During the first few days of the fever it is rare for the child to be under skilled observation, and a record of the temperature at this time is not easy to obtain. Occasionally, however, a hospital patient, admitted for some chronic complaint, sickens of the disease. Such a case occurred lately in a little girl, aged nine years, who was being treated for hip-joint disease in the East London Children's Hospital by my colleague Mr. Parker, and was transferred to my care on the outbreak of the fever. The child, whose temperature had been normal, complained of headache at 2 P.M. Her temperature was then found to be 102.6°. At 10 P.M. it had fallen to 100°. On the second day, at 6 A.m., it was 99° ; but rose gradually, being taken every four hours, till 6 P.M when the thermometer marked 103.2°. It then fell suddenly to 99°.at 10 P.M. On the third clay at 10 A.3I. it was ; at 2 P.M., 102.4° ; at 6 P.M., 101.8° ; at 10 P.M., 102.6°. After this it varied between 101° and in the twenty-four hours, until the middle of the third week when it rose rather higher.
In a case kindly communicated to me by my friend Dr. Gee, the tem perature in a little girl under his care was on the first day at 2 P.M., and at 10.30 P.M. it was 103.6°.
In a case published by Dr. Ashby, of Manchester—a little girl of nine years—the temperature was 100° on the first evening. On the second day : morning, 99.4° ; evening, 101.8°. On the third day : morning, 100.4° ; evening, 100.4°. Fourth day : morning, 101° ; evening, 103.4°.
From these three cases it appears. that there may be great variations in the degree of pyrexia at the beginning of the disease. In my own case the temperature reached its height on the second day at 6 P.M. ; but dur ing the first two days the variations were very great.
The duration of typhoid fever is from fourteen to twenty-six days as a rule. The temperature often falls in young subjects at the end of a fort night ; and sometimes, although very rarely, may become normal at a still earlier date. The possibility of so short a duration for the fever has been doubted, but that it may occur is proved by the following case.
A little girl, aged nine years, was perfectly well on September 14th. On the following day, the 15th, she complained of chilliness and frontal headache. That night the skin was noticed to be hot, and for the next week the child was apathetic, languid, and feverish, complaining of head ache and abdominal pain. She did not vomit, and there was no bleeding from the nose. The child was seen on the 22d. Her temperature was then 102°, and a rose-spot was noticed on the abdomen by the house surgeon. On the 23d (ninth day) she was admitted into the hospital. The abdomen was then moderately distended ; the spleen could be felt two fingers'-breadth below the ribs ; uo spots were to be seen ; the temperature in the was 102.6°.
After this date the temperature was never higher than and a fraction ; the child looked and expressed herself as well ; the spleen quickly retired under the ribs ; the appetite was good, and the patient complained much at being restricted to liquid food. On October 5th, the temperature having been normal for twelve days (with the exception that on one occasion, in the course of September 27th, it rose to 100.3°), and subnormal for six,
the child was put on ordinary diet. Two days afterwards the temperature rose to 102°, the spleen began to enlarge ; rose spots appeared on the ab domen ; and the patient passed through a well-marked relapse of typhoid fever which lasted the usual nine days.
In this case the early cessation of the pyrexia seemed to exclude typhoid fever ; and as the temperature continued low, a meat diet was allowed under the idea that our first impression of the illness had been a mistaken one. The prompt occurrence of a typical relapse, however, at once re moved our doubts as to the nature of the primary attack.
In some cases the temperature remains high after the usual time of fall ing at the end of the third week. In many cases this is due to progressive ulcerative enteritis. Indeed, Dr. Gee lays it down as a rule that when pyrexia and enteric symptoms last longer than twenty-six days this is the cause of the prolongation of the disease. He also suggests that " subin trant relapse " may be an occasional agent in producing the same result.
Death from the intensity of the general disease, so common in the adult, is very rare in early life. In very exceptional cases, however, the diarrhoea may be excessive ; the temperature may rise to a high level ; the pulse may be frequent, feeble and dicrotous ; the abdomen may be swollen and tympanitic ; the child is delia•ous, then comatose, and dies with a temperature of 108° or 109°. Still, although this type of the disease is occasionally met with in the child, it must happen to few prac titioners to meet with such cases. 1Vhen children die from typhoid fever, they die almost invariably from perforation of the bowel and general peri tonitis. The rupture occurs in the floor of a deep ulcer and takes place quite suddenly. It is followed by an escape of gas and of the fluid con tents of the intestine into the peritoneal cavity. Immediately, the abdo men becomes distended, and there is intense pain and tenderness. Some times there is vomiting, but the patient in any case sinks into a state of collapse with dusky haggard face, cool purple extremities, and small rapid pulse. Although the surface of the body feels cool, the internal heat re mains high (103-104°). The respiration is thoracic. According to Nie meyer, sudden disappearance of the liver dulness, on account of that organ being separated by the tympanitis from the abdominal wall, is one of the most certain signs of peritonitis from perforation of the bowel. This accident does not often happen before the end of the third week. When the peritonitis is general, it is almost invariably fatal, and death is sometimes preceded by an attack of convulsions. If the intestine have been previously matted by local inflammation, rupture of the floor of the ulcer may not lead to such serious consequences. In such a case when perforation occurs, the extravasated contents of the bowel remain encysted, and the resulting peritonitis is limited to the neighbourhood of the lesion. In the end the abscess thus formed generally makes its way to the surface and discharges its contents at some point of the abdominal wall.