Ulceration of the bowels is sometimes complicated with peritonitis. In cases of scrofulous or tubercular ulceration of the bowels, tubercular peri tonitis is a common secondary lesion. But a simple ulceration may also be accompanied by inflammation of the serous lining of the abdomen without perforation of the bowels having taken place.
A boy, aged six years, was struck on the abdomen with a heavy piece of wood. The accident made him feel faint, and he vomited several times on that and the following days. On the day after the injury he complained much of pain in the belly, and from that time suffered from frequent col icky pains in the abdomen, and diarrhoea, which often obliged him to keep his bed. He was admitted into the East London Children's Hospital six months after the accident. At this time the boy was pale, but not very thin (he weighed thirty-two pounds twelve ounces). He complained of pain in the right side of the belly and over the epigastrium, and there was considerable tension of the parietes in these situations. The abdomen was rather distended, but was not tender. There was no fluctuation or dulness in the flanks, but much gurgling could be felt and heard on palpa tion. His tongue was furred in two lateral bands. The bowels acted four times in the day, the stools being pale, small, and solid. The boy had a pinched, distressed expression, and seemed languid and dull, but expressed himself as quite comfortable except for the occasional pains in the belly. There was no albumen in his urine. The lungs and heart were healthy. His temperature at 6 P.M. was 99.4°.
A few days after the lad's admission his temperature rose ; he began to vomit, and the bowels became much relaxed. The stools consisted of dark brown liquid, or of fluid like pea-soup, with small hard faecal masses. The vomiting continued, and the belly became swollen, tympanitic, and very tender. The child then rapidly wasted and became exceedingly prostrate. Delirium came on, and he sank at the end of a fortnight. During the last week his temperature varied between 99° and 102°.
On examination of the body there were signs of old peritonitis, due probably to the accident. In addition, much recent lymph was found coat ing the intestines. In the ilium several of Peyer's patches were found to be the seat of ulceration. The ulcers were shallow, with a grayish, uneven floor and thickened edges. There were no gray granulations anywhere.
This boy's condition when he entered the hospital illustrates very well the symptoms often found in cases of ulceration of the bowels, for there is no reason to suppose that he was then suffering from peritonitis. Abdom
inal pain of a colicky character going on for months, especially if combined with tension of the parietes, and a history of more or less persistent diar rhoea, is suggestive of intestinal ulcer, and the pinched, distressed look of the boy's face quite excluded the idea that these symptoms were due to any unimportant derangement, however persistent. It is an invariable rule, which should never be forgotten in clinical investigation, that in a child a haggard face means serious illness. However insignificant the symptoms and signs may. appear, if a child look ill the case is not one to be neglected or lightly regarded. The intestinal lesion in this boy was probably the consequence of a chronic catarrh of the bowels of many months' standing ; for from the time of the accident he continued to suffer from persistent looseness of the bowels, with attacks of colicky pain. The return of the ca tarrh followed upon the action of an aperient which relieved his bowels of a large quantity of bard faecal masses, and the irritation thus excited no doubt induced the second attack of peritonitis from which he died.
If there is any reason to suspect ulceration of the mucous membrane of the bowels, aperients are not to be recommended. Our whole efforts should be directed to promote the healing of the ulcers by quieting peris taltic movement. Therefore, however important it may seem to remove fecal accumulation, we must remember that an aperient only sets up fresh irritation, and that its action may be followed by very serious consequences.
As a rule, the lower down in the colon the ulceration is seated, the more numerous are the evacuations and the more distressing the tenesmus and the pain. Still, even if an ulcer occupy the sigmoid flexure or rectum, there is not always diarrliceaindeed, sometimes the Beal matter presents itself only in the form of hard scybala mixed with very offensive muco purulent fluid. In these cases, if haemorrhage occur, it is usually more copious, and the blood more natural in colour, than when the ulcers occupy any other portion of the bowel. Constipation is most liable to be found in cases where the lesion is seated in the small intestine, the colon being healthy ; but even in this form of the disease, any additional irritation which sets up catarrh and increases the peristalsis of the larger gut may give rise to diarrhoea. An ulcer of the duodenum would probably excite distressing vomiting and pain at an interval after food. Such a lesion in the child has never come under my notice.