There are, however, cases of congenital stenosis of a less complete type which produce no cffsturbances which can be recognized clini cally, during the first months of life, and first, later, under the influence of a change in nourishment, or other factors, show the symptom-com plex of occlusion. Thus Lee:3 and Thursfield had a child of eighteen months under observation, which was previously in a perfectly normal condition, but which then had attacks of pain and diarrhcea, with bloody stools and vomiting, followed by eomplete obstruction with meteorisna and violent vomiting. It was discovered, on section, that the cause was an apparently congenital tuberculosis with numerous points of stenosis of the intestine and adhesions between the abdominal organs. Hey and Grewes saw a stricture, three inches long, of the small intestine, which hardly permitted the passage of a probe, in a boy of twenty months. Similar cases have been several times reported but they can not be said to have a symptomatology, and a diagnosis can hardly be made during life.
The acquired intestinal occlusion, apart from intestinal intussus ception, whieh, because of their characteristic symptoins, will be sepa rately described, are produced by volvuli of the intestines, by the con striction of single intestinal loops by means of Meckel's diverticulum, by the incarceration of the intestine in congenital open spaces in the mesentery, or in retroperitoneal recesses, by strangulated hernias, not visible from without (specially erural hernias), and like eonditions. (Such cases have been reported by Frolic+, Schochner, Snow, Bell, Burgess, Jancro and others.) is a rule, the development of symptoms of intestinal occlusion begins suddenly, more seldom after prodrornal manifestations, in the form of diarrhcea with bloody discharges, colicky pains, or after me chanical injury of the abdomen, through convulsions, a blow, or the like. It inay not be possible, on examination, to determine the nature of the preceding disturbance. A long mesentery provides the anatomi cal predisposition to volvulus, which occurs, however, comparatively seldom in childhood. Rarely a tumor is the cause (as in the case of a cyst of the mesentery, reported by Blum); the other factors are clear in their anatomical bearing, from what has already been said, without further explanation.
The prognosis of such cases is, in general, considerably more favorable than in the congenital stenosis, as an operation undertaken promptly has resulted in cure in the majority of instances. The simpler are the conditions present, just so much more favorable are the chances; on this account, they are particularly good in cases of constriction by Meekel's diyerticulum, the severing of which quickly and permanently removes the obstruction; while, strangulation in a peritoneal recess, or volyullts:, because of the great injury of the intestine already taken place, makes the operation more diffieult and renders the outlook less favorable.
(c) INTESTINAL INTUSSUSCEPTION—INVAGINATION As a rule, this is brought about through the invagination of a part of the intestine into another part situated below it (so-called descend ing type), more seldom the invagination takes place in the opposite direction (ascending type).
A turnor produced in this manner consists of a central canal and three lateral cylinders, lying parallel around the canal (Jalaguier); the outermost cylinder, the intussuscipiens, possesses an external serous and an internal mucous surface, which latter is turned towards the mucous membrane of the middle cylinder. The middle cylinder repre sents a fold of the intestine, and is continuous at the border of this fold with the inner cylinder. The point where the outer cylinder turns into the middle cylinder is called the neck of the inyagination; and where the middle turr.s into the inner cylinder is called the head of the inyagination. The mesentery is soon drawn into the tumor, and, situ ated between the middle and the inner cylinders, exerts traction upon the intussusception, which is thus both limited in the direction of its long axi.s, and is curved with its convexity towards the attachment of the mesentery, so that the lumen, in this manner, is flattened and shoved to one side.
In addition to this simple (three-fold) invagination there is a double one, which arises through the folding-in of the first intussuseep tion in the neighboring part of the intestinal canal so that the tumor then posseses five thicknesses of intestinal wall; a triple invagination would possess seven layers, but t.hese last are rather rare.
The mechanism of the invagination is as follows: an intestinal fold, either through its OIVII weight, or beeause of its contents, or from the pressure or the pull of a foreign bocly lying in it, sinks itself in the neighboring portion. Anomalies of peristalsis may also play a part. These are the only factors in the ascending form, and, through con traction and stiffening of a portion of the intestine, enable this seg ment, following the course of the peristaltic waves, to bury itself in a neighboring portion at rest, or relaxecl. Of course, these factors often work together, and, in a particular case, it is not always easy to deter mine the ultimate causes of the presence, of the intussusception.