In the fatal cases, death results more often from collapse than from peri tonitis. The child becomes weaker and weaker, and dies from asthenia. Sometimes death is preceded by a convulsive seizure.
The above is the course of the disease in infants and older children. Of the symptoms, the sudden occurrence of severe abdominal pain, the' vomiting, the constipation, the discharge of blood from the bowel, and the discovery of a swelling by palpation of the belly or exploration per anum, are the most characteristic.
The pain is of an excruciating character, as is shown by the child's agonising cries, his restless, jerking movements, and the death-like pallor which spreads over his face. In a case recorded by Dr. Wilks, the infant actually fainted from the intensity of his suffering. The pain comes on in paroxysms, but these do not occur at regular intervals. Often, after the first access, the colic suddenly ceases, and the child appears to be easy. He may remain free from pain, showing no sign of illness, for some hours; but sooner or later the paroxysms return. This is most often the case with infants.
Vomiting is always present, and may vary from mere regurgitation to violent retching. It is often accompanied by hiccough. The vomited mat ters consist of food and medicine, or, if nothing has been taken, of mucus and bile. Occasionally, blood is thrown up from the stomach. Mr. Macleod has recorded the case of a male infant, aged six months, in whom this symp tom was noted before death. The intussusception had occurred in the usual situation for this age.
Constipation is not a constant symptom. If the bowel below the point of obstruction contains faecal matter, this is invariably expelled early. There is then no alvine discharge for the remainder of the illness. In less common cases a certain amount of diarrhoea may be present, if the strangu lation of the bowel is not complete ; for the swelling of the invaginated segment becomes reduced after a few days, and the calibre of the canal may be partially restored.
A discharge of blood and mucus is one of the most constant symp toms. The amount varies. In some cases, it may be scanty, nothing more than a stain of blood being seen upon the diaper when the napkin is changed. In other cases, the quantity may reach several ounces. It appears early.
It may be seen at the time of the first effort of vomiting, and is seldom de layed longer than twelve hours. In infants, this symptom is almost invari ably present, and may be taken to indicate a degree of constriction of the bowel stopping short of actual strangulation and complete arrest of circu lation. In older children, as has been said, it may be wanting.
A distinct swelling in the course of the bowel, when discovered, is a valuable diagnostic sign ; but often it is not present. The tumour gener ally lies in the left iliac region, and gives a firm, doughy sensation to the finger. It is movable, and varies from a walnut to a hen's egg in size, or may even be larger. When detectable by palpation of the belly, the tu mour can often be reached by the finger introduced into the rectum ; espe cially if at the same time pressure is made upon the invaginated mass by the other hand placed upon the abdomen. A rounded lump, feeling very much like the cervix uteri in a vaginal examination, may then be felt by the point of the finger. Sometimes the mass can be seen to protrude beyond the anus, but this is exceptional. Out of forty-nine cases collected by Dr. Lewis Smith, the protrusion occurred only in six.
Tenesmus is usually present, and is often distressing. It may cease as the child's strength becomes reduced.
' The amount of fever varies. At first, the temperature is normal, but as inflammation occurs in the intussusception, the bodily heat increases, al though it is rarely excessive. The symptom is said to be less marked in infants than in older children. The pulse, after the first few days, is very rapid, and as the strength declines, becomes excessively frequent and fee ble.
The duration of the illness varies, as has been said, according to the completeness of the strangulation of the bowel, and also according to the aga and strength of the child. In infants, it rarely lasts longer than a week, and death often takes place as early as the fourth or fifth day. In older children, the course of the disease may be equally rapid ; but often it is more protracted, and cases have been recorded in which the lesion has become chronic, lasting several mouths. Separation and elimination of the gangrenous portion is never seen in infancy, and is rare even in more advanced childhood.