Experienced clinicians usually recom mend preliminary anwsthesia, but in rnanv cases the state of the patient does not warrant this proceeding: an advan tageous. one in every way when it can be adopted. D'Arcy Power places the patient under chloroform and steadily fills his intestine with hot salt solution under an hydrostatic pressure of not more than 3 feet in a child, the fluid being allowed to remain in the intestine at least 10 minutes. The inclined post ure or the germ-pectoral position may be used, but complete inversion is better. By inverting the patient, the fluid not only reaches farther, but the traction in duced by the weight of the inyaginated portion of the intes.tine tends to disen gage it. Jonathan Hutchinson further assists the above measure by thoroughly k-neading the abdomen and violent shak ing of the patient. the latter being held in the inverted position by several per sons. Plain warm water is used by some, warm olive-oil by others.
The injections, if they are to be of any use, must be given intelligently. An anmsthetic must be given, the but tocks must be raised, and warm olive-oil injected by means of an ordinary enema syringe. If the anus is held around the nozzle of the syringe, very considerable pressure can be exercised on the column of oil. Injections of warm oil should be given in all cases after the child is under the anmsthetic, even in cases of long standing when we know that it is possible to complete the reduction by this means, because it always reduces the intussusception to a certain extent, and in the best and gentlest possible way. Clubbe (Brit. Med. Jour., Nov. 6, '97).
While the liquid is being introduced, the physician's hand should assist by gentle taxis the liberation of the invagi nated or obstructed gut. Manning states that in reducing an intussusception trac tion from above the mass should never be employed; for, should the parts be gangrenous, slight traction may suffice to rend them and allow the intestinal contents to pass into the peritoneal cav ity. Pressure on the apex of the mass in the direction opposite to that which it formed will reduce it with the least danger.
There is apt to be cracking of the serous coat of the large intestine when the resultant pressure of the fluid dis tending the colon is about two and a half pounds—that is to say, when the irrigator is raised five feet above the body of the patient; and this accident usually happens when the irrigator is raised to eight feet, though the bowel may be completely ruptured when the reservoir is only raised to the height of six feet. D'Arcy Power (Brit. Med. Jour., p. 453, vol. i, '97).
The patient does not lie quietly in bed during the early hours of the disease, but is constantly tossing and moaning and continues doing so until the gut is re duced Of' gangrene and sepsis are established. If after an injection the restlessness and moaning cease,— i.e., during the first twenty-four to forty eight hours,—it can be safely stated that reduction has taken place. J. T. Ertl mann (lied. News, Dec. 24, '98).
In employing mechanical means of re ithetion of intussuseeption, the pressure of the injected fluid should on no ac count exceed that equal to a column of water three feet high, since otherwise there is a very real danger of rupturing the inflamed gut. Chances of effecting
reduction by injection are three to one against it. Therefore in all cases pri mary laparotomy is advised. Murray (Liverpool Afedieo-Chir. Jour., Jan., '99).
Cases successfully treated with quick silver. In a man of 60 years operation was refused, and 1/, pound of mercury was administered on the ninth day. lit the second ease, a, Mall of SO years. operation was considered inadvisable be cause of the patient's age, and the same dose of quicksilver was given on the third day. The symptoms were typical in each case, and were promptly relieved by the mercury. In neither instance did the drug produce an increase of abdom inal pain, nor were there any other symptoms of thercurialism. J. AfeK. Harrison (Brit. Med. Jour., April 26, 19021.
.Enemata are seldom successful after the first forty-eight hours, every hour saved up to the end of that period in creasing the chances of complete reduc tion of the obstruction. Again, the like lihood of success is far greater when the obstruction is located in the colon.
When enemata prove unsuccessful, in sufflation of air should be tried. This, however, offers greater danger of rupt ure owing to the fact that the quantity of air used cannot be carefully gauged. On the other hand, air penetrates more readily the ileo-ccal valve and may thus be more effective than water when the obstruction is situated in the small intestine. Carbonic dioxide has also been used for the purpose, but is inferior to air.
In intussusception in children distend ing the bowel by inflation of air is a better and safer method of reducing the invagination by mechanical means than the distension of the bowel by water. The child should be clothed in a jacket of wool, and the legs and arms covered with wool and bandaged. It is then anaesthetized, and an ordinary enema pipe introduced into the rectum. This pipe is connected by means of a piece of India-rubber tubing to a pair of com mon bellows, or, if it is at hand, a Lund inflator. The outside of the tube around the anus is carefully packed with wool, which i3 held in position by an assistant, so as to prevent the escape of air by the side of the tube. The child is now in verted and held by a nurse, while the bellows are slowly and steadily worked by an assistant. The surgeon should have his hand placed on the abdomen of the child so that he can feel the tumor. As the intestine is inflated he will gradually feel the colon becoming distended, and he can regulate the amount of air introduced and stop it as soon as he feels. the colon is distended as far as is safe. If the plan succeeds and the invagination is reduced Ile will sud denly feel the tumor disappear from under his hand, and the air will become diffused over the whole abdomen, so that what was at first distension of the colon is now a uniform distension of the ab domen. Afore. itnportance attached to this sign than to the sudden disappear ance of the tumor as an indication that the intussusception has been reduced.