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RECURRENT INTUSSUSCEPTION: THE RECORD OF A CASE WHICH WAS OPERATED UPON THREE TIMES.
169 which would follow the Mendelian hypothesis. That is to say, they would act as impure dominants," giving rise to three dominants to one recessive, of which the recessives would breed true and of the three dominants two would he impure. Queen Aune-street, W.
RECURRENT INTUSSUSCEPTION: THE RECORD OF A CASE WHICH WAS OPERATED UPON THREE TIMES.
BY G. GREY
TURNER, M.S. DURH., F.R.C.S. ENG.,
ASSISTANT SURGEON, ROYAL VICTORIA INFIRMARY, NEWCASTLE-UPONSURGERY IN THE UNIVERSITY OF DURHAM COLLEGE OF MEDICINE.
TYNE ; LECTURER ON
I HAVE been prompted to record the following as the result of reading an annotation on the subject in THE LANCET of Dec. 20th, 1913. cases
The patient (Reg. No. 1040) first came under my care at the Royal Infirmary on June 13th, 1907, being at that time B months old. On the day preceding admission the baby vomited and was rather restless during the night. About 4 A.M. he awakened suddenly, and the mother thought he looked very pale and ill. The bowels were moved, and blood was noticed on the napkin. From this time the child kept tossing about and crying. At 11 A.M. a medical man saw the patient and, finding an intussusception per rectum, sent the child straight into hospital, where I operated at 1 P.M. The invagination extended from the ileo-cascal valve to the rectum ; the appendix was not involved, so that it was of the ileo-colic variety. Reduction was effected by manipulation, but to complete the process it was necessary to bring the involved bowel outside the abdomen. The lower end of the ileum was found to be much thickened, and there was a very definite indentation at one point, while the glands in the mesentery were enlarged. The child made an uninterrupted recovery, and in July was seen and found to be perfectly well in every way. On Oct. 8th of the same year the child was again admitted with a recurrence of the intussusception. He had been very well until the day of admission at 3 P.M., when he had an attack of abdominal pain and passed blood per rectum. When seen the patient was found to be in good condition, but was evidently uneasy in the abdomen, and a mass could be felt in the epigastrium, but there was nothing per rectum. At 9 P.M. I opened the abdomen through the old incision. The intussusception was of the same variety as before, the ileum entering the large bowel as far as the middle of the transverse colon. This time reduction was very easy. The lower two inches of the ileum were very much congested and thickened, and felt almost as though there might be a polypoid growth inside. The bowel was opened at this point, and a small portion removed for microscopic examination ; there was no polypus, but the wall was much thickened. At the same time an enlarged gland was removed from the mesentery. Under the microscope both gland and bowel only showed evidences of inflammatory oedema and congestion, but neither was stained for the tubercle bacillus. In the hope of preventing a recurrence of the invagination the lower four inches of the ileum was stitched closely to the caecum in front of the mesentery, interrupted suture of fine chromicised catgut being used. The abdomen was closed with through-and-through silkworm gut sutures, and again the made a good recovery. These eight examples show instances of good and child On May 30th, 1908, just about a year after the first operabad stock in both concubitant and tabu families, tion, this patient was again admitted with a recurrence of and suggest that quality of stock is all-important. his previous symptoms. Since the last operation he had Arguing upon Mendelian lines, if the stock is good kept very well until noon of the day before admission, when and free from taint of hereditary deafness, there is the mother noticed that the child held the abdomen as if in no reason why the offspring of a consanguineous pain, but did not vomit. The bowels were moved naturally, and he All went well until about two a good night. should that show because passed deafness, marriage character (shown by Kerr Love to be recessive) is hours before admission, when he passed blood and vomited, not present; whereas, if deafness should happen to and from that time there had been continuous straining and further vomiting. When admitted the patient was found to be present as a family taint, the union of two blood be a big, fat, strong-looking boy in good condition. A mass : relations, both of whom may carry-although they typical of intussusception was felt in the abdomen, but may themselves be hearing-the recessive character nothing per rectum. For the third time the abdomen was in their germ cells, would be likely to accentuate it, opened by an incision through the old scar. The intusand recessive offspring would occur with a frequency susception extended from the ileo-caecal valve to the middle ,
170 of the transverse colon, and was easily reduced. The suture of the ileum to the cascum had not held firmly, though there
entering layer of bowel is found protruding from the anus. I was easily able to pass my finger up the anus between the were long flimsy adhesions between the two. There were outer layer and the entering layer of bowel. On examining two or three undoubted tuberculous ulcers in the ileum, with the abdomen I can feel no lump, probably owing to the tubercles on the peritoneum over their site; and one of child resisting." On admission the child looked in good condition ; tem. these, that nearest to the ileo-cæcal valve where the bowel had been previously incised, had formed the apex of the perature 980 F., pulse 118 ;he had not vomited for two intussusception, as it was very much indented in the hours. There was then no bowel protruding from the anus, centre and much thickened. There was also a large mass and no definite tumour to be felt abdominally, but per of tuberculous glands in the mesentery of the lower ileum. rectum a cone of bowel could be felt, the finger passing into In order to short-circuit the affected intestine, and also to its summit as though it were the apex of an intussusception. provide against recurrence if possible, a lateral anastomosis In the light of the history and the finding of the rectal by direct suture was made between the ileum above the examination I felt quite sure that the intussusception had ulcers-i.e., 18 inches from the cæcum-and the transverse recurred and decided to operate. Within an hour of my colcn. The abdomen was again closed with through-and- examination I opened the abdomen through the old incision, A careful search revealed no signs of intussusception. There through silkworm gut, and recovery was withont incident. In the light of the above findings the gland and piece of were some few flimsy adhesions in the region of the splenic bowel removed at the second operation were re-examined, flexure, and the bowel in this neighbourhood was reddened but there were no appearances that might fairly be inter- and oedematous, while the glands in the vicinity were preted as being due to tubercle. enlarged. The cæcum was large and mobile, such as is In June of 1913 the mother brought the patient to the found in children who suffer from intussusception. After hospital at my request. He was then a well-nourished, removal of the appendix the abdomen was closed, and the healthy boy between 6 and 7, and had never had a bad child made a good recovery. symptom since the last operation. The bowels acted How is the recurrence of intussusception to be regularly, and the abdominal scar was very strong. The first is
the prevented ? surgical principle good example of a recurring removal of the cause, but this is a primary diffi. intussusception, which is a rare condition, though culty, for in children it is usually an unknown I see no reason why it should be so. For me the factor. If there is anything in my suggestion as to especial interest is in connexion with the causation the relation of early tubercle to intussusception it of intussusception. Most operators have noted the does not necessitate the adoption of any special thickened, indented area in the last few inches of surgical measures. If for any reason recurrence is the ileum. I have often thought that this area especially feared, or if it has actually occurred, what probably represented an early tuberculous invasion can be done ? Some surgeons recommend putting a of the bowel wall, and in several cases I have also stitch through the mesentery of the appendix and observed the presence of tuberculous glands in the fixing it to the posterior abdominal wall, while I mesentery. In the case under discussion the con- believe others have suggested that the whole dition at the second operation strongly suggested appendix should be buried in the abdominal tubercle, and the findings at the third operation incision. Even if successful these means could left no doubt as to the tuberculous factor in this only result in fixing the caecum, and would particular case. do nothing to prevent invagination through the If an early intestinal tuberculosis is commonly valve. The measure I adopted proved futile, but the cause of intussusception it may also explain might have been more successful had I used a the infrequence of recurrence, because of the well- continuous suture of silk instead of interrupted known influence of laparotomy on abdominal stitches of even so, abundant experience catgut; tubercle. Why the disease should have steadily shows how difficult it is to fix two serous surfaces progressed in this case I do not know. together, especially when one is freely movable. In another case there was evidently a recurrent To be of much service I fancy it would be necesspontaneous sary to fix the bowel to the abdominal wall after intussusception which underwent reduction," a rare event of which I have previously separating the parietal peritoneum. If there is any recorded an example.l gross pathological condition in the lower ileum not The patient (Reg. No. 2872), aged 7 months, was easily removable, then I should be disposed to make The
case
is
a
"
admitted to the infirmary on April 20th, 1910. There had been a sudden attack of screaming and kicking at 10 A.M., and at 2 P.M. vomiting commenced and had been continuous since. Castor oil was given at 3 P.M., and at 4 P.M. blood and mucus were passed per anum. On admission at 8 P.M. the child looked in good condition, but was having A sausage-shaped tumour, which an attack of pain. hardened and relaxed, could easily be felt in the left iliac region. I operated at once, the abdomen being opened by a median incision below the umbilicus. The intussusception extended from the ileo-cæcal valve to the rectum ; it The indentawas of the ileo-caecal and ileo-colic variety. tion of its commencement was in the anterior surface of the caecum, and not in the ileum. The invagination was easily reduced. The abdominal wall was closed with through-andthrough silkworm gut sutures, and the patient made a good recovery. This child was readmitted on July 28th, 1911, apparently He had been seen with a recurrence of the intussusception. by Dr. E. D. Smith, of Swalwell, one of our old house surgeons, who sent him into hospital with the following note : ’’ This child has had diarrhoea for the last two days. To-day he was playing in afield, but came home at 2 o’clock vomiting, and when he was taken up his legs were covered with blood. I saw him at 2.45, and on examination the 1 A Note on Intussusception in Children, Northumberland and Durham Medical Journal, February, 1903.
lateral anastomosis as in the first case. Taking all the circumstances into consideration I do not think it is necessary to take any special means to anticipate recurrence (except, of course, the removal of any causative factor, such as an inverted Meckel’s diverticulum). In the rare cases in which the condition recurs it is always amenable to early diagnosis and operation. Newcastle-upon-Tyne. a
LONDON FREE SCHOOL OF MEDICINE FOR WOMEN : UNIVERSITY OF LONDON.-The council have appointed Mrs. E. Flemming, M.D., B S. Lond., to the half-lectureship in medicine, and Mr. Malcolm L. Hepburn, M.D. Lond., F.R.C.S. Eng., to the halflectureship in ophthalmology. Two St. Dunstan’s exhibi. tions of the value of L60 a year each for five years, the Isabel Thorne scholarship of the value of £30, and the Mabel Sharman-Crawford scholarship of the value of E20 a year for four years will be awarded on the results of an examination to be held in July next. A bursary for dental students of the value of £60 will also be awarded for the course beginning October, 1914. Further particulars can be obtained on application to the secretary, 8, Hunter-street,
(ROYAL
HOSPITAL)
Brunswick-square, W.C.
RECURRENT INTUSSUSCEPTION: THE RECORD OF A CASE WHICH WAS OPERATED UPON THREE TIMES.
BY G. GREY
TURNER, M.S. DURH., F.R.C.S. ENG.,
ASSISTANT SURGEON, ROYAL VICTORIA INFIRMARY, NEWCASTLE-UPONSURGERY IN THE UNIVERSITY OF DURHAM COLLEGE OF MEDICINE.
TYNE ; LECTURER ON
I HAVE been prompted to record the following as the result of reading an annotation on the subject in THE LANCET of Dec. 20th, 1913. cases
The patient (Reg. No. 1040) first came under my care at the Royal Infirmary on June 13th, 1907, being at that time B months old. On the day preceding admission the baby vomited and was rather restless during the night. About 4 A.M. he awakened suddenly, and the mother thought he looked very pale and ill. The bowels were moved, and blood was noticed on the napkin. From this time the child kept tossing about and crying. At 11 A.M. a medical man saw the patient and, finding an intussusception per rectum, sent the child straight into hospital, where I operated at 1 P.M. The invagination extended from the ileo-cascal valve to the rectum ; the appendix was not involved, so that it was of the ileo-colic variety. Reduction was effected by manipulation, but to complete the process it was necessary to bring the involved bowel outside the abdomen. The lower end of the ileum was found to be much thickened, and there was a very definite indentation at one point, while the glands in the mesentery were enlarged. The child made an uninterrupted recovery, and in July was seen and found to be perfectly well in every way. On Oct. 8th of the same year the child was again admitted with a recurrence of the intussusception. He had been very well until the day of admission at 3 P.M., when he had an attack of abdominal pain and passed blood per rectum. When seen the patient was found to be in good condition, but was evidently uneasy in the abdomen, and a mass could be felt in the epigastrium, but there was nothing per rectum. At 9 P.M. I opened the abdomen through the old incision. The intussusception was of the same variety as before, the ileum entering the large bowel as far as the middle of the transverse colon. This time reduction was very easy. The lower two inches of the ileum were very much congested and thickened, and felt almost as though there might be a polypoid growth inside. The bowel was opened at this point, and a small portion removed for microscopic examination ; there was no polypus, but the wall was much thickened. At the same time an enlarged gland was removed from the mesentery. Under the microscope both gland and bowel only showed evidences of inflammatory oedema and congestion, but neither was stained for the tubercle bacillus. In the hope of preventing a recurrence of the invagination the lower four inches of the ileum was stitched closely to the caecum in front of the mesentery, interrupted suture of fine chromicised catgut being used. The abdomen was closed with through-and-through silkworm gut sutures, and again the made a good recovery. These eight examples show instances of good and child On May 30th, 1908, just about a year after the first operabad stock in both concubitant and tabu families, tion, this patient was again admitted with a recurrence of and suggest that quality of stock is all-important. his previous symptoms. Since the last operation he had Arguing upon Mendelian lines, if the stock is good kept very well until noon of the day before admission, when and free from taint of hereditary deafness, there is the mother noticed that the child held the abdomen as if in no reason why the offspring of a consanguineous pain, but did not vomit. The bowels were moved naturally, and he All went well until about two a good night. should that show because passed deafness, marriage character (shown by Kerr Love to be recessive) is hours before admission, when he passed blood and vomited, not present; whereas, if deafness should happen to and from that time there had been continuous straining and further vomiting. When admitted the patient was found to be present as a family taint, the union of two blood be a big, fat, strong-looking boy in good condition. A mass : relations, both of whom may carry-although they typical of intussusception was felt in the abdomen, but may themselves be hearing-the recessive character nothing per rectum. For the third time the abdomen was in their germ cells, would be likely to accentuate it, opened by an incision through the old scar. The intusand recessive offspring would occur with a frequency susception extended from the ileo-caecal valve to the middle ,
170 of the transverse colon, and was easily reduced. The suture of the ileum to the cascum had not held firmly, though there
entering layer of bowel is found protruding from the anus. I was easily able to pass my finger up the anus between the were long flimsy adhesions between the two. There were outer layer and the entering layer of bowel. On examining two or three undoubted tuberculous ulcers in the ileum, with the abdomen I can feel no lump, probably owing to the tubercles on the peritoneum over their site; and one of child resisting." On admission the child looked in good condition ; tem. these, that nearest to the ileo-cæcal valve where the bowel had been previously incised, had formed the apex of the perature 980 F., pulse 118 ;he had not vomited for two intussusception, as it was very much indented in the hours. There was then no bowel protruding from the anus, centre and much thickened. There was also a large mass and no definite tumour to be felt abdominally, but per of tuberculous glands in the mesentery of the lower ileum. rectum a cone of bowel could be felt, the finger passing into In order to short-circuit the affected intestine, and also to its summit as though it were the apex of an intussusception. provide against recurrence if possible, a lateral anastomosis In the light of the history and the finding of the rectal by direct suture was made between the ileum above the examination I felt quite sure that the intussusception had ulcers-i.e., 18 inches from the cæcum-and the transverse recurred and decided to operate. Within an hour of my colcn. The abdomen was again closed with through-and- examination I opened the abdomen through the old incision, A careful search revealed no signs of intussusception. There through silkworm gut, and recovery was withont incident. In the light of the above findings the gland and piece of were some few flimsy adhesions in the region of the splenic bowel removed at the second operation were re-examined, flexure, and the bowel in this neighbourhood was reddened but there were no appearances that might fairly be inter- and oedematous, while the glands in the vicinity were preted as being due to tubercle. enlarged. The cæcum was large and mobile, such as is In June of 1913 the mother brought the patient to the found in children who suffer from intussusception. After hospital at my request. He was then a well-nourished, removal of the appendix the abdomen was closed, and the healthy boy between 6 and 7, and had never had a bad child made a good recovery. symptom since the last operation. The bowels acted How is the recurrence of intussusception to be regularly, and the abdominal scar was very strong. The first is
the prevented ? surgical principle good example of a recurring removal of the cause, but this is a primary diffi. intussusception, which is a rare condition, though culty, for in children it is usually an unknown I see no reason why it should be so. For me the factor. If there is anything in my suggestion as to especial interest is in connexion with the causation the relation of early tubercle to intussusception it of intussusception. Most operators have noted the does not necessitate the adoption of any special thickened, indented area in the last few inches of surgical measures. If for any reason recurrence is the ileum. I have often thought that this area especially feared, or if it has actually occurred, what probably represented an early tuberculous invasion can be done ? Some surgeons recommend putting a of the bowel wall, and in several cases I have also stitch through the mesentery of the appendix and observed the presence of tuberculous glands in the fixing it to the posterior abdominal wall, while I mesentery. In the case under discussion the con- believe others have suggested that the whole dition at the second operation strongly suggested appendix should be buried in the abdominal tubercle, and the findings at the third operation incision. Even if successful these means could left no doubt as to the tuberculous factor in this only result in fixing the caecum, and would particular case. do nothing to prevent invagination through the If an early intestinal tuberculosis is commonly valve. The measure I adopted proved futile, but the cause of intussusception it may also explain might have been more successful had I used a the infrequence of recurrence, because of the well- continuous suture of silk instead of interrupted known influence of laparotomy on abdominal stitches of even so, abundant experience catgut; tubercle. Why the disease should have steadily shows how difficult it is to fix two serous surfaces progressed in this case I do not know. together, especially when one is freely movable. In another case there was evidently a recurrent To be of much service I fancy it would be necesspontaneous sary to fix the bowel to the abdominal wall after intussusception which underwent reduction," a rare event of which I have previously separating the parietal peritoneum. If there is any recorded an example.l gross pathological condition in the lower ileum not The patient (Reg. No. 2872), aged 7 months, was easily removable, then I should be disposed to make The
case
is
a
"
admitted to the infirmary on April 20th, 1910. There had been a sudden attack of screaming and kicking at 10 A.M., and at 2 P.M. vomiting commenced and had been continuous since. Castor oil was given at 3 P.M., and at 4 P.M. blood and mucus were passed per anum. On admission at 8 P.M. the child looked in good condition, but was having A sausage-shaped tumour, which an attack of pain. hardened and relaxed, could easily be felt in the left iliac region. I operated at once, the abdomen being opened by a median incision below the umbilicus. The intussusception extended from the ileo-cæcal valve to the rectum ; it The indentawas of the ileo-caecal and ileo-colic variety. tion of its commencement was in the anterior surface of the caecum, and not in the ileum. The invagination was easily reduced. The abdominal wall was closed with through-andthrough silkworm gut sutures, and the patient made a good recovery. This child was readmitted on July 28th, 1911, apparently He had been seen with a recurrence of the intussusception. by Dr. E. D. Smith, of Swalwell, one of our old house surgeons, who sent him into hospital with the following note : ’’ This child has had diarrhoea for the last two days. To-day he was playing in afield, but came home at 2 o’clock vomiting, and when he was taken up his legs were covered with blood. I saw him at 2.45, and on examination the 1 A Note on Intussusception in Children, Northumberland and Durham Medical Journal, February, 1903.
lateral anastomosis as in the first case. Taking all the circumstances into consideration I do not think it is necessary to take any special means to anticipate recurrence (except, of course, the removal of any causative factor, such as an inverted Meckel’s diverticulum). In the rare cases in which the condition recurs it is always amenable to early diagnosis and operation. Newcastle-upon-Tyne. a
LONDON FREE SCHOOL OF MEDICINE FOR WOMEN : UNIVERSITY OF LONDON.-The council have appointed Mrs. E. Flemming, M.D., B S. Lond., to the half-lectureship in medicine, and Mr. Malcolm L. Hepburn, M.D. Lond., F.R.C.S. Eng., to the halflectureship in ophthalmology. Two St. Dunstan’s exhibi. tions of the value of L60 a year each for five years, the Isabel Thorne scholarship of the value of £30, and the Mabel Sharman-Crawford scholarship of the value of E20 a year for four years will be awarded on the results of an examination to be held in July next. A bursary for dental students of the value of £60 will also be awarded for the course beginning October, 1914. Further particulars can be obtained on application to the secretary, 8, Hunter-street,
(ROYAL
HOSPITAL)
Brunswick-square, W.C.