These attacks are often spoken of as "colic" or "inflammation of the bowels ;" and after recovery, a tendency appears to be left to a recurrence of the illness, for it is not uncommon to hear that this is not the first time that the child has suffered from similar symptoms. As a rule, if the lesion re main simple, and be not complicated with ulceration of the wall of the bow el, its course is rapid ; and in a few days, under suitable treatment, the pain and tenderness are no longer complained of, and the child is convalescent. In exceptional cases, the disease lasts into the second week, and the tender ness and swelling only slowly subside.
Peril yphlitis may be preceded by the symptoms described above as being characteristic of inflammation of the cmcum ; but more often—probably on account of the more limited area occupied by the morbid process—the stage of ulcerative destruction passes almost unperceived.
In the first case, the vomiting and constipation cease, and the more acute pain gives place to a dull aching, or even altogether subsides. Still, there is tenderness, and the swelling does not entirely disappear. The child does not seem well. His face retains an expression of distress, and he is dull and listless and unwilling to play about.
If the perforation occur without having been preceded by the symptoms of typhlitis, there is often nothing but a sense of dull aching or discomfort in the right iliac region, with occasional passing attacks of more acute pain. On these occasions, there is vomiting of short duration, and the child looks ill, and is feverish. This passes off in the course of a few hours, and the child remains as before—not quite well, but suffering from ill-defined symp toms to which little importance is attached. He is peevish and fretful, capricious in his appetite, subject to attacks of diarrhcca alternating with constipation, and often thirsty at night, with some increase in his tempera ture.
When perforation occurs, if extravasation take place into the perito neum, all the signs and symptoms of a localised peritonitis are at once observed. There is pain, swelling, and tenderness in the right side of the belly, with vomiting, constipation, high fever, a furred tongue, and a pinched, haggard face. The child lies on his back with his thighs flexed, and dreads the least touch. The inflammation may become general, and the child quickly die with all the symptoms elsewhere described (see Acute Peritonitis). If it remain limited, he may perhaps recover after a longer or shorter illness.
When the perforation takes place posteriorly, so that the extrava sated matters pass backwards into the loose connective tissue behind the cmcum, the symptoms are less severe. In such cases, the child at first may continue to be about. He generally looks ill, has a more or less febrile temperature, a capricious appetite, and is listless and languid. He may suffer from pain in the iliac region—not very severe, but constant and wearing ; or may be attacked by occasional pains of a colicky character, which are often excited by movement. At night, the child is restless, constantly altering his position, and sometimes crying out. At this period, the bowels are usually confined. On examination in the early stage, before any pointing of the abscess has occurred, there will often be noticed a ful ness in the right iliac fosse, and this part is tender when pressed upon.
In most cases, the child, if he continue able to leave his bed, is noticed to walk with a limp. Soon, however, he ceases to be able to walk at all, and lies in bed on his back with his right thigh partially flexed: If he be assisted to stand, he is seen to rest his whole weight on the left limb, and to keep his right limb partially bent both at the hip and knee, and rotated outwards: 'With these symptoms, especially if there be any history of a blow or fall, disease of the hip joint may be suspected. This opinion is often strengthened by the child's complaining of pain in the knee as well as in the groin, and by the suffering caused by any attempt at extension of the hip. If the tenderness is great, any rough manipulation of the limb, as in rotating the head of the thigh-bone, or communicating any concussion to the hip .by striking the knee, may be a cause of pain in. the groin.
As the disease progresses and suppuration occurs, the pallor and dis tressed expression of the patient are very noticeable. His pyrexia becomes more marked, and the evening rise is followed by depression, with sweating in the morning. He loses flesh fast, and his tongue becomes dry and brown. The constipation now usually gives place to diarrhoea, which may be copious ; and the pulse is very rapid and feeble. Great pain is com plained of in the belly which may be distended, or even tympanitic; and the swelling in the right iliac fosse increases in size, but becomes softer. Sometimes severe pains are complained of in the right knee and ankle, and cedema of the limb may occur from interference with the venous circulation.