In acute inflammation of the vermiforin appendix, bloody stools are not seen, and the tumor does not appear to be so deeply situated as in intussusception, but more in contact with the skin lying above it. From this point it may extend into the depth of the pelvis and is, as a rule, recognized by manual examination from the abdominal wall and from the rectum as a diffuse, tumor mass, not cylindrical in outline. However, as many mistakes are unavoidable, one must bear appendi citis in mind because of its much greater frequency Much more serious consequences can result if the condition is con fused with dysentery, and purgatives are given in order to empty the colon and to lessen the tenesnms. It is self-evident that this procedure leads to an increase of the symptoms of incarceration, and adds materi ally to the danger. I believe that in the examination of the bloody mucus, passed by rectum, which often contains entire bands of un changed sloughed, intestinal epithelium, we possess a pretty good means of excluding dysentery, in which the stools are full of lcucocyte.s and bacteria, and poor in epithelial cells. Moreover, the course of the two processes is rather different; particularly the initial fever, which is scarcely ever lacking in dysentery, is not present in intussusception. The severe general symptoms come on much sooner in dy-sentery and stand in no relation to the intestinal symptoms; the pain is not so localized, a tumor is never felt.
Confusion of invagination extending into the rectum, with a tumor or a polypus, is easy to avoid since the consistency, absence of a peduncle, the demonstration of a peripheral lumen, and the secretion of bloody mucus indicate that one has to do with prolapsed intestine. Likewise, a rectal prolapse is readily recogmized as such, since it can be replaced, and extends either directly into the anal mucosa, or, if not, the transitional fold is felt a short distance above the aual orifice.
It is much niore difficult, as I have already intimated, to make the diagnosis of chronic intussusception, and it is frequent to mistake this form for chronic enteritis, appendicitis, and the like. In every case a careful examination, which is directed particularly to the finding of a characteristic movable tumor, one which contracts and gurgles on palpation, and the rectal indications, also, should never be omitted. Broca, Moizard, and Gaudeau have pointed out a very important symptom in my estimation, the gaping of the anus, one already empha sized by earlier writers. This is never found in inflammation of the sigmoid flexure, nor in chronic intestinal catarrh, nor in the course of a low grade of peritonitis. This symptom led these authors to the proper recognition of two cases, and to their cure by operation.
Increase in pain, more violent recurrences of the attacks of colic, profuse evacuation of blood and mucus, violent vomiting and severe general symptoms point to incarceration. Increase in meteorism, as
well as a rise of temperature, are signs of beginning peritonitis, further indications of which soon set in.
The prognosis of acute invagination is practically,- hopeless, unless therapeutic measures are undertaken promptly, for the possibility of a spontaneous freeing of the bowel, or recovery by gangrenous demar cation, as already described, are hardly to be considered. The most favorable therapeutic results are obtained according to Frisch ill ilcocolic invagination, the mortality of which only reaches 32 per cent., while it increases to 39.5 per cent. in the ileocecal type, and to 50 per cent. in cases involving only the small intestine. Chronic invaginations, in the cases collected by him, had a mortality of but 19 per cent. Heaton, in 104 cases collected, which were operated upon early, found that 66 ended fatally. Particularly unfavorable Were the results in young infants, especially in those in whom reduction was not possible after the laparotorny rendering resection neeessary. (Only 2 cases recovered out of 24 instances of this character).
Treatment has only one object, to reduce the intussuseeption by medical or by operative methods. In recent years under the influ ence of increased confidence in aseptic techinque, the tendency has been not to tarry with manipulations of a bloodless nature such as irrigation.s of water and of air and oxygen insufflations, but immediately to open the abdomen. I hold that this procedure has gone too ftir, judging from my own experience and that of many others ;Clubbe, Wilkinson, }fond, Eve, etc.), and would recommend in fresh cases, which have lasted only a few hours from the beginning of symptoms to the time of observation, the careful use of an enema [a litre (one quart) of lukewarm water allowed to flow in from a height of metre (2 feet) while the pelvis is elevated]. Such a child must remain under observation after the reduction has been brought about, since the intussusception may form very shortly again. In addition, intestinal rest, secured by opium and continued as long as possible by means of liquid nourishment, is strongly indicated. The ballooning of the intestine, with air or oxygen, I consider as less worthy of recommendation; occasionally, repeated rupture of the intestine has occurred during this procedure ;Godlee).
Consequently, I agree with most authors, that one should not pershst in these manipulations referred to, and, w-hen the first attempt is not successful, should resort at once to operation, for which prepa ration should be made in advance, and, on this account, the transfer of such patients to a hospital is recommended. The release of the invagination, during narcosis, is an exceptional but a gratifying oc currence, which have once experienced (with permanent result), and which has also been reported by others.