Vomiting is a frequent symptom. The ' abdomen may first be flat and rigid, but soon swelling, with meteorism, super venes. The temperature usually falls below normal, and the patient becomes collapsed. The breathing is rapid, the pulse feeble and frequent, and there is partial suppression of urine. A pecul iar pinched expression of countenance, sunken eyes, and cold, clammy surface of skin are often present. In some cases ' the pain is not severe and the symptoms of collapse are but slightly marked.
[Perforation occurred in 34 of Osler's 635 cases (2.43 per cent.), and in 46S0 cases tabulated by Fitz perforation took place in 6.58 per cent. It is more fre quent in men than in women. J. E. GRAFIAM.] Study of 24 cases of peritoneal infec tion in typhoid fever. Abdominal pain in any typhoid case should be regarded as a serious danger-signal. It is most frequent in the right iliac region, and often associated with localized tender ness and muscular spasm. The suspicion of beginning peritoneal infection is con firmed by a rising leucocyte-count; ex aminations should be made at hourly intervals. Vomiting is rare, and an in crease in pain is generally accompanied by a rise in temperature and quickened pulse-rate. te G. B. ttuck J. C. War 1 - a- Shattuck, ren, and Farrar Cobb (Boston Med. and Slug. Jour., June 2S, 1900).
The importance of an early diagnosis is increased on account of the success of surgical operation when performed shortly after the occurrence of the per foration. The absence of liver-dullness is often an important sign demonstrating the fact that gas exists in the peritoneal cavity. It must be remembered, how ever, that extreme distension of the bowels may push the liver upward and backward to such an extent as to cause hepatic dullness to disappear in front. In such cases the dullness will be made out by percussion of the back to a greater extent than when gas exists in the peri toneal cavity. Hwmorrhage may accom pany perforation.
The early diagnosis in perforation may be confirmed in some cases by a careful blood-count, when the number of len cocytes will be found increased. This is not always the case; perforation may be followed by leucecytosis; and, on the other hand, an increased lencoeytosis may be present without perforation.
Peritonitis may occur without perfora tion. Inflammation and rupture of a mesenteric gland are sometimes the cause, and it may be caused directly by the presence of typhoid bacilli in the abdominal cavity.
Death may follow from collapse shortly after a perforation or the patient may rally and suffer from peritonitis. The latter is diagnosed by the presence of pain and tenderness of the abdomen, and pinched expression of countenance, with rapid and feeble pulse. Death occurs on the third or fourth day after the attack. Recovery very rarely takes place.
The S pleen. — Enlargement of the spleen is present. according to Leubc, in 90 per cent. of all cases, and Osier is of the opinion that it occurs in all cases. The enlargement continues until the fourth week, when it gradually disap pears. The normal area of splenic dull ness which extends in the midaxillary line from the ninth to the eleventh ribs may be increased upward and downward. The lower edge may often be felt under the costal margin upon deep inspiration. The enlargement is rarely accompanied by pain. Rupture has taken place spon taneously as well as from the result of a blow.
The Liver.—Jaundice is not a frequent symptom in typhoid fever. It results from toxremia, abscess, or gall-stones.
The urine usually in jaundiced cases contains bile-pigment, albumin, and casts. The stools are not clay colored, but are dark and of the typhoid charac ter. Epistaxis is frequent, and is severe in proportion to the severity of the jaun dice.
Nervous System.—In mild cases and sometimes when the disease is severe, the patient remains conscious through out, and there is little to be noted in con nection with the nervous system. Head ache is nearly always present in the early part of the disease. The pain may be felt over the whole head, in the occipital or frontal region, most frequently in the latter situation. It is usually dull, but occasionally may be so severe as to closely resemble that of meningitis.
The headache usually subsides about the end of the first or beginning of the -second week. Pain in the back of the neck is sometimes severe, and continues four or five days.