March, I945 INTESTINAL OBSTRUCTION 85suture line it may be possible, with safety, tobring operations on growths in the left half of thecolon into line with those in the right.

After TreatmentWhen the right, half of the colon has been

removed and the lower end of the ileum has beenanastomosed with the transverse colon a rectaltube should be left in situ for a week. Duringthe first 48 hours small quantities of glucose andwater should be allowed by mouth, and glucoseshould also be administered intravenously. Rectalsalines should not be given. Liquid paraffinshould be given by mouth as soon as the patientcan retain it. Thereafter a return to the pre-operative diet, by stages, should not be delayed.Notwithstanding the presence of the rectal tubethe patient is likely to suffer from flatulent disten-sion, for a few days. Enemata cannot be given,but glycerine suppositories are usually helpful,while a hypodermic injection of morphia, andwarmth applied to the abdomen (most convenientlyby an electric blanket) will bring relief.When the stethoscope reveals that peristalsis is

re-established then this should be stimulated bythe exhibition of pituitrin and eserine in repeatedsmall doses. A laxative should not be administeredduring the first ten days at least.

After the Paul-Mikulicz operation, at the end offour days, the tube in the upper, and the clampon the lower, cut end of the bowel should beremoved and the enterotome introduced, for if thisstage in the operation is delayed the spur betweenthe two openings becomes hard and fixed, anddifficult to remove even by the efficient use of theenterotome. Thereafter a return to the pre-operative diet may be achieved in a few days'time. The colostomy will not as a rule close ofitself, and a small operation may be necessary forits closure.

SummaryThe course of chronic intestinal obstruction has

been divided, into three stages, (I) proemial,(2) partial declared obstruction, and (3) completeor acute-on-chronic obstruction. From the pointof view of treatment and prognosis the firstis by far the most important, and every en-deavour should be made, even to the extent of anexploratory laparotomy in suspicious cases, toestablish the presence or absence of a conditionleading to obstruction.

In the second stage some time may be givento discover the cause of the obstruction, but in thethird no time must be wasted; a laparotomy mustbe done at once.

In this article an attempt is made to indicate

the treatment appropriate to the three stages, aswell as to point out the grave dangers attendingoperation in the third stage.

INTESTINAL OBSTRUCTIONIN CHILDHOOD

GERTRUDEHERZFELD, M.B., Ch.B., F.R.C.S. (Ed.)(Honorary Surgeon, Royal Edinburgh Hospital for

Sick Children and Edinburgh Hospital for Womenand Children; University Lecturer in Child Lifeand Health.)

Introduction.Intestinal obstruction presents many interesting

problems both in diagnosis and treatment, and thisis particularly true in the case of a young child,for here frequently the history may be misleading,the appearance of the child deceptive, and theactual examination of the abdomen both difficultand puzzling. Atypical cases of partial obstruc-tion may be missed until the small patient isdangerously ill, and the less acute cases may bewrongly diagnosed, particularly in infancy, asdisorders of feeding. Hence it is important toconsider the subject of intestinal obstruction as itaffects the young child.

It is a well-known fact that the younger the childthe greater the risk.to life of acute dehydrationwith its oft-associated toxaemia, and not infre-quently the onset of obstruction may be masked inits early stages and later progress with alarmingrapidity to a fatal issue. It is, thus, essential thatwe should make an early diagnosis and institutetreatment, whether surgical or conservative, with-out delay if a satisfactory result is to be achieved.The multiplicity of pathological conditions which

may be met with is a confusing factor, particularlywhen one remembers the number of congenitalerrors which may, at some date, be responsible forthe onset of an intestinal obstruction: it is by nomeans essential, and at times not even wise, toattempt to make an accurate diagnosis as to theexact cause or site, for the important decision tobe reached is the answer to the question, "Is thischild suffering from acute intestinal obstruction?"It is, however, certainly useful and instructive tomake a tentative diagnosis when possible, par-ticularly as to the level of the lesion, for, as in theadult, high obstruction is relatively more dangerousthan obstruction of the distal colon.

Classification.There are many potential causes of obstruction

in childhood, particularly of the acute variety, and

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POST-GRADUATE MEDICAL JOURNALin considering possible lesions we note a numberof congenital conditions which may in time produceobstruction; on the other hand obstruction due totumours, so often seen in the adult, is extremelyrare in the young child. Some of the congenitalmalformations or errors may not produce symp-toms until adolescence or adult life, e.g. congenitalbands or a Meckel's Diverticulum; but the majoritycause acute obstruction in infancy or early child-hood, and it is therefore important to have someknowledge of the actual conditions which may bemet with.

It is difficult to classify such conditions eitheron an anatomical or on a pathological basis.From a clinical point of view the following mainclassification would appear to be the most satis-factory:-

[(a) Organic obstruction (i) ACngenial.(2) Acquired.(b,) Paralytic or functional obstruction.This method of handling the problem is of value,

for the two main varieties to be described aretotally different in their causation, their mode ofonset, and above all in their treatment.

In organic obstruction we are dealing with amechanical arrest to the passage of the intestinalcontents, the cause of which is most commonlysituated outside the wall of the intestine, thoughfrom time to time it is due to a narrowing of thelumen as, for example, in a case of pyloric stenosis.

Paralytic obstruction, on the other hand, ismainly confined to the post-operative period, andin children follows only on abdominal operationscomplicated by the presence of infection.

ORGANIC OBSTRUCTION

In the first group, i.e. those due to congenitallesions of the alimentary tract, we find a con-siderable number of potential causes of obstructionthough many of these occur but rarely. Thefollowing are the principal conditions which areseen from time to time in every children's hospital,and they are tabulated in the chronological orderin which they are usually noted to occur and notin order of frequency of occurrence.

I.2.3.4.5-6.7-

Imperforate anus.Volvulus neonatorum.Congenital atresia or stenosis of the intestine.Pyloric stenosis.Hirschsprung's disease (Megacolon).Congenital bands.Internal abdominal hernia.

The acquired obstructions are relatively few innumber, and of these by far the most importantis Acute Intussusception of infancy which accounts

for fully 90 per cent of this group of cases. Muchmore rarely do we see such conditions as obstruc-tion due to T.B. peritonitis, volvulus of the pelviccolon, or obstruction due to post-operative adhe-sions.

It is not possible within the limits of this paperto describe fully all the above-mentioned lesions,hence only the clinically important and relativelyfrequent conditions will be dealt with.

Clinical Features of Organic Obstruction.Acute mechanical obstruction is characterised

by the sudden onset of colicky pain due to activeperistalsis, which is nature's attempt to overcomethe condition. The early pain is situated in themid line at varying levels corresponding to the siteof the obstruction. Vomiting, always a markedfeature of any abdominal catastrophe in childhood,occurs early, and is often reflex in type at this stage,but as obstruction becomes marked the vomituschanges from simple gastric contents to those ofthe duodenum and jejunum. It is important alsoto remember that the exaggerated peristalsis atthe onset of the obstruction frequently causesemptying of the bowel distal to the site of thelesion, the amount of faecal matter passed perrectum depending on the level of the obstructionas well as on the amount of bowel content presentat the time. Later, constipation becomes abso-lute and no flatus is passed. It is often difficultto find out about the passage of flatus in a youngchild, but a gentle rectal lavage normally isreturned with the passage of flatus, while inobstruction there is a complete absence of flatus,and the fluid returns clear as given. The childdoes not appear seriously ill at this stage, but isrestless, irritable, and, while not in continuouspain, obviously suffers marked discomfort.At this stage of the obstruction, while peristalsis

is still actively trying to overcome the obstructivelesion, we may get visible peristalsis, and as dis-tension occurs we may also see a well-markedladder pattern. The abdomen next becomesprogressively distended, and on listening one candetect gurglings and rumblings in the abdomen asthe fluid moves in the distended coils. Laterperistalsis ceases and the obstruction becomessilent.Dehydration and toxaemia become marked

within a few hours, often with great suddenness,and the child's general condition deterioratesrapidly, the tongue becomes dry and coated witha brown fur, the breath is foul, and the eyesbecome sunken, but in this late stage pain isentirely absent. The vomiting now becomes asimple regurgitation of bowel contents and is quiteeffortless. This late stage should, however, not

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INTESTINAL OBSTRUCTIONbe seen, for a careful examination should establisha diagnosis long before the child is so dangerouslyill.

General Treatment of Organic Obstruction.The treatment is of course practically invariably

operative, though in the early stages a simpleenema with perhaps gastric lavage may be triedin the hope that the obstruction is only a partialone and can be tided over. Little time should,however, be lost in such treatment, and, if it isnot entirely successful within an hour or twooperation should immediately be arranged for.

Before proceeding to operation, it is essential tojudge of the general condition of the child, as anyoperation in the presence of grave dehydration iscontra-indicated, and the fluid balance must berestored before attempting what may be a majoroperative procedure. The dehydration associatedwith obstruction is important because of its possibleinterference with metabolism leading to acidosis.Alkalosis may also occur in relation to high intes-tinal obstruction with excessive vomiting andconsequent loss of chlorides.

It is not easy to estimate the amount of intra-venous fluid required in a given case in order toestablish a reasonably good fluid balance, andwhile, as a general rule, about 50 c.c. per kilo dailyis a useful guide, it is more important to assessthe clinical condition of the child by noting thedryness of the tongue and the degree of thirstcomplained of. Six per cent glucose in saline isprobably the best fluid in the pre-operative stage,and to this can be added if necessary blood plasma,or even whole blood should a major operation,such as resection, have to be undertaken. Beforeputting the patient on the operating table thestomach should be emptied by means of a stomachtube, and, if necessary, continuous suction can becontinued throughout the operation.

CONGENITAL OBSTRUCTIONS

Imperforate Anus.This distressing malformation occurs infre-

quently, and with adequate treatment the life of theinfant can usually be saved. It is therefore ofimportance that the condition should be treated atan early stage. It occurs in various forms, andthere are degrees of failure in the development ofthe rectum and anal canal. In its most severeform there is complete absence of the anus, of thesphincter muscles, and of the anal canal, whilethe rectum itself has failed to descend into thepelvis. In other cases the anal sphincter ispresent, but the epithelial downgrowth has notproceeded far enough to join up with the descend-ing rectum, and there may be a varying amount

of tissue between the anal canal and the rectum.When this tissue consists of a membrane onlytreatment is easy, a simple slitting of the membranebeing all that is required.Sometimes the failure of development produces

a different state of affairs. In the male a recto-vesical fistula is occasionally seen with a com-pletely imperforate anus, while the correspondingcondition in the female is either a perineal anusor else often a recto-vaginal fistula. The femaleform of malformation allows of the passage of softfaeces, and consequently no immediate operativetreatment is required. In the male variety it isnecessary to carry out surgical treatment at anearly stage as the fistulous track is very small,and the mixture of faeces and urine leads sooneror later to an ascending renal infection.Where the obstruction is complete the clinical

features are obvious, both on inspection of theexternal genitalia and from the fact that nomeconium is passed. Within a few hours of birththe child begins to vomit and the abdomen gradu-ally becomes distended, though this is the leasturgent form of complete obstruction in that theinfant can survive for many days should thediagnosis be missed.Treatment is invariably surgical in the complete

obstructions, and consists either in forming ananus and anal canal in their correct anatomicalposition, or in the more severe cases of doing aleft inguinal colostomy, either as a temporary oras a permanent measure. Where no anal sphincterexists, as noted by the absence of puckering of theanal skin, it is probably wise to do a colostomy.On the other hand, in some cases an anal sphincteris present, but, on doing a perineal operation, thelower end of the rectum may be found not to bewithin reach. In order to avoid unnecessaryperineal searching, it is useful to have an X-rayphotograph taken with the baby in the invertedposition, when the appearance of gas in the blindloop will show the level to which the rectum hasdescended.These cases usually survive operation, but may

require further plastic procedure at a later stage.Volvulus Neonatorum.

This interesting though very rare condition isassociated with malrotation of the mid-gut loopearly in embryonic life. As a result there is afailure of rotation of the caecum and non-fixationof the root of the mesentery of the mid-gut. Thecondition may be present without giving rise tosymptoms, and may therefore be discovered acci-dentally either in the course of an operation or atpost-mortem; but, from time to time, there occursa volvulus of the entire loop of intestine aroundthe attachment. of the mesentery, usually in a

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POST-GRADUATE MEDICAL JOURNALclockwise direction, and this torsion may actuallytake place through 360 degrees. In associationwith such a volvulus, or even with only a partialtwist, there may be a drag on the root of themesentery which will cause partial obstruction ofthe second part of the duodenum.

This condition may produce symptoms at anyage, but most typically it is noted during the firstweek of life, and the clinical features in infancy arethose of duodenal or duodeno-jejunal obstruction.The infant, which is healthy at birth, commencesto.vomit, usually within a day or two, and thevomiting becomes gradually more marked, thoughit may be forty-eight hours or more before alarmis felt by the infant's guardians. It is character-istic that the vomited fluid always contains bilein small quantities, and it is important to rememberthis point particularly with regard to the differ-ential diagnosis between volvulus and an earlypyloric stenosis.

Abdominal distension occurs, but this is limitedin the early stages to the upper part of the abdomen,being in fact confined to the stomach and duode-num. Only after volvulus becomes complete willdistension of the mid-gut loop complicate thepicture. Constipation is rarely absolute as theobstruction is not usually complete.

Diagnosis should be easy if the possibility ofsuch a condition is borne in mind, as there are fewother conditions which give rise to bilious vomitingin the early days of life, though from time to timeadhesions between the duodenum and the liver havebeen noted to produce similar signs.

Treatment consists in early operation, shouldsimple gastric lavage over a period of abouttwenty-four hours not be successful. A rightparamedian incision is required under deepanaesthesia, and the whole twisted mid-gut loopmust be brought out on to the surface of theabdomen, both in order to be able to see the exactstate of affairs, and in order to derotate at the rootof the mesentery.These cases, if treated early, usually give a very

satisfactory result, though occasionally we havenoted a recurrence in later childhood. It shouldbe noted that it is not always possible nor advisableto place the caecum in its normal anatomicalposition, and in many cases the caecum should beleft in the position it naturally takes up once thevolvulus has been reduced, even though this maybe on the left side of the abdomen.

Pyloric Stenosis.Pyloric stenosis is perhaps the most important

of the congenital obstructions because of its relativefrequency, and because, where diagnosed early,it is possible to effect a permanent and mostsatisfactory cure.

The clinical features in brief may be stated asfollows:

I. Vomiting, occurring between the second andfourth week, increasing in intensity, andbecoming projectile in character.

2. Absence of bile in the vomit, there being onlygastric contents.

3. Increasing constipation.4. Loss of weight.5. Visible gastric peristalsis.6. The presence in some cases of a palpable

tumour at the pylorus.The diagnosis is relatively easy if the condition

is suspected, but the tragedy is that even now suchcases are often erroneously diagnosed as being dueto a digestive disturbance. The above-mentionedclinical features, together with, if necessary, theX-ray appearance after a barium meal, are abso-lutely characteristic.While medical treatment is undoubtedly often

satisfactory, it usually entails prolonged and carefulhandling during which time the infant is apt tobe in a somewhat dangerous condition, and mayeasily become extremely ill should any intercurrentinfection arise.

Surgery in an early case, particularly if the babyis still on the breast, can offer a 90 per cent cure,usually within a week. The operation consists indivision of the hypertrophied pyloric sphincterunder local anaesthesia, and in a baby, who is stillon the breast and has only a short history ofillness, the operation is so well tolerated that thechild may actually be sent home with its motherfour to six hours after operation, and can then betreated as an out-patient without any risk. Onthe other hand, infants, in whom diagnosis hasbeen delayed or who have not responded to medicaltreatment, are bad operation risks, and requirecareful pre-operative treatment in the way ofblood transfusions, intravenous fluid, etc., and arealways anxious cases for a week or ten days afteroperation.

Congenital Megacolon.This congenital form of obstruction is a chronic

one, and only rarely becomes at all acute. It israre, and the etiology is not clearly understood,though it is probably associated with a defect inparasympathetic innervation.The clinical features are at times somewhat

puzzling, though there is practically always anearly history of abdominal enlargement and dis-tension usually noted before the child is a year old.This is followed shortly by constipation whichbecomes increasingly marked, and the child maynot empty the bowel for days on end. There is

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INTESTINAL OBSTRUCTIONan associated malnutrition with failure of growth,general debility, and anorexia is often marked.On examination the most characteristic feature

is the great distension of the abdomen with aprominent umbilicus, a thin abdominal wall, com-bined with poor general nutrition. In some casesthe outline of the greatly distended colon may beboth seen and felt. An X-ray using a bariumenema will confirm the diagnosis.Treatment is on the whole disappointing. In

the earlier stages much may be done to help thecondition by dieting, the administration of liquidparaffin, and regular colon lavage. In some caseswhere there seems to be considerable anal spasm,the use of graduated anal dilators has been foundhelpful, but usually these cases ultimately come tooperation, of which the most satisfactory hasproved to be a sympathectomy, though in the acutecases a temporary caecostomy is of considerablevalue for deflating the grossly distended bowel.Resection of the colon has been practically aban-doned as a method of treatment.

ACQUIRED OBSTRUCTIONIntussusception.This somewhat dramatic condition is well known

to all who work in a children's hospital; but anindividual practitioner may see only one or twocases in a lifetime, and, unless the case is absolutelytypical, the diagnosis may be delayed and treat-ment thus rendered not only more dangerous anddifficult, but at times unavailing.The most common site of the invagination is at

the lower end of the ileum, with passage of theapex of the intussusception through the ileo-caecalvalve, and thence around the colon. It should benoted that the early symptoms are not those ofobstruction, for it is the act of invagination whichproduces the dramatic acute abdominal pain,followed by symptoms suggestive of shock; andonly after the lapse of some hours does actualintestinal obstruction occur due to the swelling andoedema of the affected gut which is associatedwith the acute venous congestion of the enteringmesentery, and it is then that the vomiting, whichat first is merely reflex, becomes more marked andultimately obstructive in nature. At the sametime, once the distal bowel has emptied itself offaecal matter, neither faeees nor flatus are passed,but we get the appearance of the typical blood andmucus which is not usually of the red currant jellyvariety, but far more often is merely dark liquidblood mixed with only a small quantity of mucus.The diagnosis of the condition is generally easy

if the possibility is suspected. The history ofintermittent colicky pains, severe in character atthe onset, with, after a varying period, the appear-

ance of blood per rectum, is most suggestive; butit is important to remember that the passage ofblood may be delayed, and the diagnosis can beestablished without this characteristic feature if acareful abdominal examination is made for thepresence of a small sausage-shaped tumour. Itmay be necessary in a doubtful case to administera short anaesthetic in order to make sure of thepresence of such a tumour as this absolutelyclinches the diagnosis.Treatment.Treatment is invariably operative for, in spite

of the possibility of either spontaneous reductionor reduction by means of, say, a barium enema,there is no doubt that early operation gives thebest results. The incision varies according to thesite of the tumour. Where the mass can be feltto the right of the mid line, a simple muscle-splitting incision as for an appendix practicallyalways suffices. If, on the other hand, the intus-susception has passed as far as the splenic flexureor beyond this point, it is essential that a para-median incision giving almost unlimited accessshould be used. The reduction of the intus-susception should be mainly accomplished insidethe abdominal cavity, using the index and middlefingers to push in a proximal direction, startingfrom the apex of the tumour. Usually the earlypart of the reduction as far as the caecum orascending colon is relatively easy, and can beaccomplished in the above-mentioned manner.When we reach the ileo-caecal region, however,we may often encounter considerable difficulty, asin this area, the first to be invaginated, there isalmost always considerable oedema with con-gestion and some degree of interference with theblood supply. At this point the whole mass shouldbe brought outside the abdominal cavity and sur-rounded with hot moist gauze. In a simple casefurther gentle pressure will "milk" the tumourthrough the ileo-caecal valve'and complete thereduction. If much swelling and oedema arepresent, before attempting the final two or threeinches, the tumour should be wrapped in moistgauze and firmly compressed to squeeze out someof the oedematous fluid. Thereafter reduction isoften surprisingly easy.During this last stage of reduction it may be

noted that the peritoneal, and at times themuscular coat of the caecum tends to split. Thisalarming complication is not as serious as itappears, and an inch or two of such damage cansafely be left with the knowledge that the bowelwall will recover, though it is sometimes advisableto insert one or two stitches.

After a difficult reduction the caecum will oftenappear congested, somewhat bruised, with several

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POST-GRADUATE MEDICAL JOURNALperitoneal tears, and to the inexperienced surgeonthe bowel will not appear to be viable so that onemay be tempted to do a resection. The properprocedure in a doubtful case, however, is to returnthe affected bowel into the peritoneal cavity, leaveit there for a couple of minutes, and then re-ex-amine it, and almost invariably it will be notedthat there is an improvement in colour and appear-ance showing that the bowel is in fact viable andcan be safely returned into the abdomen.Removal of the appendix should not be carried

out as a routine, for, though this is invariablysomewhat congested, its presence does no harm, andits removal in a young and not very fit infant mayprejudice the chances of recovery.

In the rare case where the bowel is definitely notviable, or where the intussusception is quiteirreducible, or if gangrene has already set in asevidenced by a fetid odour, a much more seriousproblem presents itself. Usually the best proce-dure is a rapid resection, and this means a hemi-colectomy with anastomosis of the ileum to thetransverse colon. Such an operation is, of course,a dangerous one, and consequently the mortalityrate is high. Another possibility is to treat thetumour by exteriorisation, together with anasto-mosis of ileum to transverse colon, and then allowthe affected mass to slough off between clamps.In either of these rather desperate methods oftreatment, it is of course essential that intravenousplasma or blood should be at hand to be givenboth during and after the operation.

PARALYTIC OBSTRUCTION

Paralytic ileus is the most dangerous form ofobstruction in the child, and is fortunately rela-tively rare. It is never seen after a straight-forward abdominal operation, but may occur afteroperation for a virulent appendicitis with eithera local or generalised peritonitis, or in associationwith any other peritoneal infection. On the wholeit is more common after a perforated appendicitiswith relatively little local reaction in the way offrank pus.Clinical Features.

Following on the original operation the patientmay appear to be doing well for the first twenty-fourhours. Thereafter one gets a vague impressionthat the child is not so well as he should be Hestill looks toxic, the pulse continues to be rapidor even increases in rate, while the temperature isfrequently normal or subnormal. The tongueremains a little dry, and the child has a somewhatanxious look and is inclined to be restless. In-spection of the abdomen reveals slight distension,but no gurgling and no peristalsis. Within the

next twenty-four hours the child usually beginsto vomit, no flatus or faeces are passed, and thechild's condition now deteriorates with alarmingrapidity. Should an enema be given, this iseither retained or returned clear without flatus.

Treatment.In this form of post-operative obstruction,

unlike post-operative obstruction due to adhesionsseen at a later stage, treatment consists in absoluterest to the alimentary tract in the hope that theparalysis may be only temporary, and will subsidewith rest. No purgatives, bowel stimulants, orenemas should be given for at least seventy-twohours, and as soon as the diagnosis is made anintravenous drip should be put up. If vomitinghas become marked, gastric or duodenal suctionshould be instituted, the Ryle's tube being passedthrough the nose. Where suction is used thechild may be allowed to drink, though only insmall quantities, and it is remarkable how placidsuch a child becomes after a few hours of thistreatment. In addition, however, large doses ofmorphia should be used in order to keep the childphysically and mentally at rest.

Usually at the end of forty-eight hours the childis obviously beginning to improve, the colour ismore healthy, the pulse rate drops, and at thisstage the fluid withdrawn by suction becomesclearer. After a further 12 to 24 hours the suctiontube should be removed, and an injection ofpituitary extract followed twenty minutes laterby a soap-and-water enema may now be tried.In the favourable case flatus and possibly a littleliquid faeces will be passed, and the danger periodmay now be said to be over. If this treatment,however, is not successful further suction can betried for another twenty-four hours, but the ques-tion of jejunostomy should be seriously consideredthough the prognosis in such a case in childhoodis grave.To recapitulate, as soon as paralytic ileus is

suspected, splint the bowel and keep up the waterbalance by means of intravenous fluid, and themajority of cases will recover within three days.

ConclusionIntestinal obstruction in infancy and childhood

is thus represented by a great variety of conditions,and though in essence the condition in childhoodresembles that seen in the adult, there are greatvariations in pathology and above all in thereaction of the child to the various lesions whichmay produce obstruction. As in other abdominalconditions it is essential in childhood to make anearly diagnosis and institute treatment withoutdelay, in which case surprisingly good results will beobtained even in some of the most serious lesions.

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RADIOGRAPHS ON INTESTINALOBSTRUCTION

ByP. H. WHITAKER

PLATE I

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JEJUNUM AND ILEUM WITH FLUID LEVELS.

PLATE 2

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·····:xialgi... i::,::,:.;.....:.:..····-::i:::%:·

SMALL BOWEL DILATION AFTER FLUID MEAL. OBSTRUCTIONIN RT. ILIAC FOSSA.

PLATE q

i·:···

::r::·;:

Ileaaap.n.s.i.are.s..f.;i.;·.;i.9.c.:"j.gq.L:e;;:: L:iii....ii.

:II:::i·:·.i'113.a&L ..F.*8..i· ·d:':*·..

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li.LIDii

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::::

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BiPi.i::-::.::::i:.: ii:iliiil

DUODENAL ILEUS DUE TO EXTRINSIC PRESSURE AFTERFLUID MEAL.

PLATE 5

t i

....... ... . . ill

a::::~l~I.":i:.ii: llZ~: llll

HYPERPLASTIC TUBERCLE-DEFECT IN THE CAECUM WITHPALPABLE MASS.

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PLATE 6

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m. ..aC I I -X..··: ·· ila~~l|-;sar:: uB,J̀...~~ L.. . : ·:....-

if 1·.\:~

KROHN'S DISEASE-DEFECT IN THE CAECUM AND TERMINALILEUM.

PLATE 7

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adi~:···.I:I:q~ij,,,: ··:····

ACTINOMYCOTIC ABSCESS-RIGHT ABDOMEN INCLUDINGCAECUM AND ASCENDING COLON.

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PLATE 8

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MALIGNANT LESION NEAR SPLENIC FLEXURE.

PLATE 9

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TUBERCULOUS ENTERITIS. MULTIPLE STRICTURES OF THE COLON.

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DEFECT IN COLON-DUE TO ADHESIONS FROM POST-GASTROENTEROSTOIY--NOTE LENGTH OF DEFECT.

PLATE I

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DISPLACEMENT AND COMPRESSION OF PELVIC COLONDUE TO OVARIAN CYST.

PLATE 12

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.I iiI|~i-~l~sa: d~ -| XU~i~j

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INTISTINAL OBSTRUCTION.

INTUSSUSCEPTION OF PELVIC COLON. SITE OF A RINGSTRICTURE.

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PLATE 13

.:9Bir':·'·

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DIVERTICULOSIS OF PELVIC COLON WITH DIVERTICULITISPELVI-RECTAL JUNCTION.

1'LATl'E I4

iii

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DILATATION OF THE COLON.

HIRSCHPRUNG'S DISEASE. BA. ENEMA.

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