The swelling of the abdomen is due to accumulation of flatus through decomposition of food and inability of the bowels to expel their gaseous contents. This loss of contractility is the consequence of lack of nerve power or of local injury from ulceration. Consequently, if in the third week of illness there is deep ulceration of the intestine and great bodily prostration, the distention of the belly may be extreme. The amount of abdominal tenderness varies. In the mildest cases it may be absent. When present it may be local, limited to the splenic region and the right iliac fossa, or may be general over the abdomen. It is sometimes a well-marked symptom, the slightest touch being productive of great pain, and this in cases where there is no reason to suspect the presence of peritonitis. The bowels may be confined throughout, or loose throughout, or constipation may alternate with a mild diarrhoea. It must be remembered that loose ness of the bowels is due not to the ulceration but to coexisting catarrh. If catarrh be insignificant or absent, the bowels are not relaxed. As a in children the looseness is not extreme and is easily controlled. The relaxed motions always assume at one time or another the " pea-soup " character ; they have an alkaline reaction and a faint offensive smell. Hmmorrhage from the bowels to any amount is rare, but small black clots of blood may be sometimes found in the grumous matter at the bottom of the stools.
The urine is at first scanty, with a high density. It contains an excess of urea and uric acid, but is poor in chlorides. Later it becomes more copious, the specific gravity falls, and it may contain a trace of albumen. During the height of the fever there may be retention of urine, with dis tention of the bladder and tenderness over the pubes. Sometimes the catheter has to be employed. There is no gravity about this symptom, and it need cause no anxiety if care be taken to empty the bladder by degrees. The distention is due to loss of contractile power of the muscu lar coat. If, then, a greatly distended bladder be suddenly and com pletely emptied of its contents, the organ contracts imperfectly, and a cer tain amount of air enters and causes great irritation. An obstinate cystitis may be produced in this way.
The pulse is quick as a rule, but sometimes for a time sinks in rapidity although the fever continues high. The frequency of the pulse is not, as has already been stated, any trustworthy guide to the degree of fever ; nor, as taken at a single examination, is it necessarily any test of the severity of the illness.
The respirations are hurried, and there may be slight disturbance of the normal pulse-respiration ratio without any pulmonary complication being present. (Thus John II , aged four years, sixth clay, 4 P.M. : temperature, 103° ; pulse, 120 ; respiration, 46). If a pulmonary complica tion actually arise, the breathing increases in rapidity and there is lividity of the face.
The skirt may be moist at times during the course of the disease, and towards the end of the third week, especially if the fever has subsided, there may be copious sweating. Sudamina then appear on the chest. The abundance of the rash varies greatly in different cases. It may be
very copious or completely absent ; but these extremes bear no relation to severity or mildness of attack. It is well to be aware that fresh crops of rose-spots may continue to appear for a week after the temperature has fallen to the normal level. I have noticed this on several occasions. The facies is important. The child seldom looks very ill in the early stage ; and even later, unless the abdominal mischief be severe, it is exceptional for his face to wear the anxious haggard look which is so common in many other serious di§eases, and forms such a striking feature in acute tubercu losis. In ordinary cases the expression is more stupid and listless than anxious.
The special senses may be affected. Deafness is common. Epistaxis is a frequent symptom, and may be repeated again and again. The con junctivae look red, and the pupils are large. The headache in children is seldom very severe. It ceases about the end of the first week, when the delirium begins. Sometimes cervical neuralgia is noticed after the second week, and every movement of the neck may be accompanied by pain. De lirium is the rule, beginning towards the end of the first week. Some times from this cause older children try to get out of bed and are noisy. Convulsions may precede death in fatal cases ; but typhoid fever, unlike many other febrile complaints in childhood, is very rarely ushered in by a convulsive attack. Still, a form of disease is usually described in which the early symptoms are those of high nervous excitement. The child is convulsed and has marked delirium. I have never met with a case of this form of typhoid fever in a young subject.
The pyrexia, like most forms of febrile movement in the child, is re mittent, but the degree of remission varies at different periods of the dis ease. In the second week there is, as a rule, less variance between the maximum and minimum temperatures than at an earlier or a later stage of the complaint. To test the bodily heat with any exactness, the tempera ture should be taken every three or four hours, both day and night. Very false conclusions may be drawn from a merely diurnal use of the ther mometer, for the mercury is not necessarily at its lowest point at S or 9 A.M., nor at its highest at 6 or 7 o'clock in the evening. Again the mini mum temperature may be non-febrile, or even subnormal. (Thus, in the case of Lilly F , aged eleven years, a patient in the East London Children's Hospital, the temperature during the morning hours from 8 o'clock to noon was subnormal after the ninth day. It was often as low as and yet this was an undoubted case of typhoid fever. In the even ing the heat was 102° or 103°.) It is difficult to lay down a rule in a matter which is subject to such enclless variety ; but perhaps the minimum temperature is reached more often between the hours of 10 A.M. and noon than at any other time, and the maximum shortly before midnight or in the early morning hours. In the third week of the disease the remissions generally become very marked, and the minimum registered is often little higher than a normal temperature. This is especially noticeable towards the end of the week.