If the course of the pus be downwards to the pelvis, so as to show no signs of pointing externally, these symptoms, coupled with the resemblance of the local condition to hip disease, may suggest a secondary tuberculosis. But a careful examination of the belly will usually detect considerable fulness and tension in the situation of the ccum. If the pus discharge itself into the rectum or bowel, great relief is experienced, and the local swelling and tenderness undergo considerable diminution. Often, the course of the pus is towards the surface in the neighbourhood of the abscess. The skin then becomes darkish red or purple, and swollen. It gives a doughy sensation to the touch, and, on pressure, we may notice a slight emphysematous crepitation. An incision into the softened skin allows the escape of brownish, offensive pus and bad-smelling gas.
These cases generally end fatally. If peritonitis occur, either from direct rupture or extension of the inflammation, death usually ensues in a day or two. If a fcal. fistula remain open, life may be preserved for a considerable time—often for years. In most cases, unless the abscess have pointed early, the child is so much reduced by pain and hectic fever that he does not long survive the opening of the abscess.
A little girl, aged thirteen years, had an attack of typhoid fever when eight years old. After that time she was subject to occasional attacks of " colic " and vomiting. Early in December she was ill with what was called "inflammation of the bowels with colic," but recovered for the time. In the middle of February her bowels became very much confined, and after four days' constipation, she had fsecal vomiting. An injection was given, and a large amount of fcal matter was brought away.
When admitted into the hospital on February 21st, the child looked ill, and was very pale. The belly was distended and tympanitic, with some. uniform tension of the parietes, but no tenderness or fluctuation. She complained of slight colicky pain at times. Her tongue was covered with brownish fur, and was inclined to be dry. There was no sickness. The bowels had been confined since the injection two days before. The tem perature at 6 P.M. was 93.4°.
The bowels were unloaded by repeated doses of an aperient saline. Afterwards, small quantities of laudanum were given to relieve the colicky pains which still returned at intervals ; and the child was kept quiet in bed, with hot applications to her belly. After this, the bowels continued to act twice a day, and the stools were normal.
On March 3d it was noted : " Face pale ; expression distressed ; abdo men not full or tender. The temperature since admission has varied, some
times reaching 101°." A week afterwards the child complained of more pain in the belly, but this part was not swollen or tender. The bowels were a little relaxed. The child began now to lose flesh fast. She continued pale and very haggard-looking ; but although she complained of occasional pains in the belly, there was no tenderness or swelling, and she never vomited. The diarrhoea, however, continued. On March 14th, she began to localise the abdominal pain in the right side just over the situation of the quad ratus lumborum. The abdomen was natural in appearance, and not tender. The bowels were still loose, and the stools liquid and homogeneous, without blood or shreddy matter.
After a few days, a fluctuating tender swelling appeared just below the ribs on the right side, and in front of the mass of the quadrates lumborum. This grew larger, and there was much subcutaneous oedema around the swell ing. The child looked ill, and wasted rapidly. Her temperature was be tween 100° and 101°. The swelling was opened by the aspirator, and an ounce of brownish, fetid pus was removed. The child, however, sank and died two days afterwards.
On examination of the body, a large abscess was found at the back of the cmcum, containing much purulent brown matter. The ilium just above the ilio-cgecal valve was distended, and an ulcerous opening was found in the wall just above its junction with the cgecum. A probe could be passed through this opening into the abscess. There was, besides, some slight but general peritonitis. The liver was fatty, and both it and the spleen were adherent to the diaphragm. Many of the mesenteric glands were enlarged. This case of perityphlitis, although really the consequence of ulceration of the small bowel, and not of the crecum, illustrates very well the ordinary history and symptoms of the disease. The early attacks of colic, accom panied by vomiting, were no doubt owing to the occasional occurrence of inflammation in this part of the intestinal tube ; but the ulcerative process probably dated only from the illness from which the child had suffered in the previous December. This was probably a more severe attack of local ised enteritis. The treatment pursued in this case is not to be recom mended for imitation. Repeated aperients under such circumstances as must have existed when the child came under observation, could only be injurious. It would have been more judicious to have left the bowels alone, or to have administered a simple enema.