In more severe cases the diseased glands, instead of undergoing healthy resolution, take on a further morbid action. Small points of ul ceration appear on the surface of the patch. These enlarge and unite so as to form an ulcer which may cover the whole of the diseased surface. Sometimes, instead of ulcerating at separate points, the mucous membrane covering the affected patch sloughs over a larger or smaller area and sep arates from the tissue beneath. If the whole of the patch have been thus uncovered, the resulting ulcer is oval, and has its longer axis in the direc tion of the canal. Smaller ulcers may be circular or sinuous. The solitary glands may also go through the same process, and leave small, round ul cers scattered over the surface of the mucous membrane. The edges of the ulcers are thick and sharply cut, or even undermined ; and the floor is formed by the submucous tissue, the muscular coat, or, in bad cases, merely by the peritoneal covering of the bowel.
After a time, a process of repair is set up and the ulcers begin to heal. This favourable change seldom occurs before the end of the third week, and the process of cicatrization occupies a variable time. Under favourable con ditions it may be completed in two or three weeks, but it is often spread over a longer period. The healing of the ulcer is not followed by any con traction of the bowel.
The morbid process above described attacks especially the glands in the neighbourhood of the ileo-cmcal valve, and extends upwards for a varia ble distance. In some cases the solitary glands in the cfccum and part of the ascending colon may be also affected. The deeper ulcers are usu ally in the lower part of the ilium near the valve ; and when perforation occurs, it is by rupture of one of these, whose floor is formed only by the peritoneal coat of the intestine. That this accident does not occur oftener is due to a local peritonitis having been At up, gluing the affected part of the bowel to a neighbouring organ. Children who die from this disease die almost invariably from perforation of the bowel ; but an unfavorable ending to enteric fever is comparatively a rare accident in young sub jects, in whom the unhealthy action in the glands often stops short of ulceration.
Besides the special changes in the glands, the whole mucous mem brane of the bowel is swollen and relaxed. The enlarged mesenteric glands seldom suppurate in the child. They usually rapidly undergo res olution as soon as the process of repair has begun in the intestine. The spleen is enlarged and congested. It is dark red in color and is softer than natural. enlarged kidneys are sometimes congested. In all cases of ty phoid fever the lungs are the seat of catarrh, so that the mucous mem brane of the air-tubes is red and congested, and the bronchial glands are enlarged and vascular.
Symptorns.—After exposure to the contagious poison there is a period of incubation varying from ten days to a fortnight, at the end of which the symptoms of the fever begin to manifest themselves. These are at
first very slightly marked ; so much so, that it is sometimes difficult to fix the exact time at which the illness began. In most cases, however, careful questioning of the parents will enable us to determine the first day of the disease. One of the earliest symptoms is frontal headache. It is com mon to be told that a child returned from school saying lie had a headache, that he looked pale, was languid and could eat no dinner. There is fever at this time, but the child, not being supposed to be really ill, is not treated as an invalid. In other cases headache is not complained of at first. The child is merely pale and listless, with some fever, and cannot be persuaded to eat. For the first few days little else can be discovered. The tongue is coated with a thin, white fur, through which red papillae project. There is often slight redness of the throat. The bowels are either confined, or one or two loose, rather offensive, stools are passed in the twenty-four hours. The child is drowsy, but sleeps restlessly, although without de lirium. He generally complains of his head, and often of aching pains about the body and limbs. Sometimes there is vomiting after food, and there may be trifling epistaxis. Cough is a more or less constant symp tom, but varies greatly in amount. Usually it is insignificant at the first.. During this time, unless medical assistance be summoned, the patient is seldom confined to his bed, but is dressed in the as usual. In deed, in mild cases, children will often walk considerable distances to the out-patients' room of a hospital, for the muscular weakness is much less marked than might be anticipated.
So far, then, the symptoms are vague ; and if it were not for the de cided character of the pyrexia, there would be nothing to help us to come to any conclusion as to the nature of the illness. It is only at the end of the first week that more characteristic symptoms are observed. About the sixth or seventh day the spleen begins to enlarge. The organ can be felt to project inward towards the middle line from under the cover of the ribs. Its texture is soft, so soft, indeed, in many cases, that the enlarge ment can be only detected by a practised finger ; and it appears to be tender, for pressure over its substance usually produces some manifes tation of diseomfort. Tenderness can generally be noticed at this time over the whole belly, and is not confined to the region of the spleen. The belly is now a little swollen ; borborygmi are frequent ; and gurgling may be often felt on pressure in the right iliac fossa. This, however, is a symptom as often absent as present. The bowels are relaxed in the ma jority of cases, although, as a rule, only moderately so, and the stools exhibit the yellow ochre "pea-soup " appearance which has been so often remarked upon. Still, constipation is a more common phenomenon in the child than it is in the adult, occurring in at least one-third of the cases.