- Email: [email protected]
Perforation of colon in the newborn infant
fast Reports PERFORATION OF COLON IN THE NEWBORN INFANT* RECOVERY FOLLOWING OPERATION JOHN E . STANDARD, M .D . Brooklyn, New York ERFORATION of the colon in the newborn is relatively rare and is associated with a high mortality . Several examples of this disorder have been recorded in the literature but the only survival thus far following definitive surgery was the one reported by Lee and MacMillan . 12 The case herein recorded was not associated with a congenital anomaly of the colon as was present in the case of Lee and MacMillan . Furthermore, the cause of perforation of the rectosigmoid in this case was never established . The subject of ruptured hollow viscus in the newborn has been comprehensively reviewed by many authors .'- 2,9,15,16 Therefore, it seems unnecessary to review the literature . It seems appropriate, however, to mention the possible etiologic factors of perforation of the colon and the diagnosis and surgical management of patients with this lesion . The causes of perforation of the colon in the newborn may be varied . Not uncommonly the presence of such a lesion may escape detection with the resultant mortality mentioned heretofore . It seems highly probable that the incidence is greater than reported . The etiologic factors of perforations of the colon may be conveniently divided into those associated with obstruction, proximal dilation and subsequent perforation of the dilated segment of the intestine and those with perforation without associated distal obstruction . Obstruction is usually secondary to a congenital anomaly . In some the obstruction is frequently the result of atresia . Stenosis not uncommonly produces incomplete obstruction but perforation proximal to such a lesion is relatively rare .
P
Ladd and Gross" have not encountered perforation of the bowel secondary to stenosis. Reduplication of the colon is indeed rare, yet its resultant obstruction, although usually incomplete, could lead to proximal perforation . Summarily the most likely cause of perforation in the obstructed group would be atresia . Perforations of the colon secondary to an obstruction in some distal part of this organ frequently occur in the cecum which has distended to the extent that the blood supply has been compromised. Lee and MacMillan's 72 case is an excellent example of this pathogenesis . In the perforations at the site of a focal process many causes have been reported such as trauma, intestinal aplasia, primary vascular insufficiency, congenital or acquired diverticuli, peritoneal bands, adhesions and inflammation from one cause or another . Trauma inflicted during delivery as an etiologic agent in the rupture of the large bowel has been suggested by Zillner, 75 Paltaul," Titus 17 and Russell . 15 Zillner reported four cases of rupture of the sigmoid colon during delivery which he attributed to compression of the free loop of the sigmoid between the lumbar vertebrae and the anterior abdominal wall . Paltaul described spontaneous perforations of the colon and sigmoid in five newborn infants. These had all been spontaneous, easy deliveries . Titus stated that injuries of the intra-abdominal viscera could be caused by manual compression of the abdomen of the infant during breech extractions . However, in the nine previously mentioned cases all were vertex presentations . Russell in his review of thirtynine cases of rupture of the bowel reported
` From the University Surgical Service, Kings County Hospital, and State University of New York College of Medicine at New York City.
January, 1952
107
108
Standard-Perforation of Colon in Infant
twenty-eight cases including the aforementioned, which might have indirectly been related to obstetric trauma. He postulated that hydrostatic pressure transmitted by meconium could cause rupture of the bowel . All four of the infants in the series of Zillner had enemas which were given by unskilled midwives . It seems unlikely that a non-distended bowel only partially filled with meconium and containing no gas could be ruptured during passage of the infant through the birth canal. The possibility of rupture secondary to an improperly given enema or an improperly taken rectal temperature seems more feasible . Congenital defects in the bowel wall may be the fundamental factor of the perforations, especially the true and false diverticuli which have been carefully reviewed by Boikan,' Fischer'' and Rudnew . 14 Abtl reported the presence of peritoneal bands and adhesions but concluded that they were probably secondary to the perforation . Bacterial invasion of the intestinal wall has been postulated as a cause of perforation but to date this has not been established as a primary factor . Finally, spontaneous rupture of the colon is not infrequent . Such perforations may occur anywhere from the cecum to the rectum and because of the inability to demonstrate either local or indirect causes may be classified as idiopathic . The diagnosis of perforation of the large bowel in the neonatal period can be made if one considers the possibility of its presence . The clinical picture presented by the infant has been vividly described by Thelander 16 as follows : "An infant with perforation peritonitis present at birth or occurring soon after, presents a fairly classic picture . The little patient looks sick . He is cyanotic, the respirations are rapid and grunting, the abdomen is distended and the abdominal wall, the flanks and the scrotum or vulva are usually edematous . Frequently brown induration of the edematous area, which may resemble erysipilas, is also present . Food is taken poorly or not at all . Vomiting is frequent and persistent . The vomitus contains bile and may contain blood . The stools are either absent or scant . Some mucus or blood may be passed . The temperature may be sub-normal, but varying degrees of fever have been reported . The blood count is of little or no value. The hemoglobin content may be very high, which probably indicates only dehydration . The leucocytes may or may not respond with a
rise . In cases of intra-uterine perforation the abdomen has at times been so distended at birth that delivery was impossible until paracenteses of the abdomen had been performed ." Roentgenologically, the diagnosis of perforated intra-abdominal viscus can be made by means of a scout film of the abdomen . Characteristically, there is massive pneumoperitoneum with or without associated hydroperitoneum . If the obstructed colon has not been decompressed by a rupture into the peritoneal cavity, its site may he demonstrated on the film. The administration of barium by mouth or by rectum in the presence of pneumoperitoneum is obviously contraindicated as is demonstrated by the case herein reported. Barium may escape into the free peritoneal cavity . The presence of free gas inn the peritoneal cavity in a patient suspected of having perforation is sufficient evidence to warrant laparotomy. An attempt to establish a positive diagnosis by means of further x-ray studies in an already desperately ill patient is unwarranted . The surgeon, at laparotomy, should be able to discover the cause of the perforation and its site, and institute the proper surgical therapy . CASE REPORT
A 7 pound s ounce female, normal vertex presentation, was delivered without instrumentation at 11 :53 P.M . on March 21, 199o . The infant's general condition was excellent . The neonatal examination carried out the next morning revealed an apparently normal and healthy infant . One meconium stool had been passed . On March 23rd at 10 :00 A .M . the patient vomited . The abdomen was markedly distended and tympanitic with mild erythema of the abdominal wall . Bowel sounds were absent on auscultation . The patient appeared listless and the cry was feeble . The temperature was loo°a. at this time . A small soapsuds enema was given with little or no return . The impression of the pediatrician was, "an obstruction secondary to some congenital anomaly of the intestinal tract ." Unfortunately a barium enema was given before a scout film of the abdomen had been taken . These films revealed massive hydropneumoperitoneum but no evidence of intrinsic disease of the colon . (Fig. 1 .) Examination at this time showed an acutely ill, listless, cyanotic, dyspneic, forty hour old infant with marked abdominal distention and American Journal of Surgen
Standard-Perforation of Colon in Infant
FIG .
Barium cl sma demonstr mg massive hydropneumoperitoneum and a no mal colon .
2
3
Gastric instillation of lipiodal . Extraluminal barium on the right side of the peritoneal cavity . The gas in the peritoneal cavity was removed during the paracentesis . Far . 3 . Interval barium clysma showing the presence of an intact colon to the colostomy site and residual barium in the peritoneal cavity . FIG . 2 .
January, 1952
log
IIO
Standard-Perforation of Colon in Infant
Fm . 4 . Infant at ten months of age .
edema and erythema of the abdominal wall . The stump of the umbilical cord was normal . Rectal examination disclosed no abnormalities . Because of the marked dyspnea and cyanosis secondary to the tense pneumoperitoneum, a paracentesis was performed in the right subcostal region in hopes of relieving the respiratory distress . A large amount of odorless gas gushed forth and was followed with 20 cc . Of cloudy yellow fluid which was alkaline in reaction and contained numerous pus, cells . The infant's condition improved immediately . Palpation of the abdomen, which was now scaphoid, revealed no masses or collections. A catheter was passed into the stomach through which g cc . of lipiodal were instilled . X-rays revealed no evidence of perforation of the stomach or duodenum ; however, extraluminal barium was obvious and the impression was that perforation of the colon was present . (Fig. 2 .) An immediate laparotomy was performed . Under inhalation ether anesthesia forty-four hours after delivery the abdomen was entered through a right rectus muscle-splitting incision . Peritonitis and free barium were disclosed . Exploration revealed the colon to be normal except in the region of the rectosigmoid immediately over the peritoneal reflexion where
barium continued to puddle after repeated aspirations . The barium presumably came from a perforation at this site which could not be visualized with certainty . Because of the precarious condition of the patient no further exploration was deemed advisable . A right transverse loop colostomy was performed and the wound closed in layers with interrupted silk sutures. Cultures of the fluid taken at the preoperative paracentesis and at laparotomy revealed Escherichia coli and lactobacillus . The patient was placed in an oxygen tent and intragastric suction instituted . She was given parenteral fluids and penicillin, 300,000 units every three hours, and streptomycin, 26 gm . every six hours . On the first postoperative day the abdomen was soft . The colostomy was opened on the second postoperative day and functioned well by the third . On the fourth day after operation normal feedings were begun following which the patient's condition improved rapidly. There was progressive gain in weight for five weeks when marked dehydration secondary to diarrhea was present . Treatment was effective and the diarrhea subsided . Eight weeks postoperatively x-ray studies revealed the colon to be normal in appearance with no evidence of additional extra vasation of barium . (Fig . 3 .) On September 16th intraperitoneal closure of the colostomy was performed . Three days later the infant passed a normal stool . She was discharged from the hospital in excellent condition on October loth . (Fig . 4 .) COMMENT
When the diagnosis of pneumoperitoneum has been established roentgenologically, it is advisable not to administer barium either by mouth or by rectum in an attempt to demonstrate the site of perforation . The patient whose case is recorded herein was subjected to this diagnostic procedure and as a result barium escaped into the peritoneal cavity. Fortunately the infant survived despite this added insult . The presence of pneumoperitoneum is sufficient clinical evidence to justify surgical exploration . The surgeon under these conditions should make a very thorough search for possible obstruction . In the presence of massive pneumoperitoneum with associated dyspnea and cyanosis, as demonstrated by the case being reported, it is advisable to perform an abdominal paraAmerican
Journal of Surgery
Standard-Perforation of Colon in Infant centesis to release the intra-abdominal pressure thereby increasing the infant's vital capacity . This procedure was thought to be life-saving in this instance . It is well known that infants tolerate enterostomy poorly and that colostomy, although not associated with as high a mortality as enterostomy, is not infrequently followed with a critical postoperative course . However, this infant suffered no apparent ill effects . The colostomy effectively diverted the fecal stream from the unrepaired perforation of the rectosigmoid thus permitting spontaneous healing of the perforation . At a later date closure of the colostomy was performed . CONCLUSIONS
Perforations of the colon in the newborn are undoubtedly more prevalant than reported . The attendant high mortality associated with this condition can be reduced by early diagnosis and proper surgical management . Perforations of the colon are due to some associated congenital anomaly with obstruction and proximal perforation, focal lesions of the colon and to unexplained causes . If massive pneumoperitoneum is present, an abdominal paracentesis should be performed prior to surgery to decrease respiratory distress . The diagnosis can usually be made by a scout film of the abdomen and in the presence of pncumoperitoneum barium should not be introduced either by mouth or rectum . REFERENCES I . ART, I . A . Fetal peritonitis . M. Clin . North America, 15 : 611-622, 1931, 2 . AGERTY, 11 . A ., ZISERMAN, A . J . and SHOLLENBERGER, C . L . A case of perforation of the ileum in a newborn infant with operation and recovery . J . Pediat., 22 : 233- 238, 1943 .
January 1952
111
3 . ANDERSON, D . H . Cystic fibrosis and its relation to celiac disease- Am . J. Dis. Child., ;6 : 344 -399, 1950 . 4 . BOIxAN, W . S . Meconiura peritonitis from spontaneous perforation of the ileum in utero . Arch . Path ., 9 : 1164-1183, (9305 . BRONAUCH, W . and LATtIMER, R . D . Intestinal obstruction from inspissated meconium . Am. J . Dis . Child ., 6w : 1371 -1374, 1940 . 6. COLE, W . H . Congenital malformations of the intestinal tract and bile ducts in infancy and childhood. Arch . Surg ., 23 : 820-847, 19317- DEVEL, L . Intestinal perforation with pneumoperitoneum in the newborn infant . Am . J. Uis. Child ., 45 : 587-589, 1933 . 8 . FARBER, S . The relation of pancreatic achylia to meconium ilcus . J . Pediot ., 24 : 387-392, T9449 . FtsciEx, A . E . Fetal peritonitis : report of a case following spontaneous rupture of the large ictestnc . Am. J_ DS . Chiid., 36 : 774 -784, 1928,0 . HIATT, R . B . and WILSON, P . E . Celiac syndrome, therapy of meconium ileus . Surg., Gynec . er Obst ., 84 : 317- 327, 1948 . i, . LADD, WV . E. and GRoss, R . E . Abdominal Surgery of Infancy and Childhood . Philadelphia, 1941W. B . Saunders Co . 12. LEE, M . C ., JR . and MACMILLAN, B . G . Rupture of the bowel in the newborn infant, including a case report of rupture in the large intestine with recovery . Surgery,2S :48-66,1950 . 13 . PALTAGL, A . Die Spontane Dickdarmruptur de Neugeburnen . Virchows Arch . J . path . Anat ., 111 : 461-474, 1888 . 14. RUDNE W, W . Uber Die Spontanen Dormrupture bei Foeten and Neugeburnen . Base!, 1913 . lnagu, Dissert . 15 . RussELL, T . H . Spontaneous rupture of the intestine in the newborn . Tr . New England Soc., 21 : 286 -294, 1940, i6. THELANDER, 11 . F . Perforation of the gastrointestinal tract of the newborn infant . Am . J . Dis . Child., 58 : 371-393, 193917. TITUS, P . Management of Obstetric Difficulties . St . Louis, 1945 . C . V . Mosby Co. 18 . ZILLNER, F . Ruptera Flexurae Sigmoidis Neonati ., 96 : Inter Partum. Virchows Arch . f. path . Anal 307- 318,1884.
P
Ladd and Gross" have not encountered perforation of the bowel secondary to stenosis. Reduplication of the colon is indeed rare, yet its resultant obstruction, although usually incomplete, could lead to proximal perforation . Summarily the most likely cause of perforation in the obstructed group would be atresia . Perforations of the colon secondary to an obstruction in some distal part of this organ frequently occur in the cecum which has distended to the extent that the blood supply has been compromised. Lee and MacMillan's 72 case is an excellent example of this pathogenesis . In the perforations at the site of a focal process many causes have been reported such as trauma, intestinal aplasia, primary vascular insufficiency, congenital or acquired diverticuli, peritoneal bands, adhesions and inflammation from one cause or another . Trauma inflicted during delivery as an etiologic agent in the rupture of the large bowel has been suggested by Zillner, 75 Paltaul," Titus 17 and Russell . 15 Zillner reported four cases of rupture of the sigmoid colon during delivery which he attributed to compression of the free loop of the sigmoid between the lumbar vertebrae and the anterior abdominal wall . Paltaul described spontaneous perforations of the colon and sigmoid in five newborn infants. These had all been spontaneous, easy deliveries . Titus stated that injuries of the intra-abdominal viscera could be caused by manual compression of the abdomen of the infant during breech extractions . However, in the nine previously mentioned cases all were vertex presentations . Russell in his review of thirtynine cases of rupture of the bowel reported
` From the University Surgical Service, Kings County Hospital, and State University of New York College of Medicine at New York City.
January, 1952
107
108
Standard-Perforation of Colon in Infant
twenty-eight cases including the aforementioned, which might have indirectly been related to obstetric trauma. He postulated that hydrostatic pressure transmitted by meconium could cause rupture of the bowel . All four of the infants in the series of Zillner had enemas which were given by unskilled midwives . It seems unlikely that a non-distended bowel only partially filled with meconium and containing no gas could be ruptured during passage of the infant through the birth canal. The possibility of rupture secondary to an improperly given enema or an improperly taken rectal temperature seems more feasible . Congenital defects in the bowel wall may be the fundamental factor of the perforations, especially the true and false diverticuli which have been carefully reviewed by Boikan,' Fischer'' and Rudnew . 14 Abtl reported the presence of peritoneal bands and adhesions but concluded that they were probably secondary to the perforation . Bacterial invasion of the intestinal wall has been postulated as a cause of perforation but to date this has not been established as a primary factor . Finally, spontaneous rupture of the colon is not infrequent . Such perforations may occur anywhere from the cecum to the rectum and because of the inability to demonstrate either local or indirect causes may be classified as idiopathic . The diagnosis of perforation of the large bowel in the neonatal period can be made if one considers the possibility of its presence . The clinical picture presented by the infant has been vividly described by Thelander 16 as follows : "An infant with perforation peritonitis present at birth or occurring soon after, presents a fairly classic picture . The little patient looks sick . He is cyanotic, the respirations are rapid and grunting, the abdomen is distended and the abdominal wall, the flanks and the scrotum or vulva are usually edematous . Frequently brown induration of the edematous area, which may resemble erysipilas, is also present . Food is taken poorly or not at all . Vomiting is frequent and persistent . The vomitus contains bile and may contain blood . The stools are either absent or scant . Some mucus or blood may be passed . The temperature may be sub-normal, but varying degrees of fever have been reported . The blood count is of little or no value. The hemoglobin content may be very high, which probably indicates only dehydration . The leucocytes may or may not respond with a
rise . In cases of intra-uterine perforation the abdomen has at times been so distended at birth that delivery was impossible until paracenteses of the abdomen had been performed ." Roentgenologically, the diagnosis of perforated intra-abdominal viscus can be made by means of a scout film of the abdomen . Characteristically, there is massive pneumoperitoneum with or without associated hydroperitoneum . If the obstructed colon has not been decompressed by a rupture into the peritoneal cavity, its site may he demonstrated on the film. The administration of barium by mouth or by rectum in the presence of pneumoperitoneum is obviously contraindicated as is demonstrated by the case herein reported. Barium may escape into the free peritoneal cavity . The presence of free gas inn the peritoneal cavity in a patient suspected of having perforation is sufficient evidence to warrant laparotomy. An attempt to establish a positive diagnosis by means of further x-ray studies in an already desperately ill patient is unwarranted . The surgeon, at laparotomy, should be able to discover the cause of the perforation and its site, and institute the proper surgical therapy . CASE REPORT
A 7 pound s ounce female, normal vertex presentation, was delivered without instrumentation at 11 :53 P.M . on March 21, 199o . The infant's general condition was excellent . The neonatal examination carried out the next morning revealed an apparently normal and healthy infant . One meconium stool had been passed . On March 23rd at 10 :00 A .M . the patient vomited . The abdomen was markedly distended and tympanitic with mild erythema of the abdominal wall . Bowel sounds were absent on auscultation . The patient appeared listless and the cry was feeble . The temperature was loo°a. at this time . A small soapsuds enema was given with little or no return . The impression of the pediatrician was, "an obstruction secondary to some congenital anomaly of the intestinal tract ." Unfortunately a barium enema was given before a scout film of the abdomen had been taken . These films revealed massive hydropneumoperitoneum but no evidence of intrinsic disease of the colon . (Fig. 1 .) Examination at this time showed an acutely ill, listless, cyanotic, dyspneic, forty hour old infant with marked abdominal distention and American Journal of Surgen
Standard-Perforation of Colon in Infant
FIG .
Barium cl sma demonstr mg massive hydropneumoperitoneum and a no mal colon .
2
3
Gastric instillation of lipiodal . Extraluminal barium on the right side of the peritoneal cavity . The gas in the peritoneal cavity was removed during the paracentesis . Far . 3 . Interval barium clysma showing the presence of an intact colon to the colostomy site and residual barium in the peritoneal cavity . FIG . 2 .
January, 1952
log
IIO
Standard-Perforation of Colon in Infant
Fm . 4 . Infant at ten months of age .
edema and erythema of the abdominal wall . The stump of the umbilical cord was normal . Rectal examination disclosed no abnormalities . Because of the marked dyspnea and cyanosis secondary to the tense pneumoperitoneum, a paracentesis was performed in the right subcostal region in hopes of relieving the respiratory distress . A large amount of odorless gas gushed forth and was followed with 20 cc . Of cloudy yellow fluid which was alkaline in reaction and contained numerous pus, cells . The infant's condition improved immediately . Palpation of the abdomen, which was now scaphoid, revealed no masses or collections. A catheter was passed into the stomach through which g cc . of lipiodal were instilled . X-rays revealed no evidence of perforation of the stomach or duodenum ; however, extraluminal barium was obvious and the impression was that perforation of the colon was present . (Fig. 2 .) An immediate laparotomy was performed . Under inhalation ether anesthesia forty-four hours after delivery the abdomen was entered through a right rectus muscle-splitting incision . Peritonitis and free barium were disclosed . Exploration revealed the colon to be normal except in the region of the rectosigmoid immediately over the peritoneal reflexion where
barium continued to puddle after repeated aspirations . The barium presumably came from a perforation at this site which could not be visualized with certainty . Because of the precarious condition of the patient no further exploration was deemed advisable . A right transverse loop colostomy was performed and the wound closed in layers with interrupted silk sutures. Cultures of the fluid taken at the preoperative paracentesis and at laparotomy revealed Escherichia coli and lactobacillus . The patient was placed in an oxygen tent and intragastric suction instituted . She was given parenteral fluids and penicillin, 300,000 units every three hours, and streptomycin, 26 gm . every six hours . On the first postoperative day the abdomen was soft . The colostomy was opened on the second postoperative day and functioned well by the third . On the fourth day after operation normal feedings were begun following which the patient's condition improved rapidly. There was progressive gain in weight for five weeks when marked dehydration secondary to diarrhea was present . Treatment was effective and the diarrhea subsided . Eight weeks postoperatively x-ray studies revealed the colon to be normal in appearance with no evidence of additional extra vasation of barium . (Fig . 3 .) On September 16th intraperitoneal closure of the colostomy was performed . Three days later the infant passed a normal stool . She was discharged from the hospital in excellent condition on October loth . (Fig . 4 .) COMMENT
When the diagnosis of pneumoperitoneum has been established roentgenologically, it is advisable not to administer barium either by mouth or by rectum in an attempt to demonstrate the site of perforation . The patient whose case is recorded herein was subjected to this diagnostic procedure and as a result barium escaped into the peritoneal cavity. Fortunately the infant survived despite this added insult . The presence of pneumoperitoneum is sufficient clinical evidence to justify surgical exploration . The surgeon under these conditions should make a very thorough search for possible obstruction . In the presence of massive pneumoperitoneum with associated dyspnea and cyanosis, as demonstrated by the case being reported, it is advisable to perform an abdominal paraAmerican
Journal of Surgery
Standard-Perforation of Colon in Infant centesis to release the intra-abdominal pressure thereby increasing the infant's vital capacity . This procedure was thought to be life-saving in this instance . It is well known that infants tolerate enterostomy poorly and that colostomy, although not associated with as high a mortality as enterostomy, is not infrequently followed with a critical postoperative course . However, this infant suffered no apparent ill effects . The colostomy effectively diverted the fecal stream from the unrepaired perforation of the rectosigmoid thus permitting spontaneous healing of the perforation . At a later date closure of the colostomy was performed . CONCLUSIONS
Perforations of the colon in the newborn are undoubtedly more prevalant than reported . The attendant high mortality associated with this condition can be reduced by early diagnosis and proper surgical management . Perforations of the colon are due to some associated congenital anomaly with obstruction and proximal perforation, focal lesions of the colon and to unexplained causes . If massive pneumoperitoneum is present, an abdominal paracentesis should be performed prior to surgery to decrease respiratory distress . The diagnosis can usually be made by a scout film of the abdomen and in the presence of pncumoperitoneum barium should not be introduced either by mouth or rectum . REFERENCES I . ART, I . A . Fetal peritonitis . M. Clin . North America, 15 : 611-622, 1931, 2 . AGERTY, 11 . A ., ZISERMAN, A . J . and SHOLLENBERGER, C . L . A case of perforation of the ileum in a newborn infant with operation and recovery . J . Pediat., 22 : 233- 238, 1943 .
January 1952
111
3 . ANDERSON, D . H . Cystic fibrosis and its relation to celiac disease- Am . J. Dis. Child., ;6 : 344 -399, 1950 . 4 . BOIxAN, W . S . Meconiura peritonitis from spontaneous perforation of the ileum in utero . Arch . Path ., 9 : 1164-1183, (9305 . BRONAUCH, W . and LATtIMER, R . D . Intestinal obstruction from inspissated meconium . Am. J . Dis . Child ., 6w : 1371 -1374, 1940 . 6. COLE, W . H . Congenital malformations of the intestinal tract and bile ducts in infancy and childhood. Arch . Surg ., 23 : 820-847, 19317- DEVEL, L . Intestinal perforation with pneumoperitoneum in the newborn infant . Am . J. Uis. Child ., 45 : 587-589, 1933 . 8 . FARBER, S . The relation of pancreatic achylia to meconium ilcus . J . Pediot ., 24 : 387-392, T9449 . FtsciEx, A . E . Fetal peritonitis : report of a case following spontaneous rupture of the large ictestnc . Am. J_ DS . Chiid., 36 : 774 -784, 1928,0 . HIATT, R . B . and WILSON, P . E . Celiac syndrome, therapy of meconium ileus . Surg., Gynec . er Obst ., 84 : 317- 327, 1948 . i, . LADD, WV . E. and GRoss, R . E . Abdominal Surgery of Infancy and Childhood . Philadelphia, 1941W. B . Saunders Co . 12. LEE, M . C ., JR . and MACMILLAN, B . G . Rupture of the bowel in the newborn infant, including a case report of rupture in the large intestine with recovery . Surgery,2S :48-66,1950 . 13 . PALTAGL, A . Die Spontane Dickdarmruptur de Neugeburnen . Virchows Arch . J . path . Anat ., 111 : 461-474, 1888 . 14. RUDNE W, W . Uber Die Spontanen Dormrupture bei Foeten and Neugeburnen . Base!, 1913 . lnagu, Dissert . 15 . RussELL, T . H . Spontaneous rupture of the intestine in the newborn . Tr . New England Soc., 21 : 286 -294, 1940, i6. THELANDER, 11 . F . Perforation of the gastrointestinal tract of the newborn infant . Am . J . Dis . Child., 58 : 371-393, 193917. TITUS, P . Management of Obstetric Difficulties . St . Louis, 1945 . C . V . Mosby Co. 18 . ZILLNER, F . Ruptera Flexurae Sigmoidis Neonati ., 96 : Inter Partum. Virchows Arch . f. path . Anal 307- 318,1884.