Intestinal Obstruction

bowel, symptoms, child, measures, invaginated, taxis, serious, successful and prevent

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Sometimes, in intussusception, the amount of blood discharged from the bowel is very copious. Still, the other symptoms of invagination are present, and it is only necessary to be aware that haemorrhage may be oc casionally profuse, to prevent this fact from casting any doubt upon the correctness of the diagnosis.

If attention be paid to the symptoms which have been pointed out as characteristic of intussusception, we shall be able, in most cases, to arrive at a correct conclusion. An examination per anum should never be neg lected ; nor, in a doubtful case, should we omit to inspect the ordinary sit uations of rupture, for although strangulated hernia is rare in young subjects, it does, occasionally, occur.

Prognosis.—When we have satisfied ourselves of the presence of intus susception, the prognosis is excessively grave. In the young baby, in spite of a few recorded cases of spontaneous reduction of the invaginated portion of the bowel, and of others in which remedial measures promptly applied proved successful, any measures we may resort to must be-under taken with serious forebodings. The danger is in direct proportion to the urgency of the symptoms. If the acuteness of the case indicates tight ness of constriction, the prognosis is most serious, whatever measures are adopted; and however quickly assistance is rendered. In almost all cases of successful reduction by taxis, inflation, or injection, the symptoms have not been very severe. To be successful, treatment must be early ; but delay is less fatal if the constriction be only moderate, than when strangu lation is complete. If the infant is seen after the end of the third day, and acute symptoms have undergone no alleviation, a fatal issue to the illness can hardly be doubted.

In older children, whose superior strength enables them to resist for a longer period the prostrating effects of the obstruction, recovery by slough ing and discharge of the invaginated segment is possible, and may even take place when the child is in extremis, and after all hope has been abandoned; but this is a result which in any individual case we can never dare to an ticipate. Certainly, there are no indications by which so favourable an issue can be foretold. Even if the evacuation of the slough by stool shows that elimination has actually been accomplished, we must still not be hasty in declaring the danger at an end ; for the greatest care will yet be required during the period of convalescence to prevent the newly-formed adhesions from being injured or detached.

Treatment.—Accuracy of diagnosis, and especially early recognition of the nature of the complaint, are of great importance in this disease. If the real cause of the vomiting and colic are discovered at the beginning, remedial measures may be applied with greater hope of success. As it•is, medical

advice is seldom sought until the bowel has been irritated by one or more doses of aperient medicine, to the serious aggravation of the patient's con dition and the lessening of his 'chances of recovery.

The only admissible remedy is opium. This should be given at once, and repeated as often as is necessary to lull the pain, and keep the child under the influence of the narcotic. It is best given by subcutaneous in jection, and may be usefully combined with atropine. It is well to begin with small quantities, although it will be generally found that the system, even in infancy, is singularly tolerant of the drug. For a child of twelve mouths old, one-twentieth of a grain of morphia and a sixth of a grain of atro pine may be used every half-hour until some sensible effect is produced upon the symptoms. This not only relieves the suffering of the patient, but also tends to prevent any increase in the invagination and to check the vomiting.

If the case is seen sufficiently early, the question of endeavouring to re duce the invagination by mechanical means must be considered. Mechan ical interference is only allowable during the first few days of the illness, before exudation of lymph has caused adhesion between the serous sur faces ; and will be useless if great tenderness on pressure of the invaginated mass indicates the presence of inflammation. The means employed may be taxis, insuifiation of air, or the injection of water. Before proceeding to any of these measures, the child, unless a young baby, should be placed under the full influence of an Taxis consists in kneading and other wise manipulating the abdomen with the hand. This method is generally employed in conjunction with either of the others. The child is laid upon his back with the nates raised so that the body is inclined at an angle of 45 degrees. A large quantity of tepid water is then injected very slowly into the bowel by a Davidson's syringe capped with a long tube. Every now and again the abdomen must be kneaded with the hand so as to work the fluid along the bowel upwards towards the obstruction, and this process of taxis may be continued for several minutes. As much fluid must be used as the bowel can be made to contain. The best proof that reduction has been effected is sleep. As a rule, directly the child's more pressing symp toms are relieved, he sleeps at once. The return of the invaginated bowel is also sometimes marked by a discharge of blood and mucus, followed by a copious, offensive, semi-fluid stool.

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