The simple form of ulcer may cicatrise and leave little trace ; but this termination is less common in the more severe form which is dole to a tubercular or scrofulous cachexia. Still, even in these cases cicatrisatiou may take place here and there, and on account of the transverse extension of the breach of surface, may lead to serious contraction of the channel of the gut.
Symploms.—Ulceration of the bowels may be attended by few symp toms, and if, as sometimes happens, diarrhoea is absent, the nature of the illness may be completely overlooked. As a rule, the special symptoms of the intestinal lesion have been preceded by a prolonged attack of purging, which has caused serious interference with nutrition, and greatly reduced the general strength. Abdominal pain is not present, but often attacks of pain of a colicky character are complained of, and these are usually found to precede the passage of a stool. There may be no ob vious tenderness on pressure of the abdominal wall, but, in many instances, deep pressure in the course of the colon seems to ive rise to uneasiness. Still, even in cases where tenderness appears to completely absent, some tension of the abdominal parietes will be noticed. Indeed, this symptom is nearly always present, and careful palpation of the abdomen will rarely fail to detect it. The tension is not necessarily general. Often it is limited to the side upon which the ulceration exists, as if the muscular parietes contracted instinctively to protect the sensitive part from injury. The belly. is usually more or less distended from flatulent accumulation, but this symptom varies in degree. Still, although fuller than natural, it appears normal to the eye ; and there is no loss of the natural markings such as is seen in cases of peritonitis. If the mesenteric glands are en larged 'they may be often felt on deep pressure, and the superficial veins of the abdomen are then unnaturally visible.
The appearance of the stools is very characteristic. The bowels may not be relieved many times in the day. Sometimes they are even costive. In the latter case the stools vary in character. They may consist for the most part of light-coloured lumps, often covered with mucus, and some times showing a streak of blood. But every now and again a loose motion will be passed which at once discloses the nature of the case. The mo tions which are characteristic of the lesion are of two kinds. The first consists of a dark reddish-brown water, intensely offensive and putrid Smelling. It deposits a sediment of shreddy, flaky matter, often contain ing little black spots which are minute clots of blood, and sometimes small, pale, bard faecal lumps. The second is a pale yellow homogeneous fluid of the consistence of cream or thin paste. It often has a curious mucila
ginous appearance as the vessel containing it is tilted from side to side. This form of stool has, like the first, an offensive smell, but not, like it, an odour of putrefaction.
Hemorrhage from the bowels is seldom copious. Usually it occurs as black clots, like little particles of soot ; but sometimes larger black lumps may be seen. If there be an ulcer at the lower part of the rectum the blood is redder in colour, and may be in larger quantity. The number of the stools varies from one or two to twenty, or even more, in the twenty four hours. Their passage is sometimes preceded by slight colicky pain ; and if the lower part of the rectum is the seat of ulceration, there may be some straining at stool, and the bowel may prolapse. It is not common for an ulcer to occupy this part of the rectum ; but should it do so, some serious consequences have been noted. The irritation excited by the le sion just within the internal sphincter may cause spasmodic closure of the lower outlet, so that much difficulty is met with in evacuating the bowels. As a result of this obstruction, great enlargement and hypertrophy of the rectum may occur, and we find tympanitic distention of the belly, and many of the symptoms of impaction of faeces.
A child who is the subject of intestinal ulceration is not necessarily very thin. The degree to which nutrition is interfered with depends upon the amount of intestinal catarrh and consequent cliarrhcea. If the purging is severe, wasting is rapid ; but if the bowels are not much re laxed, nutrition may go on well, and the child progressively increase in weight, although: the character of the stools indidates that the ulcers are still unhealed. The appetite is often good, and the tongue clean ; and ex cept for a certain pinched look of the face and distress in the expression of the child, he might be thought to be suffering from a very trifling com-_, plaint. Even in cases where the ulceration is of a scrofulous nature thew" same rule holds good, provided the lungs are healthy. Gaseous enlarge ment of the mesenteric glands does not necessarily produce wasting ; and if the ulceration is not extensive, the temperature high, or the purging se-11 were, the lesion may produce no noticeable impairment of the child's nu trition. The heat of the body is not always increased. I have known cases where characteristic stools, containing shredcly matter and blood clots, continued to be passed for months, and where caseous glands could be distinctly felt in the abdomen on deep pressure, run their whole course and end in recovery, with a temperature which seldom rose above 99°.