In 
 one case it may be enough to rupture the intestine instantly, and 
 in another not as much as might have been used with perfect 
 safety. 
 
 Surgeons would perhaps be surprised did they know how 
 much force can be obtained from the Davidson's syringe. I find 
 that the grasping power of my own hand as measured by the 
 dynamometer is about ninety pounds. Now, apply this force to 
 the bulb of a Davidson's syringe, and if the syringe be a good 
 one, we can bring to bear on a column of water within the colon 
 a pressure of ninety pounds to the square inch, provided, of 
 course, the colon does not rupture. Experiments, given later, 
 show that it will usually rupture under a pressure of fifteen 
 pounds to the square inch. Hence with the Davidson's syringe 
 the surgeon does not know whether he is exerting a pressure of 
 five or thirty pounds to the square inch in the colon. This 
 syringe, then, is not an instrument of precision at least. Then 
 again the intermitting force given from the Davidson's syringe 
 is objectionable. It tends to excite peristaltic action in the in- 
 testines which should be avoided as much as possible. 
 
 Injection of air : insufflation by means of a bellows is fre- 
 quently practised in England in the treatment of these cases 
 This method is open to the same objections and on the same 
 grounds as the treatment by the Davidson's syringe. 
 
 Bryant, of London, reports a number of cases where the intes- 
 tines were ruptured by insufflation from a bellows. This method, 
 then, is not unaccompanied with danger. 
 
 A still more dangerous instrument is the one that succeeded 
 in cases I. and II. reported by me, namely, the siphon of Vichy 
 or carbonic acid water. I am surprised to find that Treves, in 
 recommending this method of treatment, gives not one word of 
 caution as to the dangers to be guarded against. The precautions 
 to be used are given on a preceding page and need not be re- 
 peated here. 
 
 The most dangerous method of all in the treatment of these 
 cases is that recommended by Ziemssen, namely, to first inject 
 a solution of bicarbonate of soda, and then immediately to inject 
 a solution of tartaric acid so as to set free carbonic acid gas by 
 
16 Forest : Intussuscep>tion in Children. 
 
 their union. This may not be as dangerous as exploding dyna- 
 mite within the intestine, but the same principle is employed in 
 producing force in either case, namely, a rapid chemical change 
 with a sudden liberation of gas. 
 
 The fountain syringe, then, is the only one that can be used 
 in these cases with accuracy, and therefore it is the only 
 one that should be employed. By it the amount of force used 
 can be accurately measured, as every two and one-half feet in 
 /(eight of the reservoir above the point of delivery 'represents 
 about one pound pressure on every square inch of the intestine 
 helow the p>oini of obstruction. Tims if the reservoir is sus- 
 pended seven and one-half feet above the child, a force of three 
 pounds to the square inch is exerted on the obstruction. If the 
 rubber tube be tifteen feet in length and vertical, the pressure 
 will be six pounds to the square inch. With a tube of sufficient 
 length any pressure can be brought to bear on the tumor as de- 
 sired. This law of the relation of pressure to height comes from 
 the well-known physical fact that our atmosphere, weighing 
 fourteen and three-fourths pounds to the square inch, balances a 
 column of water thirty-four feet high. Hence each pound of 
 the atmosphere balances a column of water 2.37 feet in height. 
 It will be accurate enough for all practical purposes to say then 
 that a column of water two and one-half feet high exerts at its 
 base in every direction a pressure of one pound to the square 
 inch. Hence the exact force used in giving an injection can be 
 obtained in this manner. The only important feature about the 
 siphon syringe is the long tube, or a number of pieces of rub- 
 ber tubing that can be spliced. 
 
 Not less than from twelve to twenty feet of tubing should be 
 at hand. The reason for this will appear later. Into the upper 
 end of the tubing a funnel can be inserted in which to pour the 
 water ; or the water can be conducted into the tube from an or- 
 dinary pitcher on the principle of the siphon. 
 
 A convenient way of getting sufficient elevation (for most 
 rooms are not twelve to twenty feet high) would be to have one 
 person carry the reservoir of water to the stairway while the 
 patient could be in the hall-way or in a room opening into the 
 hall near the stairs. I have dwelt at some length on these 
 details because it can only be by paying attention to them that 
 we can treat intussusception successfully by means of injec- 
 tions. 
 
Forest : Intussusception in Children. 17 
 
 Whether one use the Davidson's syringe in giving the injec- 
 tion or the siphon, the recal tube I have described as made 
 from a glass vaginal syringe with a shoulder one inch from the 
 end will be found a very important adjunct. By this simple 
 contrivance an injection may be given without fear of wound- 
 ing the intestine, without making painful pressure on the parts 
 about the anus, without the escape of a drop of the liquid used, 
 and with the utmost ease and convenience to the operator. Its 
 effectiveness is clue to the fact that during the terrible expulsive 
 efforts of the patient the stretched sphincter is supported by 
 the large tube and the shoulder, and thus none of the liquid 
 used can escape. Owing to this fact we can measure accurately 
 how large a quantity of liquid is injected. A shoulder on the 
 nozzle of the Davidson's syringe will not answer the same pur- 
 pose at all, because the diameter of the nozzle is only about a 
 quarter of an inch and hence does not support the relaxed 
 sphincter. 
 
 Mr. Lund, of Manchester, England, has devised a rather 
 elaborate instrument for this purpose, consisting of a nozzle like 
 that of a Davidson's syringe, an air-inflated rubber ring on it to 
 press against the anus, a metallic shoulder to support the rub- 
 ber ring, a double canula, and a handle to hold the whole by. 
 This ajDparatus, which Treves figures and speaks very highly of, 
 is not so simple, so cheap, so safe, or so effective as the one de- 
 vised by me. So far as I know, this instrument, if I may so 
 designate a very homely and simple contrivance, has not been 
 before used in these cases. A trial of it alone can show its 
 value. 
 
 5th. How much force may he safely used in giving the in- 
 jection, provided we do not think sloughing has commenced f 
 
 I shall have to disagree with Dr. H. B. Sands in his views on 
 this point. He says in the JSf. Y. Medical Journal for 1877 : 
 " If injection or insufflation causes severe pain, it should be con- 
 sidered as dangerous." This rule, of course, could not be 
 applied if the child was under the influence of opium or 
 an anesthetic, and one or the other should be used in most 
 cases. Then, again, the greatest pain experienced by the child 
 and the most violent struggles take place at the beginning of 
 treatment, especially if the tumor be in the lower part of the 
 colon. 
 
 When the injection is properly given, especially if the nozzle 
 
18 Forkst: Intussusception in Children. 
 
 I hare described be used, it will be found in most cases that 
 the pain becomes less as the force of the injection is increased, 
 up to of course a safe limit. It was so in the cases I have re- 
 ported in this paper and it is so given in reports of other cases. 
 
 My answer to the question would be that a pressure of six 
 pounds to the square inch may be employed in any case seen 
 within three or four days of the inception of the attack, pro- 
 vided, of course, that a lesser pressure does not succeed. This 
 pressure could be reached very gradually by elevating the reser- 
 voir up to a height, if necessary, of fifteen feet above the patient. 
 My reasons for deciding upon this particular amount of force 
 as the limit to which we may go, if a lesser force does not suf- 
 fice, will appear from the following experiments. 
 
 Experiment I. — Child ten days old, died of marasmus not 
 accompanied with any fever. Opened the abdomen without 
 disturbing the intestine. Injected cold water from a fountain 
 syringe, the reservoir suspended five and one-half feet above the 
 point of delivery, this giving a pressure of a little over two 
 pounds to the square inch within the intestine. The liquid dis- 
 tended the colon and penetrated to the ileo-cecal valve, but did 
 not pass that point. Manipulating the intestine so as to make 
 slight traction on the ileum at its point of junction with the 
 cecum, opened the valve so that the liquid passed easily while 
 the pressure remained as before. 
 
 Suspending the child by the feet, with the head downwards, 
 also made the ileo-cecal valves pervious, without increasing the 
 pressure. 
 
 These experiments would seem to show that massage and po- 
 sition may, in some cases, aid in opening the ileo-cecal valve to 
 the passage of an injection. 
 
 Experiment IL— Reservoir suspended nine feet above the point 
 of delivery, thus making the pressure within the colon about 
 four pounds to the square inch. This caused the liquid to pass 
 the valve when aided by the position of the child, with its head 
 downwards. 
 
 The liquid, however, did not penetrate beyond the middle of 
 the small intestine, owing to the friction in the small intestine 
 and the obstruction from numerous sharp turns. Experiment 
 repeated several times, with the same result each time. The 
 practical deductions from this experiment would be, that the 
 pressure from the rectal injection will always be greater in the 
 
Fokest : Intussusception in Children. 19 
 
 colon than in the small intestine, and the pressure in the small 
 intestine will decrease directly as the distance from the ileo- 
 cecal valve. 
 
 An obstruction in the small intestine, especially if it be in 
 the upper half, can only be overcome by the expenditure of great 
 force at the rectum. 
 
 Experiment III. — Used the siphon apparatus described in 
 the first part of this paper. The liquid and ,gas were al- 
 lowed to escape very slowly. The colon, intestines, and stomach 
 were each dilated in turn, and in a few minutes the gas bubbled 
 out of the subject's mouth and nose. It seemed almost impos- 
 sible to rupture the intestine by pressure, as long as the nose 
 or mouth were pervious. 
 
 Experiment IV. — A ligature was placed about the small in- 
 testine five feet from the ileo-cecal valve; when the pressure be- 
 came too strong -to be resisted, the intestine gave way, not at the 
 point of obstruction in the small intestine, but in the middle of 
 the transverse portion of the colon. 
 
 Experiment V. — Child three weeks old, dead three days. 
 Pressure from a fountain syringe, equal to five pounds to the 
 square inch, was put upon the colon without rupturing it or 
 even destroying its elasticity. This pressure, however, did not 
 force the water through the ileo-cecal valve (as did a less pres- 
 sure in the other case), although position of the child and ma- 
 nipulation of the intestines were used as aids to the injection. 
 
 Experiment VI. — By the courtesy of Dr. Taft, chemist 
 for John Matthews, I had been furnished with a five-gallon 
 fountain filled with water and charged with carbonic oxide gas, 
 under a pressure of fifty pounds to the square inch. The de- 
 livery pipe from the fountain had a pressure gauge so arranged 
 on it that the gauge measured the pressure in the delivery tube 
 at any given moment. Xow, when 'this tube was connected 
 with the rectum by means of the nozzle of the syringe, and the 
 stop-cock slowly opened, the gauge measured the pressure upon 
 each square inch of the colon at any instant. TVhen all was 
 read}*, the water and gas were allowed to escape slowly from 
 the fountain and thus to gradually increase the pressure in the 
 colon. The gas causes a more rapid and forcible dilatation of 
 the intestines than does a liquid, even under the same pressure. 
 A force of six pounds to the square inch was used without fore- 
 
20 Forest : Intussusception in Children. 
 
 ing the ileocecal valve, and without rupturing or even over- 
 distending the colon. 
 
 Experiment VII. — The bands of the peritoneum binding 
 the ileum to the colon at the ileo- cecal valve were divided 
 without cutting any of the muscular coats of the intestine. 
 Tliis allowed the end of the ileum to be drawn out from the 
 colon and destroyed the integrity of the valve. 
 
 Experiment VIII. — Made an impassable obstruction in the 
 small intestine by means of a ligature, and then turned the 
 stop-cock so as to allow the pressure to slowly increase in the 
 intestine up to the point of rupture. Rupture took place at 
 about the middle of the transverse colon on the anterior surface. 
 The intestine bore a pressure of nine and three-quarter pounds 
 to the square inch before rupturing. The subject was a child 
 a few months old. 
 
 It may be said here that rupture in all the experiments took 
 place in the colon, and usually in the transverse colon. This 
 shows, not that the colon has less resistance than the small in- 
 testine, but that in a rectal injection the pressure must always 
 be greater in the colon than in the small intestine, even though 
 the valve be pervious. 
 
 Experiment IX. — Male about forty years of age ; died of 
 cirrhosis of liver. Connected the colon with the carbonic acid 
 fountain and allowed the colon to fill slowly. When the gauge 
 indicated a pressure of nine pounds to the square inch, the gas 
 passed the ileo-cecal valve. 
 
 At a pressure of thirteen and one-half pounds to the square 
 inch the longitudinal bands on the colon that give it its charac- 
 teristic appearance gave way in places with a snap. The pressure 
 was allowed to run up to fifteen pounds to the square inch, and 
 still the intestine did not rapture. The gas and water passed 
 freely through the whole length of the intestinal canal and out 
 of the mouth. 
 
 Experiment X. — Eight months' fetus that died during de- 
 livery. A pressure of two pounds to the square inch forced 
 liquid through the ileo-cecal valve, and a short distance into the 
 small intestine. A pressure of three and one-half pounds 
 forced the liquid through the whole length of the alimentary 
 canal and out of the mouth. A ligature was placed around the 
 intestine at about the junction of the jejunum and ileum, and 
 the intestines subjected to a pressure of six pounds to the square 
 
Forest: Intussusception in Children. 21 
 
 inch. There was no rupture. It would seem from these few 
 experiments that the following conclusions might be drawn : 
 
 a. That position and manipulation, in some cases at least^ 
 aid in forcing an injection through the ileo-cecal valve. 
 
 b. That in most cases, not in all, the valve will give way so 
 as to permit of the passage of an injection before a rupture of 
 the colon would take place. 
 
 c. That the valve is not the only obstacle to the passage of 
 liquids or gas from the anus to the mouth, but that friction in 
 the small intestine is an important factor. 
 
 d. That if. an injection be given with force sufficient to 
 cause rupture of the gut, the rupture will occur in the colon. 
 
 e. Injections cannot be relied upon to overcome obstruc- 
 tions in the small intestine. 
 
 f That the colon, both in the child and in the adult, bears 
 a surprising amount of pressure without rupture, a force of 
 eight or nine pounds in the infant, to twelve or fifteen pounds 
 in the adult. 
 
 These latter conclusions are the ones that concern us most in 
 this inquiry. We would then be justified, in any case of intus- 
 susception in a child, where the disease has not lasted long 
 enough for sloughing to commence, or adhesions to form, to 
 gradually apply a pressure within the colon of at least six pounds 
 •to the square inch. This could be done by raising the reservoir 
 .about fifteen feet above the subject operated on. 
 
 If the invagination be reducible, this pressure would seem to 
 be sufficient in any ordinary case to reduce it, for it must be 
 borne in mind that practically the intussusception in children is 
 always in the large intestine, and so will receive the full force 
 of the injection. A pressure of six pounds to the square inch is 
 a safe force to use in any acute cases seen within the first 
 three days. If the case be subacute or chronic, this pressure 
 would be safe to employ for any time within a week, or perhaps 
 three weeks. Cases are rejDorted where an injection has suc- 
 ce eded in reducing the invagination as late as a week after the 
 aff ection appeared. 
 
 6th. How shall the injection be given % Keep up a very slow 
 o ut steadily increasing pressure until the tumor gives way or 
 th e safe limit of pressure be reached without reducing the in- 
 v agination. Then keep the pressure at this point, fifteen, 
 t wanty, sixty minutas, if necessary, meantime manipulating 
 
22 Forest : Intussusception in Children. 
 
 the abdomen gently. Of course, if the case be thus obstinate, 
 the child should be under the influence of ether. 
 
 I am aware that this continuous pressure is not the method 
 usually practised or taught. 
 
 We are told to inject as much liquid as we can, and then let 
 it ran out. Then repeat the maneuvre. Tins method is 
 admirable for exciting the large intestine to expel any offending 
 substance from it, whether that be hardened feces or the 
 invaginated intestine. Our object, however, is not to cause 
 the expulsion of anything, but to mechanically force back an 
 intestinal tumor. 
 
 Therefore, it seems evident that a continuous pressure will 
 acconrplish this result better than an intermittent one. It will 
 be observed in case I. in the paper that the intermittent pres- 
 sure from the Davidson syringe did absolutely no good ; on 
 the other hand, the continuous pressure from the siphon, with- 
 out the escape of any of the injected liquid, soon stopped the 
 pain and straggles of the child, and steadily forced back the 
 tumor. It overcame the spasmodic expulsive efforts as the con- 
 tinuous but gentle pressure of the sound overcomes spasm of 
 the urethra in the male. 
 
 I regard this principle of continuous pressure as a very im- 
 portant one in these cases, and one that both experience and the 
 laws of hydrostatics would seem to indicate. In order to realize 
 the full value of this principle, it must be borne in mind that 
 hydraulic pressure is always the same in every direction. Hence 
 when a column of water is put into the colon in these cases under 
 a certain pressure, it not only is pushing back the tumor, but at 
 the same time, and with exactly the same force, it is dilating the 
 sheath of the tumor and compressing the tumor on every side, 
 and thus lesssening its calibre ; even for this reason alone, if for 
 no other, the pressure should be continuous instead of intermit- 
 tent, until the object in giving the injection is obtained. 
 
 There can be nothing gained in such a case by forcing back 
 the tumor for a short distance and then allowing it to be pushed 
 clown again by an expulsive effort. 
 
 If continuous pressure be used, the injected liquid might be 
 warm milk, or milk and water, or beef-tea, as in the fifteen to 
 sixty minutes that this would be contained in the colon, a not 
 inconsiderable amount would be absorbed, and thus aid to keep 
 up the vital powers of the child. 
 
Forest : Intussusception in Children. 23 
 
 But suppose that this plan of treatment has been faithfully 
 -tried and still the case does not yield to the treatment ; what is 
 to be done % 
 
 There are three courses open : First. An operation by laparot- 
 omy, opening the abdomen and attempting to reduce the invag- 
 ination by traction on the intestine. 
 
 Second. Leaving the case to nature, with the chance of a cure 
 by spontaneous elimination of the invaginated portion of the 
 intestine ; or, 
 
 Third. The use of a more forcible injection, even though 
 there be the possibility of rupturing the intestine by so doing. 
 
 Let us consider these plans separately and in order. 
 
 Laparotomy. In recent years surgeons have advocated this 
 method of treating intussusception as being comparatively safe, 
 and more certain than other means of treatment. 
 
 Modern surgeons, unlike our surgical forefathers, do not re- 
 gard the abdominal cavity as the ancient Hebrew did the " Holy 
 of Holies," a place never to be entered except under certain rare 
 conditions. On the contrary, they talk of making explorative 
 openings into the belly, for the purpose of diagnosis, as calmly 
 as if there was no danger in such a procedure. 
 
 It is hardly to be wondered at, then, that opening the abdo- 
 men to reduce an invagination should be looked upon with 
 favor. 
 
 Of course, most surgeons advise a trial of other methods be- 
 fore proceeding to this last resort, but we find in practice 
 that they don't " waste much time," as they call it, on insuf- 
 flations and injections. For instance, Mr. Goodlie reported 
 three cases of laparotomy for intussusception in children before 
 the London Clinical Society. In the first case he says : " It was 
 not thought wise to spend much time in attempts at inflation, 
 and accordingly abdominal section was performed at once." 
 The tumor was ileo-cecal and easily reduced, and there was no 
 apparent reason why an injection, properly administered, might 
 not have done just what his fingers did, i. e., reduced the invagi- 
 nation. In case II., reported by him, the trouble had lasted but 
 a few hours, the tumor was not large, and there was no contra- 
 indication to attempts at reduction by injection. Yet he pro- 
 ceeded at once to open the abdomen. The tumor was very 
 easily and quickly reduced. The child died, however, and Mr. 
 -Goodlie, in commenting on it, says that in a case no worse than 
 
24 Forest : Intussusception in Children. 
 
 this he should another time try inflation before opening the 
 abdomen. 
 
 In case III., the invagination had lasted some days, and 
 laparotomy in this case may have been justifiable. 
 
 "Actions speak louder than words " in such cases, and show 
 the drift of surgical opinion to be towards a quick resort to 
 aparotomy. 
 
 Treves, of London, says : " There is no reason why in the 
 future, with a fuller knowledge of the technical details essential 
 to the operation, with a surer acquaintance with the clinical 
 aspects of obstruction, and with the exercise of a sounder judg- 
 ment in the selection of cases, the procedure of laparotomy 
 should not have a mortality but little higher than that of the 
 operation of strangulated hernia." 
 
 The height of boldness in these cases, however, is reached by 
 Bryant, of Guy's Hospital, London. He advises in his lectures 
 that iu every case of acute intussusception we should not wait 
 for other treatment, insufflation, injections, etc., but open the 
 abdomen at once and reduce the invagination, precisely as in a 
 case of a strangulated hernia. 
 
 In regard to Mr. Bryant's position, this question occurs : 
 Suppose the abdomen opened ; the invagination is still to be 
 reduced. Now, can traction by the surgeon's fingers on the 
 invaginated intestine reduce the tumor, if it be reducible, with 
 less danger and more readily than a forcible injection into the 
 colon ? 
 
 The injection is an elastic pressure, and, as has been said, di- 
 lates the sheath of the tumor at the same time that it with equal 
 force presses the tumor back. Can the surgeon's fingers act in 
 this manner? Does not their tractile force act on the in- 
 testines in one or two lines, and thus would it not be more 
 liable to tear the intestine than an equal force from a liquid 
 injected into the colon ? 
 
 Professor J. B. S. Jackson, of Harvard College Medical 
 School, said on this point that " He considers opening the ab- 
 dominal cavity for intussusception with a view to withdrawing 
 the invagination a foolhardy procedure, since it (the intestine) 
 would usually tear before it could be withdrawn, even in com- 
 paratively recent cases." 
 
 If, however, the danger of lacerating the intestine be the 
 same by either method, and their effectiveness in reducing the 
 
Forest : Intussusception in Children. 25 
 
 tumor be equal, yet how infinitely more dangerous is the treat- 
 ment advocated by Mr. Bryant than that of a properly adminis- 
 tered injection. 
 
 His method adds to the possibility of lacerating the intestine 
 the certain danger of death from peritonitis or shock aris- 
 ing from the abdominal incisions and manipulations. The 
 latter danger is not a slight one by any means. The abdominal 
 cavity, in children at least, cannot be opened with impunity. 
 Treves' tables show that after laparotomy the death-rate in chil- 
 dren, even though the invagination was "easily reduced," is 
 43 per cent. 
 
 What is this high death-rate due to % Not to the reduction 
 of the invagination, for that was " easily reduced." 
 
 It must be mainly due to the abdominal section. It will be 
 said that delay in operating and consequent exhaustion of the 
 patient is the cause of the fatal result. It may be said in reply 
 that, had a properly given injection reduced the tumor without 
 opening the abdomen, the patient, however weak and collapsed, 
 would in the very large majority of these cases have quickly 
 rallied and recovered. Numerous cases are reported where the 
 prostration and collapse was profound and had continued for 
 days, and yet when the invagination was reduced without open- 
 ing the abdomen the patient quickly recovered. In fact, I can 
 find no case on record where the patient died after the tumor 
 was once reduced by insufflation or injection. 
 
 But we need to ask here^ if the reduction of the invagination 
 was " easy," why was the operation of laparotomy necessary at 
 all? 
 
 It would seem, from the nature of the problem, that any case 
 of invagination in the large intestine that can be easily reduced 
 by the surgeon's fingers might have been safely reduced by the 
 direct pressure of liquid injected into the colon. 
 
 The force thus exerted ought to be as safe and effective in 
 untwisting and pushing back the intestinal tumor as the pulling 
 and pushing by the surgeon's fingers after the abdomen i& 
 opened. 
 
 Surely, then, the grave operation of laparotomy should be 
 reserved for cases that cannot be reduced by the simple opera- 
 tion of giving a forcible injection. 
 
 Now, what have been the results of laparotomy for intus- 
 susceoticn in children where the invagination " was reduced with 
 
26 Forest: Intu$susce2ition in Children. 
 
 difficulty or was irreducible " ? According to the statistics of 
 Leichtenstern, of Treves, and of Schramm, who have collected 
 by far the largest number of these cases of any authors, the 
 death-rate after laparotomy " where the invagination was diffi- 
 cult or irreducible " was just 100 per cent ; not a single case 
 recovered. Laparotomy has succeeded in 57 per cent of the 
 cases where it was not indicated at all, where simpler, and 
 less dangerous methods would have succeeded far better ; and, 
 according to statistics, has failed in every case where laparotomy 
 was really indicated. These conclusions only apply to children 
 under 12 or 15 years of age. 
 
 Spontaneous Cure. The second course open in an obstinate 
 case is to leave it to nature. What are the statistics of opera- 
 tions by sloughing of the invaginated portion of the intestine, 
 and how do these compare with laparotomy ? 
 
 In the infant, spontaneous elimination takes place in only 2 
 per cent of the cases, and even these do not recover. In the 
 second to the fifth year of age, spontaneous elimination takes 
 place in only 6 per cent of the cases, and most of these die. 
 Hence, up to the sixth year of age nature fails to cure these 
 cases because the child's strength gives out before the slough 
 can be thrown off. 
 
 Between the sixth and eleventh year, however, spontaneous 
 elimination takes place in 38 per cent of the cases ; and recovery 
 takes place in 42 per cent of those that undergo spontaneous 
 elimination. In other words, 22 per cent of all cases of intus- 
 susception that occur between 6 and 10 years of age recover 
 by nature's operation. 
 
 We may suppose those cases of spontaneous elimination cases. 
 " difficult or impossible to reduce" — at least they never were 
 reduced, although in most of them attempts were made to do 
 so. When we compare nature's results in these cases with those 
 of laparotomy in " difficult " cases, we are struck by the advan- 
 tage of nature's method over that of the surgeon. 
 
 In children over 10 years of age, nature's operation gives still 
 better results. 
 
 Hence it does not follow that, if one cannot reduce an inva- 
 gination in all cases by an injection, he should, of course, call 
 in a surgeon to open the abdomen. 
 
 This depends, among other things, on the age of the patient.. 
 
 Forcible Injections. The third course open in any case that 
 
Forest : Intussusception in Children. 27 
 
 resists an injection given with a safe degree of force (six or 
 seven pounds pressure to the square inch) is to resort to still 
 greater force, say nine or ten pounds pressure to the square inch. 
 This cannot be done without danger of rupturing the intestine, 
 and thus causing the death of the patient. 
 
 But it must be borne in mind that these cases are dangerous 
 ones, at the best, and — whether we leave them to nature, or re- 
 sort to laparotomy— the death rate must be very high in any case. 
 In children under 6 years of age, either laparotomy or nature's 
 operation is almost always fatal ; hence we would be justified 
 in running some risk in giving a forcible injection in these cases. 
 Not to draw this out too far, let me state in a few words the 
 course I would recommend in all oases of intussusception in 
 children. 
 
 A pressure of six pounds to the square inch having failed to 
 reduce the tumor after a lengthened trial, I should cautiously 
 raise the pressure to seven and eight pounds, and even nine 
 pounds to the square inch, depending on the acuteness of the 
 attack and the length of time the invagination had continued. 
 This having failed, what course should then be followed % 
 
 If the child be under 2 years of age, open the abdomen at 
 once and resect the intestine. The child will probably die ; but, 
 if left to nature, the case it absolutely hopeless. 
 
 If the child be between 2 and 5 years of age, and injections 
 have failed, the chances of cure by sloughing or from lapa- 
 rotomy are about equal, and the surgeon will be justified in 
 following either course. Remember that the invagination prob- 
 ably cannot be reduced even by traction, and the principal ob- 
 ject in opening the abdomen is to resect the intestine, or to per- 
 form enterotomy. 
 
 If, however, the child be over five years of age, and the tumor 
 has resisted a pressure of eight or nine or ten pounds to the 
 square inch without being reduced, we must conclude that it is 
 irreducible. 
 
 Now, according to statistics given above, the operation of 
 laparotomy in these cases shows a greater death rate than the 
 cure by sloughing, the " spontaneous cure ; " therefore, nature's 
 operation, nearly hopeless as it is, should be preferred to lapa- 
 rotomy. 
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