ROENTGENOLOGIC STUDIES OF THE INFANT'S

GASTROINTESTINAL TRACT

JOI:IN S. BOUSLOG, ~V~.D., T. D. CUNNINGHAM, ~V[.D., JAMES P . HANNER, M.D. , JAMES B. WALTON, M.D. , AND HAROLD D. WALTZ, ~V[.D.

D~NVE~, CoLo.

INTaODUCTION

R OENTGENOLOGIC studies of the infant 's gastrointestinal tract have been made by several investigators. The early work on this sub-

ject was carried out by Levcn and Barret t l in Paris (quoted by Car- man),2 and by Ladd, ~ and Pisek and Le Wald 4 in this country. Since that time there have been several publications on Similar studies. On reviewing this literature, we were impressed with the diversity of opinions concerning the size, shape, and emptying time of the stomach. Several of these studies were carried on under special conditions, which may account for some of the variations in the results. We believed that a routine study of the infant gastrointestinal tract would be of value since, in practical radiology, routine rather than special methods are most often used. It is then the purpose of this study to attempt to define the variations which may be found in the gastro- intestinal tracts of average healthy infants as seen under routine conditions.

MATERIAL AND TECHNIC

Our studies have been made over a period of four years at the

Florence Crittenton Home, Denver. l~oentgen ray gastrointestinal

examinations were made on ]33 infants (63 boys and 70 girls), aged

from one week to six months. 'Each infant was given a barium meal,

and I00 of this same group, a barium enema. On some of the infants,

several examinations were made at different ages. The age periods

varied somewhat, but an attempt was made to obtain the first ex-

aminations during the second week of life; the second, third, and fourth series at one month, three months, and six months, respectively. The barium enema was given only during the first ten days of life.

In this group there were included those who were healthy and nor- mal according to history and careful clinical examination and forty- one abnormal infants. In the abnormal groups there were eleven

From the Child I~esearch Council and the University- of Colorado School of Medi- cine.

Thanks are due to Jennie Pings, R. N., and the staff of the Florence Crittenton Home.

234

BOUSLOG ET AL. : G A S T R O I N T E S T I N A L TI~ACT STUDIES

T k ~ E I

T H E NUlV~BEE 01~ EXAMINATIONS P E a INI~ANT

235

Infants with one examination 43 Infants with two examinations 38 Infants with three examinations 46 Infants with four examinations 6

Total number of infants 133 Total number of examinations 281

babies f rom syphil i t ic mothers , nine infants with eczema, five p rema- tu re infants wi th b i r th weights f rom 2.0 kg. to 2.2 kg., and s ixteen infants showing minor disturbances, such as uppe r r e sp i r a to ry infec- tions, mild diarrhea, mild constipation, and quest ionable hyper tbni - city. As a careful examina t ion and comparison of the roen tg~nograms fa i led to show any dis t inguishing features, the normal and abnormal cases are all considered ton'ether as represent ing a group of ave rage nur se ry babies.

The bar ium meal c~nsisted of 5 c.c. of a 2 per cent gum arabic solution mixed with 8 gin. of ba r ium and added to each ounce of the i n f an t ' s usual formula . (The m a j o r i t y of the group were on whole milk, w a t e r and dextr i -mal tose mixtures , ave rag ing app rox ima te ly 45 calories pe r pound.) The meal was bot t le fed. Immedias a f t e r complet ion of the feeding, the in fan t was ro ta t ed on the r ight side and the first x - r ay exposure was made with the rays pass ing th rough the lef t post- ax i l l a ry line (Fig. 2). This posit ion was used in an effort to p o r t r a y the pylorus and duodenum bet ter . The progress of the meal th rough the gas t ro in tes t ina l t r ac t was then followed by pos ter ior -anter ior films made at one and one-half hours, three hours, five hours, eight hours, and twenty~four hours a f t e r complet ion of the meal. The infants were p laced in no special position dur ing the process of digest ion of the meal. In t~he series of the 133 in fan ts the r egu la r feedings were con- t inued at four-hour intervals. In a special series of ten infants noth- ing was given by mouth unti l the s tomach was empty.

The ba r ium enema consisted of 5 c.c. of 2 per cent gum arabic solu- t ion and 8 gin. of ba r ium for each ounce of water . About 30 c.c. was given th rough a small catheter. Fol lowing the enema a film was made in the pos te r ior -an te r ior position.

The gum arabic solution was added to the bar ium mix tu re for both the meal and enema, as it was found, in our experience, to give be t t e r suspension of the ba r ium and a be t t e r filling of the s tomach and in- testine. When ba r ium alone was given wi thout the gum arabic solu- tion, the meal tended to prec ip i ta te out and form a small ball in the s tomach and intestine and gave poor visualization. Fu r the rmore , the gum arabic ba r ium meal does not tend to const ipate the infan t as much as is sometimes noted the bar ium alone does.

236 T H E J O U R N A L OF PEDIATR.ICS

OBSERVATIONS O~ T H E BARIUM M E A L

1. Esophagus.--No a t t empt was made to visualize the esophagus. I t was, however , seen seven times in the 281 examinai ions on the film made immedia te ly a f t e r complet ion of the ba r ium meal. I t did not cont inue to show on subsequent examinat ions, nor was it present on examinat ions made on the same in fan t at different age periods.

2. Stomach.--a. Shape : The infant s tomach does no t tend to assume fa i r ly definite types or forms as does the so-called " a d u l t t y p e " ' of s tomach. In our series we are unable to classify in fan t s tomachs into

Fig'. 1. R o e n t g e n o g r a m s of s t o m a c h s of s ix i n f a n t s f r o m 3 w e e k s to 4 m o n t h s old, s h o w i n g d i f fe ren t s izes a n d shapes .

definite types. They a p p e a r to assume m a n y shapes f rom " p e a r s h a p e , " " o v a l s h a p e , " " r e t o r t s h a p e , " " t o b a c c o pouch s h a p e , " to in te rmedia te shapes which we were unable to classify. The s tomach m a y change f rom one type to ano ther or m a y assume several dif- f e ren t shapes dur ing the process of empty ing and a t different ages in the same infant . In the series we found five s tomachs which appeared as " s t e e r h o r n " type and one s tomach which appea red as " f i s h h o o k " type. Even in these cases the s tomach assumed different shapes dur- ing the process of emp ty ing and also at subsequent examinat ions (Fig. 1).

BOUSLOG ET AL. : GASTROINTESTINAL TI~ACT STUDIES 237

b. Size: The size o~ the stomach is difficult te estimate. I t appears to v a r y g rea t ly dur ing the process of empty ing and a t subsequent examinat ions made on the same infant at different age periods. Usu- ally it extends f rom the dome of the lef t half of the diaphragzn to jus t beyond the midline of the spine. However , it m a y a p p e a r g rea t ly enlarged if there is a l a rge accumula t ion of gas; and in several cases it appea red to ex tend across the entire abdomen (Fig. 1).

c. Position of thv Stomach: The infan t s tomach varies f rom the horizontal to the oblique and a lmost ver t ical position. F r o m our series we found the hor izontal posi t ion to be f a r more f requent . The posi- t ion f r o m the hor izontal to the oblique m a y change in different ex- aminat ions on the same infant, and also during the period of emptying of the stomach.

TABLE II

POSITION OF THE STOI~AC'I:I A:~'TEF~ BARIUM MEAL

Horizontal 265 Vertical 3 Ob]iqu~ 13

Total examinations 281

A n y classification into horizontal , oblique, or ver t ica l posit ions i s more or less a rb i t ra ry , as there is a grea t var ia t ion in the different angles, and at t imes it is difficult to determine whe the r it should be called horizontal or oblique.

d. Height of the Lower Pole: The height of the lower pole var ied f rom the top of the first l u m b a r ve r t eb ra to the middle of the th i rd l um ba r ve r t eb ra as shown on the film t aken immedia te ly a f t e r the ba r ium meal. I t was noted t h a t the height m a y v a r y a t different examinat ions of the same in fan t f rom one to one and one-half ver te- brae, and also dur ing the process of emptying.

e. Peristalsis: Per is ta l t ic waves were r a re ly seen in our series. In the series of 133 infants, only five examinat ions showed peristalsis, two on the immedia te films and three on the one-and-one-half-hour films. In the special series of ten infants, in whom. no th ing was given by mou th fol lowing the ba r i um meal unti l the s tomach was empty , films were made a t two minutes, 5 minutes and 10 minutes a f t e r the meal was begun, and then every hal f -hoar unti l the stomach was empty. A to ta l of 137 films were made on these ten infants and even wi th the compara t ive ly shor t t ime in tervals between each film peristalsis was r a re ly seen.

f. A i r Bubble: I t has been observed by Dr. W. W. Wasson and others tha t soon a f t e r the first inspira t ion of the newborn in fan t a i r can be demons t ra t ed in t h e s tomach by x - ray pictures. This air bub- ble changes size and shape dur ing different examinat ions and dur ing the process of emptying . Though no definite conclusions can be drawn, it appears to exert no influence upon the emptying t ime of the stomach.

238 TI:IE JOURNAL OF PtgDIATI~ICS

I t is s i tua ted in the cardia of the s tomach and in some cases appears to increase in size as the s tomach empties.

g. Empty,ing Time: The films t a k e n immedia te ly a f t e r complet ion of the b a r i u m meal showed the presence of the mea l in the small in- test ine in 244 out of 281 examinat ions. This would seem to indicate t ha t the s tomach begins to emp ty ve ry soon a f te r the meal is given. This was borne out by fluoroscopic examina t ion of three cases and in the special series of ten cases, which showed small masses in the small intest ine in f rom five to ten minutes a f te r the beginning of the meal. The empty ing time. of the regular series of 133 infants as checked b y films t aken one and one-half hours, th ree hours, five hours, and eight hours a f t e r the complet ion of the ba r ium meal is shown in Table I I I .

TA~E I]:I

VARIATION IN THE E M P T Y I N G T I M E 0 t ~ THE STOMAClrI

NO. PEI%CENTAGE

E m p t y i n g t ime a t one and one-half hours 5 E m p t y i n g t i me f rom 11/~ to 3 hour s 27 E m p t y i n g t i me 3 to 5 hours 56 E m p t y i n g t ime 5 to 8 hours 80 E m p t y i n g t ime more t h a n 8 hours 123

To ta l s 281

2. 9

19 g7 43

100

No~E: The t r ue e m p t y i n g t ime m a y be obscure as the e s t ima t i on o f the a m o u n t o f b a r i u m res idue appea r i ng on the film is qui te difficult. The res idue in some eases appea red to be a l a rge amoun t , while in o thers i t was only a smal l amount . W h e n t he s t omach showed only a few flakes, appa ren t l y adhe ren t to the gas t r i c mueosa , i t was considered as empty . (See Fig . 4, series 2.)

In some cases there appeared to be rap id empty ing dur ing the first few hours, then somewhat slower emptying . In several eases in which the small intestines were appa ren t ly e m p t y in f rom five to eight hours, the colon was fa i r ly well filled, and there appea red a gast r ic residue. The empty ing t ime of the s tomach does not t end to be the same at d i f ferent examinat ions of the same infant . An example of this is shown in one of the infants whose s tomach empt ied in one and one- ha l f hours at one examinat ion, in five to eight hours, and in more t h a n eight hours on the second and th i rd examinat ions. I t mus t be no ted tha t the above da ta applies to those eases which were given the r egu l a r fo rmula four hours a f t e r the ba r ium meal. The ten special eases in which no food was given fol lowing the ba r ium meal unti l the s tomach was e m p t y showed a s l ight ly different t ime of emptying . F ive of the ten infants showed an empty ing t ime of f rom three to five hours, and five infants, f rom five to eight hours. None of these showed a residue a t the end of eight hours. I f we m a y be al lowed to d r aw conclusions f rom this small group, it would a p p e a r tha t feeding the in fan t wi th in the four-hour period, or before the s tomach was empty , did t end to lengthen the emp ty ing time.

B O U S L O G E T A L . : G A S T R O I N T E S T I N A L TI%ACT S T U D I E S 239

h. Pylorus: The pylorus was seen on the immedia te film in only eleven instances out of 281 examinat ions. I t was more f r equen t ly seen on the one-and-one-half-hour films (f i f ty-eight t imes) and on the three-hour films ( th i r ty - two t imes) . I t does not a p p e a r to be as well m a r k e d in the infan t as in the adul t (Fig. 2). In the special series of ten cases, wi th the films made at f r equen t intervals, i t was not seen until about one and one-half hours and then inf requent ly . Three in- fan ts were given the meal and its p rogress was was unde r the fluoroscope. The s tomach was pa lpa ted to fill the duodenum. In these cases i~ was noted tha t the pylorus was no t well defined.

3. Small Intestine.---As the s tomach began to empty , the small in- testine became visualized by small separated i r regular masses of bar ium. In the special series of cases these ba r ium masses appea red be tween five and twelve minutes a f t e r the b e g i n n i n g of feeding (Fig. 2). In the general series they were seen in 244 out of 281 examinat ions on the immedia te film, made a f t e r the complet ion of the feeding.

a. Duodenum: The duodenum was rare ly seen on the film made im- media te ly a f t e r complet ion of the bar ium meal (9 t imes in 281 exami- nat ions) . On the one-and-one-half-hour and three-hour films, it was seen t w e n t y t imes and three times, respectively. A s tudy of the ob- servat ions under the fluoroscope of the th ree infants and the special series of 10 cases showed the pylorus and the duodenum to be seen most often f rom one to three hours a f t e r the ba r ium meal. When the duodenum was seen, it differed f rom the adtflt appearance . The typica l cap was seen only once. Usual ly it appea red as an annu la r s t ructure , all por t ions being a p p r o x i m a t e l y of the same size, and curv- ing downward and to the left (Fig. 2).

b. J e j u n u m : The j e junum was ra re ly visualized with bar ium, and, when it was seen, it did not present the " f e a t h e r y ' " appea rance of t h e " a d u l t " type. Ins tead, it appeared somet imes as small isolated masses of bar ium and other t imes as a thin cont inuous line of bar ium. Occasionally these separa ted globules were fuzzy in appearance in cont ras t to the c lear ly cut masses in the lower p a r t of the small intes- t ine (Figs. 2 and 4). The progress of the meal f rom the pylorus th rough the duodenum and j e j unum was ra re ly seen in our films.

c. I leum: Small globules of bar ium were f r equen t ly seen in the i leum on the immedia te and subsequent films as late as five hours. These globules m a y a r range themselves to show m a n y p a t t e r n s ; as more or less isolated f rom each other, g rouped in several bunches, or even g rouped in masses in the lower r ight or lef t q u a d r a n t (Figs. 2 and 4).

4. Large lnte'stine.--a. Cecum: On the three-hour film globules of ba r ium were f r equen t ly g rouped near the ileoeecal junction, and the cecum often showed par t i a l filling'. A t five hours it was usually well filled, and at eight hours there were still a large n u m b e r of examina-

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B O U S L O G E T A L . : G A S T R O I N T E S T I N A L T R A C T S T U D I E S 241

t ions which showed the cecum to be well filled. A t twen ty - four hours

there were only two out of 281 examina t ions which showed the cecum filled and the rest of the colon empty.

b. Append ix : The a p p e n d i x was visual ized in only two ins tances

out of 281 examinat ions . Both visual iza t ions be longed to cases which fa i led to show the append ix on subsequent examinat ions .

e. Colon: Fo l lowing the b a r i u m meal the colon was empty in 9 out

of 281 examina t ions at e ight hours. A t twen ty - fou r hours the amoun t of f i l l ing is shown in Table IV.

Fig. 3.--Roentgenograms of colons after barium enema.

TABL~ IV

2kI~KOUNT OF FILLING OF THE COLON TWENTY-FouR HOURS AFTER BARIUPI MEAL

Colon--entire colon filled Sigmoid to hepatic flexure Sigmoid to splenic flexure Sigmoid colon alone Cecum slone filled Colon entirely empty

Total examinations

24 4

17 64 2

170

281

In those twen ty - fou r examina t ions in which the ent i re colon was filled and in the fou r cases in which i t was filled f rom the s igmoid to

242 T H E J O U R N A L Of~ PEDIATRICS

the hepa t ic f lexure fo l lowing the ba r ium meal, i t was noted tha t the haus t r a t ions were more m a r k e d than shown on the same cases follow-

ing a ba r ium enema. As there were so few colons f i l led fo l lowing the ba r ium meal, a de ta i l ed s tudy of the colon was made a f t e r the ba r ium

enema. The resul ts of the ba r ium enema fo r a rou t ine s tudy were d i sappoin t ing . I t was found tha t the in fan t r e t a ined the ba r ium bet- t e r i f no c leansing enema had been given p r io r to the giving of a

ba r ium enema. Even when this technic was fol lowed, the colon in a number of instances d id not r e t a in sufficient ba r ium for a long enough

in terva l to allow the making of a sa t i s fac tory x- ray exposure (Table V) .

TABLE V

AMOUNT OF FILLING OF THE COLON AS SHOWN ON THE ~OENTGENOGRAM AFTER B~IUM ENEMA

Not tilled 41 Filled to the sigmoid 16 :Filled to the splenic flexure 7 Filled to hepatic flexure 18 Filled to cecum 18

Total cases 100

d. Redundancy of the Sigmoid: All of the ba r ium enemas were

s tud ied fo r the degree of r e d u n d a n c y of the s igmoid (Fig . 3). Even in those cases in which the re was no fi l l ing of the colon, the amount of gas presen t and the few flakes of ba r ium remain ing usua l ly showed the loca t ion and course of the sigmoid.

TABLE VI :P~EDUNDANGY Ole THE SIG~V[OID

Barium enema films not readable Mild redundancy Moderate redundancy Marked redundancy Very marked redundancy

19 2

]3 62 4

Total cases 100

A p p a r e n t l y there was no cor re la t ion be tween the r e d u n d a n c y of the

s igmoid and the empty ing t ime of the colon. In the four cases which showed the most m a r k e d r e d u n d a n c y and the two cases which showed no redundancy , t h e empty ing t ime of the colon va r i ed g r e a t l y as shown by Table VII .

I n cases showing modera te and m a r k e d r edundancy , the corre la t ion seemed equa l ly impossible as the empty ing t ime of the colon va r ied in different individuals of the same age and on different examinat ions of the same ind iv idua l over a per iod of months.

e. Spasm of the Colon: Thi r ty -s ix cases which showed sufficient b a r i u m filling of the colon a f t e r the ba r ium enema were examined as

to the amount of spasm shown on the films (Fig. 3). The resul ts showed no spasm in 20 cases and spasm in 16 cases. T h e locat ion of the spasm var ied in the di f ferent cases. As only one ba r ium enema

BOUSLOG ET AL. : GASTROINTESTINAL TI%ACT STUDIES 243

TABLE VI I

CASE 1"70. TWENTY-FOUR-HOUR FILIVi FINDING

Cases Showing Very Ma~ked Eed/andaney 77 1st Examination Entire colon filled

2nd Examination Colon empty 3rd Examination Colon empty

82 1st Examination Colon empty 2nd Examination Sigmoid colon filled 3rd Examination Sigmoid colon filled

85 .lst Examination Sigmoid colon filled 2rid Examination Sigmoid colon filled 3rd Examination Colon empty

125 1st Examination Colon empty 2nd Examination Colon empty

Case~ Showing No Rec~undanc~j 57 1st Examination Sigmoid filled

2nd Examination Entire colon filled 127 1st Examination Colon empty

2nd Examinat ion Colon empty 3rd Examination Sigmoid filled

was given to each infant, the location of the spasm was not deter- mined on different examinations of the same infant. Well-filled colons af ter the bar ium meal rare ly showed spasm al though af ter the bar ium enema these infants sometimes showed spasm. Wi th the barium enema, six infants showed spasm in more than one port ion of the colon. There was no significant correlat ion between the degree of spasm shown in the colon fol lowing barium enema and the speed of emptying of the same colons following the bar ium meal.

f. Haustrations: Twenty-eight infants given barium enema could be examined for the presence of haustrations. No haustrat ions were found in 16 cases, and haustrat ions were found in 12 cases. The position a n d degree of haustrat ions appeared to v a r y greatly. They are not as marked as i n t h e adult type of colon.: In: the same ~cases the colon as seen on the eight-hour and twenty=four-hour film follow- ing bar ium meal usual ly showed more haustrat ions than on the barium enema film.

g. Flexures: There were thir ty-one infants in whom the flexures could be studied. Nine of these showed annular or very poorly marked flexures, and twenty- two showed angulated flexures (Fig. 3).

ABNORMAL CASt!IS

Premature In fan ts . - -There were five premature infants with bir th weights f rom 2.0 kg. to 2.2 kg., on whom fourteen examinations were made. There Was no marked decrease in the emptying t ime of the stomach. Of the four teen examinations made eight showed emptying at five hours, thus showing a larger pe rcen tage empty in five, hours than that shown by the group as a whole. No other differences were noted. However, this series is too small ! to :d raw a n y conclusions.

Eczema.- -There were nine cases of eczema. The examinations showed no significant changes as compared With the no rma l group.

244 TI=IE J O U R N A L OF PEDIATRICS

Syphilis.--The eleven infants f rom syphilit ic mothers also showed no marked changes in the gastrointest inal roentgenograms.

Minor Disturbances.--Sixteen infants comprising those showing minor clinical disturbances, such as slight constipation, upper resp i ra tory in- fections, mild diarrhea, and questionable hyper tonic i ty , were not found to differ f rom the r e s t of the series in the roentgenologic studies.

DISCUSSION

According to the literature, there is great variance in the observa- tions and conclusions in r ega rd to the gastrointest inal t r ac t of infants. We should like to compare some of our findings wi th those of earlier workers.

There has b e e n a great deal of difference of opinion as to stomach form. Alwens and Husler ~ described three types of stomach dependent on the taking of fluids in the vert ical position, the taking of fluids in the horizontal position, or the taking of gruels of thick consistency in the vert ical position. The basis of this classification is the air bubble.

Theile 6 describe two main types of stomach, the " b a g p i p e " form of Leven and Bar re t t and the " t o b a c c o p o u c h " fo rm of Pisek and Le Wald. However , he states there m ay be infinite variet ies of transi- t ional forms. Pisek and Le Wald s ta ted tha t there is no definite form of stomach in the infant .

F ina l ly l=togatz 7 using no contrast medium divided the infant stom- ach into two main types: (1) the shape of a pear or flask lying on its side with h large, c i rcular fundus and a smaller nar row pyloric

a r e a ; (2) smooth elliptical or oval in shape, occurr ing less f requent ly . He also describes a th i rd form, common to both when thick gruels are ingested, namely, a small circular or oval form about one-third the size Of the fluid forms with lit t le or no air bubble a t all.

F rom our observations we are forced to the conclusions, in agree- ment with Pisek and Le Wald, tha t there is no constant form of the infant stomach in the roen tgenogram and tha t there are wide varia- t ions in different individuals and even in the same individual at various times. In agreement with Pisek and Le Wald, Leven and Barre t t , Flesch and Peteri , s Trumpp, 9 and l~ogatz7 we found tha t the long axis of the stomach is almost always horizontal .

In agreement with Ladd and other workers we ra re ly found peri- stalsis in the stomach. Rogatz z~ described a definite "per i s to l ic func- t i o n , " tha t is the capaci ty of the stomach walt to sur round or grasp its contents fol lowing the ingestion of food. This is not to be confused wi th the more famil iar peris tal t ic function.

T h e emptying t ime of the in fan t ' s s tomach has been studied by various workers and the times given v a ry great ly. (See Table VIII . )

We have found in normal infants some bar ium may be visualized in t h e stomach even rafter 8 hours. Ladd states tha t if a feeding is given a f t e r the bar ium meal, there is a t endency to fas ter emptying. We

BOUSLOG ET AL. : GASTROINTESTINAL TRACT STUDIES 245

TA~L~ V I I I

EN~PTYING T I ~ Or STO~AC~

Tn~E WITH BREAST TIME WITI=I AETIFI- AUTHOR FEEDING CIAL FEEDING

Newborns Nurs l ings

Av.

2 -3 hr. 3 -4 hr. 3 hr. 5 hr. 2V.2 hr. 2 ~ - 8 hr. 3 hr. 4 hr. 2 -3 hr. 3 -4 hr. 11~-2 hr. 3 -5 hr. 11/2-4 hr. 21~-4 hr.

1 hr. 40 min.- over 3 hr. 40 min.

3 -4 hr. 31~-42~ hr.

3 ~ - 6 ~ hr.

Vogt l l Alwens~ Ladda Kerley12 Theile~ Kahnla BessauZ4 Shukryl~

Izumlta16

Demuth17

were not able to confirm this. In our r egu la r series t h e i n f a n t s were fed again the i r r egu la r fo rmula four hours a f t e r the ba r ium meal, and it will be noted (Table I I I ) t h a t as high as 43 pe r cent of these chil- dren showed some residue a f t e r eight hours. In the ten special cases in which no feeding or wa te r was given a f t e r the ba r i um meal unt i l the s tomach was empty, our longest empty ing t ime was between six and one-half and seven hours.

De Buys and Henr iques 18 s ta te tha t mot i l i ty of the s tomach is more rap id when the child is p laced in the r ight la tera l position, and com- pa ra t ive ly slow in the supine position. In our series the child was usual ly in the supine posit ion though no a t t empt was made to have the child in any fixed position.

In ag reement wi th other observers we found t h a t the meal finds its way into the small intest ines v e r y quickly a f t e r the beginning of feed- ing. Le Wald 19 s tates tha t the duodenum ra re ly shows the caplike appea rance in infants . We found tha t this was the case and also t ha t the py torus and duodenum were difficult to visualize. F r o m our ob- servat ions the in fan t j e junum does not present the adu l t f ea the ry ap- pearance. We have not found this previous ly ment ioned in the l i tera- ture, and we have no exp lana t ion for it. The empty ing t ime of the small intest ine in chi ldren has been s tudied by K a h n 2~ who gives the t i m e in s tomach as four to five hours, small intestines, as seven to eight hours, large intestines, as two to four teen hours. Wi th dye stuff the entire passage took f rom four to t w e n t y hours, on the aver- age about fifteen hours. De Backe r and van de Pu t t e 21 found tha t the small intes t inal t r ac t is not empt ied unt i l a f t e r eight hours ; a f t e r two and one-half hours the con t ras t meal may be in the cecum, in six to seven hours to the splenic flexure, and in eight hours in the s igmoid flexure, and the entire intest inal t r a c t is f ree in f rom eighteen to twen ty - four hours.

I n our series of 281 examinat ions the eight-hour fihn showed nine instances and the twen ty - four -hour film, 170 instances iri which the entire t r ac t was e m p t y (Table IV) . Al though there has been a ve ry

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BOUSLOG E,T AL. : GASTI~OINTESTINAL TRACT STUDIES 247

adequate anatomic s t udy of the in fan t colon by Scammon, 22 roen tgen studies of the normal colon seem to have been neglected. In a gen- eral w a y our observa t ions bear out the anatomical f indings of Scam- mon: i.e., haus t ra t ions were poor ly m a r k e d ; the s igmoid colon ap- pea red re la t ive ly long and r e d u n d a n t ; and the flexures were not as welt m a r k e d as in the adult .

R~SUMI~ OF F I N D I N G S I N AVERAGE CASE

The progress of the meal m a y be briefly summar ized as follows (compare Fig. 4) :

Immediate film The s tomach began to empty. Small globules of ba r i um were seen

in the lower p a r t of the small intestine. The pylorus, duodenum, and j e junum were r a r e l y seen. No meal was visualized nea r the ileoceeal junct ion.

One-and-one-half-hour film The s tomach still showed a considerable quan t i ty of meal. I t was

e m p t y in five out of 281 examinat ions. F r e q u e n t l y it had changed its shape f rom tha t shown on the immediate film. The pylorus, duo- denum, and j e j unum were more often seen on this examinat ion than on the immedia te film. Globules in the i leum had increased in n u m b e r and were well d isseminated or shown as groupings in var ious pat terns . The mea l had not ye t reached the ileoeecal junction.

Three-hour film The s tomach was empty in th i r ty- two, 11 per cent, out of 281 ex-

aminat ions. The pylorus , duodenum, and j e j unum were not. seen as often as on the one-and-one-half-hour film. When there was a gast r ic residue, i t var ied cons iderably as to the amount of meal in different cases and different examina t ions in the same case. The shape h a d . f r equen t ly changed f rom tha t shown on the previous films. Globules of ba r ium were f r equen t ly g rouped near the i leocecal junction, and the cecum often showed par t ia l filling.

Five-hour film The s tomach was e m p t y in eighty-eight , 30 per cent, out of 281 ex-

aminations. The pylorus, duodenum, and j e junum were uncommonly seen. Sca t te red masses were of ten seen th roughou t t he , sma l l intes- tine, and the colon was usually well filled from the cecum to the mid- dle of the transverse colon, and sometimes to the splenic flexure (twenty-four examinations).

E~ght-hour film The s tomach was emp ty in 168, 47 per cent, examinat ions out of 281.

I n the 123, 43 per cent, examinat ions which showed gast r ic residue, it usual ly appea red as a ve ry small amount . The gas bubble was of ten quite la rge whe ther or not the s tomach was empty. The small intest ine f r equen t ly showed small sca t te red masses of bar ium. The colon was well filled in ten cases, in the o ther cases there, were isolated masses

248 THE JOURNAL OF PEDIATRICS

of bar ium. The colon and ent i re gas t ro in tes t ina l t r a c t were emp ty in n ine examinat ions out of 281.

Twenty-four-hour film The s tomach was e m p t y in all examinat ions. Small intes t ine ra re ly

showed a few isolated globules of bar ium. The colon was ent i rely e m p t y in I70 out of 281 examinat ions (Table IV) .

SUIVIMARY

1. ~ Two hundred and eighty-one roentgenologic gas t ro in tes t ina l ex- amina t ions were made on 133 infants (s ixty- three boys and seventy girls) , aged f rom one week to six months.

2. Ba r ium enemas were given to 100 of these infants. 3. The s tudy of the films shows tha t m a r k e d var ia t ions m a y be

found between individuals or in any one individual at different times. 4. These are i l lus t ra ted by such findings as: (1) the var ia t ion in

the empty ing t ime of the s tomach which is f rom one and one-half to more than eight hours ; (2) the lack of any constant shape of the s tomach ; (3) the changing pa t t e rn p resen ted by the globules of bar ium in the j e junum and i leum; or (4) the va r ia t ion in the amount of re- dundancy of the sigmoid.

5. Th i r ty - four roen tgenograms selected f rom the 1,686 films of these 133 infants have been reproduced to i l lus t ra te the individual varia- t ions noted.

REFERENCES

1. Levea and Barrett : Quoted from Carman.2 2. Carman, ]%. D., and Miller, Albert: The Roentgen Diagnosis of Diseases o~

the Alimentary Canal, Philadelphia, 1921, W. B. Saunders Company, pp. 371-376.

3. Ladd, M.: Arch. Pediat. 30: 740, 1913. 4. Pisek, G. R., and Le Wald, L. T.: Am. J. Dis. Child. 6: 232, 1913. 5. Alwens, W., and Husler, J.: Fortschr. a. d. Gob. d. RSntgenstrahlen 19: 183,

1912. 6. Theile, P.: Ztschr. f. Kinderh. 15: 152, ]916. 7. Rogatz, J . L . : Am. ft. Dis. Child. 28: 53, 1924. 8. Fleseh, I-I., and Peteri, I . : Ztschr. f. Kinderh. 2: 263, 1911. 9. Trumpp, ft.: Verhandl. d. Versamml. d. Gesellsch. f. Kinderh . . . . deutsch.

Naturf . u. Aerzte. 24: 490, 1907. 10. Rog~tz, J . L . : Am. 5. Dis. Child. 28: 69, 1924. 11. Vogt: Fortschr. a. d. Geb. d. l~Sntgenstrahlen 28: 287, 1921. 12. Kerley, C.G.: New York State J. Med. 20: 45, 1920. 13. Kahn, W.: Ztschr. f. ]Kinderh. 29: 321, 1921. 14. Bessau, G.; Rosenbaum, S.; und Leichtentritt , B.: Jahrb. f. Kinderh: 45:

123, 1921. 15. Shukry, t{assan: J. Egyptian M. A. 14: 361, 1931. (Orig. not available--per-

sonal communication.) 16. Izumita~ Tomotake: Jahrb. f. Kinderh. 128: 108, 1930. 17. Demuth, ~.: Ergebn. d. inn. NIed. u. Kinderh. 29: 90, 1926. 18. De Buys, L. R., and tienriques, A.: Am. J. Dis. Child. 15: 190, 1918. 19. Le Wald, L. T.: Radiology 21: 221, 1933. 20. :Kahn, W.: ~tschr. f. ]~inderh. 33:487 1922. 21. De Backer and van de Put te : u geneesk, tljdsehr. 5: 825, 1924.

(Quoted from Demuth, F.:17 Ergeb. d. inn. ]~ed. u. Kinderh. 29: 90, 1926.) 22. Scammon, R . E . : A Summary of the Anatomy of the In fan t and Child, Ab t ' s

Pediatrics 1: 257-444, 1923.

4200 EAST NINTH AVENUE