The headache now usually subsides, and the patient begins to have slight delirium at night. He asks constantly for drink, but seldom shows any disposition to take food. His expression at this time is dull and heavy, and he lies quietly on his back, often with a dull flush on his cheeks, taking little notice of what passes around him. By the end of the first week the fever has reached its maximum. The skin, however, although generally dry is not always so, and there is occasionally a ten dency to perspiration. The breathing is quickened, and the frequency of the pulse is increased. There is no constant relation between the pulse and the heat of the body. The pulse may be only moderately quick with a high temperature, and its rapidity undergoes frequent variations. (Thus, Edith H , aged thirteen, on the eighth day at 9 P. : pulse, 86 ; respiration, 36 ; temperature, 103.6°. At 9 A.M. on the following morning : pulse, 100 ; respiration, 36 ; temperature, By the end of the first week the cough becomes more troublesonte, and may assume such prom inence that a lung affection is suspected ; but only dry rhonchus, with per haps an occasional coarse bubble, is heard about the chest.
After the eighth day the typhoid eruption should appear. In children this symptom is sometimes absent ; but careful inspection of the chest, abdomen, and back will generally discover a few—it may be only one or two—of the characteristic spots. Sometimes they can be detected upon the limbs. The rash appears in the form of small, slightly elevated, len ticular spots of a delicate rose tint, varying in size from half a line to a line and a half, and disappearing completely under pressure of the finger. Their number varies, but they may be very numerous. These spots come out in successive crops, each one lasting two or three days. If scanty, they have to be searched for with great care, especially when the back is examined, for here, on account of the general congestion of the surface, they may not be readily seen.
In this the second week of the illness as each clay passes the child seems to become duller and more indifferent. He is drowsy and sleeps much during the day, but at night may be more restless, and sometimes he tries to leave his bed. His weakness has now become more marked. The pulse is quick and feeble ; and towards the end of the week muscular tremors and twitchings may be noticed. The belly is much swollen and assumes the characteristic barrel shape. The looseness of the bowel continues, or is replaced by constipation, and sometimes—although this is rare in the child—the motions contain blood. At this time the heart-sounds become feeble and soft to the ear, and there is often a prolongation of the first sound at the apex, or even a soft systolic murmur. On the other hand, in
old standing cases of cardiac disease a murmur previously heard may be lost as the heart's action becomes enfeebled, only to reappear when the strength is restored.
In the third week of the illness the fever usually begins to diminish. In the mild cases the temperature becomes natural as early as the fourteenth day. If it persist, its mean is lower than before, and the morning tem perature may be almost normal. The feebleness of the patient is now sufficiently pronounced, but as the days pass by his symptoms become more favourable. He grows less heavy and lethargic ; the swelling of his belly diminishes ; the spleen retires under the ribs; diarrhoea, if it had previously existed, ceases, and the motions become more natural ; and as the tongue cleans, the child begins to show some dissatisfaction at being still restricted to liquid food. As the fever subsides, the pulse often be comes intermittent, and is very soft and compressible. When the fever is at an end the child is left very weak in the mildest cases, and he only slowly regains his strength. In bad cases the prostration is very great, and the child has to be nursed through a protracted period of convalescence. Sometimes oedema, more or less general, is seen as a consequence of the impoverished state of the blood.
The above is a sketch of the ordinary course of enteric fever in the child. There are, however, many variations in the symptoms, and it is desirable therefore to refer again to some of the principal phenomena.
The Digestive Organs.—The tongue in mild cases remains moist through out the whole course of the illness. It has a delicate coating of grayish fur, through which the papillae are seen to project. The tip and edges are only moderately red. Thirst is often a marked symptom, and liquid food is taken readily to satisfy this craving for fluid. Appetite is generally lost, but not in every case. A little lioy in the East London Children's Hospital complained to me on the sixth day of the disease that he was hungry, although his temperature was then 105°, and his tongue was thickly furred, with sorties on the lips. His mind was quite clear. If the symptoms are severe the tongue generally becomes dry in the course of the second week. It may be fissured across the dorsum, and the lips may be cracked and blackened. Sore throat is a very common symptom during the first few days, and there is some little redness of the fauces. Vomiting is frequent at the beginning ; occasionally it recurs later and may then give trouble.