Other complications which give rise to discomfort or clanger are : inflammation of the parotid gland, or of the middle ear, bronchitis, pleurisy, pneumonia, and catarrhal pneumonia. In one case—a boy aged thirteen, under my care in the East London Children's Hospital—an extensive plastic pericarditis arose during the third week of illness. Bedsores rarely occur unless the child is greatly reduced by protracted illness ; but boils and abscesses are not uncommon. Ulceration of the larynx has been described, but must be very rare. Another rare complication is throm bosis of the veins of the lower extremities.
After the fever has subsided, the temperature usually remains subnor mal for some time. Not unfrequently, however, after the lapse of a few days, the child is noticed to be feverish again. These secondary pyrexias are very common. They may be due to a real relapse ; to the presence of some irritant in the bowel, such as hardened fecal matter or undigested food ; or to some febrile complication which may be called accidental, as an abscess.
Real relapses are far from uncommon. They begin after a variable in terval—four or five days, or longer—and seem in many cases to be deter mined by injudicious feeding in the stage of early convalescence. The temperature rises ; the spleen again enlarges ; fresh spots appear ; and the bowels may be again relaxed. Usually the symptoms are milder than in the primary attack and last a shorter time. The average duration of a re lapse is nine days.
Constipation and the irritation of the bowel by hard fecal masses is a common cause of secondary pyrexia. The temperature usually rises to 102° or 103°, but may be higher. When the irritant has been removed by a copious injection, the pyrexia, at once disappears. These attacks of tem porary elevation of temperature may recur again and again in the course of convalescence, but need occasion no anxiety.
Convalescence from typhoid fever is often tedious. The child is left and low, and nutrition may not at once be re-established. It is a re markable fact—to which attention has been drawn by Dr. West—that the patient is enfeebled intellectually as well as physically by his illness. For some weeks after the fever is over he may remain dull and indifferent, taking little interest in pursuits and amusements which formerly delighted him. A child of three or four years of age may seem to have forgotten how to talk ; and the persistence of this mental weakness for some time after the strength has been restored is often a cause of great anxiety to the patient's friends. Such anxiety is, however, groundless, for the return of mental tone at no long interval may be confidently predicted.
These cases appear to be clue sometimes to defective action of the kid neys. In one case which came under my notice the child (a boy of seven) left after typhoid fever in an apathetic, stupid condition, taking no notice of anything, and never speaking even to make known his natural wants. He appeared to be in a state of great weakness, and had occasion ally nervous seizures in which he became quite stiff, and seemed to be conscious. His skin was dry and excessively inelastic ; there was no dis coverable disease of any of his organs ; his temperature was subnormal. At first he had a slight trace of oedema of the legs, but this quickly passed off. His urine never contained albumen, but its quantity was small. For a long time the boy passed no more than ten or twelve ounces in the twenty-four hours, with a specific gravity of 1.015. The excretion of solid matter by the kidneys was so evidently deficient that diuretics were or dered, and the boy was forced to take a larger quantity of fluid. Under this treatment he soon began to mend ; his urine became more copious with a higher density ; the elasticity of his skin returned ; his nervous seizures ceased ; and his strength, mental and bodily, rapidly improved.
A:child with any diathetic taint may have his predisposition strength ened by his illness. Tuberculosis sometimes occurs ; and scrofulous ten dencies may receive a distinct impulse.
Diagnosis.—On account of the negative character of the symptoms at the beginning of the illness, enteric fever is often difficult to recognize in the early stage ; and even at a later period the nature of the complaint must be sometimes a matter of doubt. Still, the disease is one of such frequent occurrence that we should always remember the possibility of its being present, and should never omit in a doubtful case to make inquiry as to the existence of the disease in the neighbourhood. The beginning of measles, scarlatina, and variola is sufficiently distinctive to prevent their being confounded with this disorder, and moreover, the absence of the specific eruptions of these complaints will serve for their exclusion. A high temperature on the second day in a child who suffers from nothing but an ill-defined malaise is enough to give grounds for suspicion. If, as the days pass, no other symptom develops itself, our suspicions are ma terially strengthened ; and when at the end of the week, enlargement of the spleen with swelling and tenderness of the belly can be detected, especially if there is also looseness of the bowels, there is hardly room for further hesitation.