Diagnosis.—If the symptoms of ulceration are well marked, there is little difficulty in ascribing them to their true cause. An abdomen full, without great distention or loss of the natural surface markings ; increased tension of the parietes, with tenderness on deep pressure ; diarrhcea, with colicky pain, the stools consisting of dark, putrid-smelling, watery fluid, de pogting brown or yellow shredcly matter and small black blood-clots—this group of symptoms, when combined with a distressed expression of face, is very characteristic of intestinal ulceration. The chief difficulty in such a case would be to exclude tubercular peritonitis ; for this additional lesion might be present without excessive tenderness, without fluctuation, and without any caseous lumps being detected on palpation. The belly, how ever, would be more distended and globular ; the natural markings of the surface would be absent ; the temperature would probably be decidedly febrile ; and in most cases, if the child were laid on his side so as to allow of the fluid accumulating in one flank, some evidence of its existence would be perceived on turning him rapidly on to his back and immediately pal pating or percussing the part which had been dependent. It is, however, fortunately, uncommon to find cases of chronic tubercular peritonitis in which the symptoms are so obscure. Usually semi-fluctuation is readily discovered, and caseous masses, or unequal resistence of the abdominal con tents, can be noticed on examination.
If the ulceration be accompanied by constipation or solid stools, the case may be mistaken for one of faecal accumulation. The colicky pains and small lumpy evacuations are very suggestive of this condition, and even if the stools are occasionally loose, the symptom is not unknown in cases of impacted rectum. A little reflection will, however, convince us that there is more in the case than a loaded bowel is capable of explaining. We find in most instances a history of previous continued diarrhoea ; if tenderness be absent, there is still some tension of the abdominal wall ; and the distressed expression of the child's face assures us of the existence of serious disease. Moreover, an examination per anuin detects no accumu lation in the rectum, and a copious enema, although it may remove solid fecal lumps, in no way improves the condition of the patient.
If we are satisfied as to the presence of the ulceration, we have still to decide whether the lesion is of a simple character, or is the consequence of a scrofulous or tubercular cachexia. The older the child, the greater the likelihood that the ulceration is not simply catarrhal. After the age of three years, the manifestations of the scrofulous diathesis become common ; and at this age, chronic catarrh of the bowels seldom runs a sufficiently persistent course to set up ulceration unless aided by some vice of the constitution. If, however, the child have scrofulous or tubercular tenden cies, a much less prolonged irritation of the mucous membrane will give rise to caseation and softening in the glandular follicles. The presence of
enlarged mesenteric glands, chronic lung disease, or other sign of the scrofulous constitution, allows us to infer that the intestinal lesion is of a similar pathological character. The temperature is not greatly to be relied upon in these cases; for it is not necessarily elevated in cases of scrofulous ulceration, while it may be raised from accidental causes in the simple form of the lesion. Nor is the state of nutrition of much value as a guide ; for this depends less upon the nature of the ulcer than upon the degree to which catarrh of the bowels may have reduced the strength, and interfered with the digestion and absorption of food. If the child show no sign of the scrofulous cachexia, if his lungs appear to be healthy, and if tubercu lar peritonitis can be excluded, we may infer the ulceration to be of a sim ple character, although his general strength be poor, and his nutrition un mistakably impaired.
If the ulceration be tubercular from a secondary formation of the gray granulation around the ulcer, and in other parts, nutrition is at once pro foundly affected, and wasting goes on with rapidity. In such a case, all the symptoms of general tuberculosis are present, and the child often dies from tubercular meningitis. Still, it must be confessed that cases sometimes present themselves in which all the symptoms of acute tuberculosis are noticed without a single gray granulation being discovered in the body after death. The case may even terminate with head symptoms indistin guishable from those of tubercular meningitis, although the interior of the cranium appears to be healthy, and the most thorough search discovers no gray tubercle in the meninges of the brain. It is difficult to explain these cases. Fortunately, they are very exceptional.' Prognosi..s.—In a case of simple ulceration from prolonged intestinal catarrh, recovery will often take place under judicious treatment if there be no complication, and if oedema have not occurred. The latter symptom, although it is far from indicating that the patient will certainly die, is yet of unfavourable import, as it shows a state of great weakness, and weakness in itself renders a child less responsive to the action of remedies.
If the ulceration be scrofulous, the prognosis is still less favourable ; but here, if the strength is not greatly reduced, and if other organs are healthy, recovery may take place. Gaseous enlargement of the mesenteric glands does not appear to add to the danger of the case ; but if serious lung mis chief is present, the concurrence of the two lesions leaves us little room for hope. If secondary tuberculosis occur, with formation of the gray granu lation in the neighbourhood of the ulcer and elsewhere, death is certain.