Vomiting is also frequent, but as Heubner has lately again pointed out, it is by no means a constant symptom. It begins relatively early. The vomitus at first consists of food, later it may become mueoid and bilious, and finally, because of the unusual strain upon the stomach mucosa, the vomitus may be mixed with blood. It has rarely a fecal character; often it continues from the beginning to the end of the ill ness, again, it may usher in the attack and afterwards cease, or it may occur only now and then during its course. There are cases described, however, in which vomiting, at first, unimportant, later could not be checked. It is the intussuseeption of the small intestine which is accompanied by- marked stomach symptoms.
One of the most important signs is the appearance of blood-stained mucus, or stools consisting of pure blood. The blood springs from the invaginated portion of the intestine, and can be evaeuated in such quan tities as to be fatal. As a rule, however, this is not the ease, and this symptom is limited to the passage of from one or more bloody, mueous stools, which finally, especially in the low situation or in the descent of the invagination, can be accompanied by tenesmus, so that the con dition is similar to dysentery. This mellena is so frequent in intestinal invaginations during childhood (indeed Jalaguier says it never fails), that when it is present it possesses a pathognomonic importanee; the failure of it, however, does not exclude the invagination. My experience agrees with that of Vernon and Audeoutl, who saw a number of these cases without this symptom. Often the bloody stools appear for the first time so late in the illness that they arc of no diagnostic value.
In addition to these blood-stained, mucus masses, a certain amount of fecal material is also evacuated, and, from time to time, gas is passed. Afore seldom there is remarkable absolute obstruction of the intestine, such as is seen in the other forms of intestinal occlusion. This is present, particularly in the invagination of the small intestine. Where the process goes on to gangrenotis decomposition of the intussuscepted bowel, and extrusion of the same per anum, normal passages may be re.surned after the expul.sion of the dark, foul-smelling shreds of tissue which often still retain the form of the bowel.
Invagination exerts its illfilleller also upon micturition, as does every localized painful change in the region of the intestine. This may be expressed by- tlysttria and pronounced diminution in the amount of urine. This occurs. in all types and therefore possesses no significance of local diagnostic value.
The general condition of the child is soon altered, in a manner very characteristic to one of even moderate experience; there is a peculiar iHostration which is out of proportion to the severity of the symptoms at onset; the features become sharp, the expression of the face anxious, and soon the true facies abdominalis is noticed, which arouses the attention of the physician. In addition, cyanosis and dyspncea are often present; the pulse becomes small and frequent and the temperature subnormal. Tonic contractures of the extremi ties occur and in infants, convulsive seizures may complicate the picture, until, filially-, collapse or pneumonia ends the scene, or it may lye peritonitis, with au increase in temperature, carries the child away.
The examination of the abdomen should be made during an interval free from pain, for in an attack such an examination is not possible lAecause of the strong tension of the abdominal muscles and the great sensitiveness. A particular point of pain can be ascertained localized in a definite situation, and an oblong, sausage-formed, slight curved mass lying under the abdominal walls ean often he felt in this region. The form of this mass is sometimes altered during manipulation, and on firm palpation it may produce a gurgling sound. When permanent contraction of the abdominal wall and great sensitiveness make an exact examination impossible, narcosis can be employed, by the help of which the diagnosis of the tumor can usually be successfully made. At the same time however, there are a number of cases in which such a mass vannot be felt, after combinN1 examination from without and per rectum, or after amesthesia, and only the whole picture of the illness, and the manner of its development could suggest the diagnosis of an invagination.
The facts become much more simple and certain when the intus suseeption is situated low down, so that the palpating finger can reach it from the rectum. It feels like a polypus, or the soft vaginal portion of the uterus, but neither a peduncle nor the transitional folds can lie made out as in prolapsus. In an invagination, situated sufficiently low, the finger collies upon the slit-like lumen, plaeed, for the most part, at the side, or feels two openings (in the ease of ileocceal invagination with inversion of the appendix). On removing the finger, one finds it covered with bloody mucus, which trickles out of the relaxed anus, and whieh under the microscope is seen to contain red eorpuseles, leueocytes, and numerous intestinal epithelial cells.