Intestinal Obstruction

child, usually, bowel, discharge, complete, portion and symptoms

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The course of the illness is apt to vary according to the degree of strangulation of the invaginated segment, and the more or less complete ness of the obstruction to the passage of the contents of the bowel. In rare cases, the passage is not completely occluded, so that faecal matter can still make its way, although, of course, in small quantity, through the narrow channel. The constipation is then not obstinate, but the stools are scanty, and consist more of mucus and bloody fluid than of the ordinary constituents of an evacuation.

The symptoms continue without improvement. The pains return at intervals. The child, in some cases, turns away from his bottle ; in others, he sucks greedily to assuage his thirst ; but, whether he swallow willingly or not, the effect is the same, and he usually vomits almost immediately. If he vomit at other times, the ejected fluids consist of bile-stained mucus, and very rarely of fmcal matter. The face gets pale and more haggard ; the eyelids close incompletely, and the eyeballs are sunken. Occasionally he strains, but only blood and mucus escape from the rectum. His belly is often tender over the seat of the tumour, and may become fuller and more tympanitic, with some tension of the parietes. Sometimes the sphincter is relaxed and open.

The symptoms of collapse come on early if the obstruction of the bowel is complete, and usually, on the third clay, the child is found in the state described. Unless general peritonitis occur, there is seldom much pyrexia ; indeed, the child, as a rule, feels cold and damp ; and even if the internal temperature is higher than natural, the extremities feel cold. In this state, he remains until he dies. A convulsive seizure may precede death, and sometimes convulsions occur in the course of the illness, and are repeated several times. Before death, the invagivated mass may be perhaps seen to protrude for an inch or two outside the anus, as a dark-coloured, elongated lump. This, however, is not common. When the strangulation is complete, the disease seldom lasts longer than a week, and death often occurs in three or four clays. If the obstruction is not complete, the prog ress of the case is longer ; scanty loose motions may be passed at inter vals, and the child often lingers for a fortnight or more.

If, by any means, the invaginated portion of the bowel can be returned, the vomiting ceases ; the bowels discharge a copious, semi-fluid, offen sive stool, and the child sleeps. On waking, he takes the bottle or the

breast, and seems cheerful and contented, although necessarily languid and feeble.

In older children, the symptoms correspond, in the main, with thoSe already described, but certain differences are noticed. Thus, the disten tion of the belly is usually greater after the age of infancy, and comes on earlier. It is sometimes extreme, and the coils of dilated intestine can be made out through the abdominal parietes. Also, vomiting is generally persistent, and is apt soon to be feculent. The child will take no food, but is excessively thirsty. The discharge of blood from the anus occurs less frequently the more advanced the age of the child. If the invagina tion occupy the large intestine, the strangulated portion of the bowel is approached near to the outlet, and haemorrhage from the ruptured vessels is likely to take place. If, however, the intussusception is higher up, and is confined to the small intestine without implication of the colon, no htem orrhage at all may be noticed. There is then, in most cases, obstinate con stipation. the stage of collapse comes on, the tongue becomes dry, and is covered with a brown fur ; the belly is tympanitic ; the eyes are sunken, and the face of the child is ghastly'and death-like.

If separation and elimination of the gangrenous portion of the bowel takes place, this favourable change is usually noticed in the course of the second week. In these fortunate cases, the dark-coloured gangrenous seg ment of the intestinal tube is passed with much straining, and often a quan tity of dark, offensive feculent matter comes away with it. The amount of this varies, and is often very considerable. The discharge is followed by symptoms of great relief. The child usually falls into a profound sleep from which he wakes greatly refreshed. His thirst is diminished, his appe tite begins to return, and his whole aspect betokens great improvement. The gangrenous portion may not be expelled in one piece, but sometimes comes away in patches and shreds, mixed with foul-smelling and blood. After the separation and discharge of the slough, recovery usually follows with great rapidity.

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