Not infrequently the invagination comes still lower, so that it filially- extends from the anal orifice as a dark red, slightly bloody mass, over an inch in length, on the surface of which are ulcers covered with a greenish gray deposit. In appearance the mass resembles a prolapse of the rectum. It is, however, distinguished from the latter by absence of the reduplications, and by the severe symptoms of intestinal occlu sion which mark its onset. Other signs of intestinal invagination, as a rule, precede the descent of the intussuseeption by several days (more seldom three to four generally live to six).
The phenomena of chronic i nvagination are numb less striking. Often they are not recognized, and then only in the later stages when the symptoms of ineareeration have already set in. There arc indeed attacks of pain in the abdomen, still these are not severe and are usually separated by long intervals; vomiting is rather an inconstant symptom; the stools are at times constipated, at times loose; in the latter in stances they are mingled with 1111.1C116 Or accompanied by tenesmus, so that one thinks of catarrh of the large intestine. Constitutional symptoms are few: the abdomen is soft, not sensitive; a tumor is not often felt. If one is palpated the resistance is very,' little increased. Its situation cha.mges during the examination and it disappears when the intestine lies deeply in the abdonutn. It is, of course, (mite differ ent when a tumor is palpable per rectum, or prolapses at the anus, the recognition of which removes all doubt. The prolapsed chronic invag illation produces mueh less congestion than the acute, and, what is particularly important, is easily replaced. The first symptoms of oncoming incarceration increase the congestion, and produce a secretion of mueopurulent masses and hinder its reduction.
The course of an acute intussuseeption can be intense through out; a fatal result may result in a half a day after the beginning of the symptoms. Generally, however, it takes almost a week before the symptoms have reached this height, from severe intoxication by poisons absorbed from the intestinal traet, or as the result of complications, or from peritonitis. In older children the disease may be prolonged into the second week. Spontaneous invagination, before the occurrence of the more severe symptoms of inearceratiou, or the formation of firm adhesions between the single layers of the intestine, can occur iAttlas), but is a very- exceptional termination. Stenosis of the intestine, after
spontaneous sloughing of the gangrenous intussuscepted portion is also described (Orange and Hau). In any case, the relatively- favorable terminations referred to, which rnay, however, be altered through peritonitis, pneumonia. septic infection and similar causes, corning on later, are not to be counted on. Acute intussuseeption, left to itself, can be regarded with certainty as having a fatal result.
The prognosis in chronic invagination is somewhat more favorable. This form may last for months or years, but here, too, a spontaneous cure can not be expected; and, during every portion of its varying course, there exists the danger of incarceration and the imminent risk to life produced by it. The importance of the recognition of this form is evident when the relatively favorable outlook, following timely operation, is considered.
From the reasons above mentioned the necessity of an early diagnosis is urgent. This diagnosis is made with great probability when a child, previously well or suffering from mild digestive disturbances, is suddenly taken ill with violent paroxysmal pain in the abdomen, passes no stool, vomits frequently, and discharges blood or bloody mucus masses by the anus. A tumor of characteristic form and posi tion, palpable in the abdomen, renders this assumption still more plausible. A tumor palpable by rectum, or visible at the anus, makes the diagnosis certain.
The differentiation from intestinal occlusion brought about by other factors, such as volvulus of the intestine, constriction of the bowel by adhesions forrned in peritonitis, persistent duetus omphalo mesentericus and such causes are not always possible. The factors in differential diagnosis given by- individual authors (for example by Jalaguier), such as the absence of a tumor and bloody evacuations, as well as the absolute occlusion by interference with the feces, arising through some other cause than intestinal intussusception, do not always hold as I have previously pointed out, since they all can occur in invagination, for example, in intussusception of the small intestine. Moreover, the confusion of these forms of occlusion is not of so much importance, since in every case early operation is advised.