The loss of appetite (though usually not absolute), the high fever, the diarrhoea, and the insufficient night's rest lead in children to great emaciation, which at times becomes extreme, but during convalescence conditions quickly improve. Often the hair falls out and is replaced by a thin, lustreless aftergrowth; but, in contrast to the adult, rarely is any permanent harm done. The finger nails exhibit transverse furrows and flutings; often the nails drop off, and new ones grow in, but not, as Feer believes, such as are characteristic of scarlet fever. Under the trophic disturbances we note desquamation of the skin such as described by Hamernik, in the form of branlike or large scaly cxfoliations of the trunk and of the extremities, while the face, hands, and feet remain unaf fected. Rachmaninow observed this desquamation in one-third of all the eases of typhoid fever in children that came under his notice. It appeared either during the stadium decrementi or not until after the temperature reached normal and continued from S to 14 days. The severity of the disease had no influence on its occurrence.
Patients frequently have a peculiar craving for certain undigestible foods, obstinately rejecting what liquid food is offered them, and their aversion lasts as long as the fever. Frequently as early as the period of deferescence, and regularly during convalescence, ravenous hunger is present which demands firmness on the part of the physician and his assistants, since the foods which are permitted do not satisfy the appetite and more food must be refused.
In the typhoid of childhood, the tongue often presents a character istic appearance. It seems to be narrowed, covered at first with a gray transparent coating and later with a thick white deposit, sharply con trasting with the dark red border and the clean moist tip. There are, however, as I have seen repeatedly, eases in which during the whole course of the disease the tongue showed no coating or at most only a slight, breath-like turbidity. The clearing of the tongue begins at the tip, whiCh gives rise to the so-called "typhoid triangle" with its apex towards the root of the tongue. A dry tongue, looking as if it had been smoked, or covered with a thick black coating, is met with only in se vere cases in which also the lips are dry and fissured, presenting bleeding rhagades encrusted with a dark brown deposit. A foul odor issues from the mouth; the bases of the teeth are covered with a slimy yellowish brown mass; and the nostrils, which the patients are constantly picking as they are their lips, appear ulcerated and incrusted. On the other hand, mycoses, which in the severe typhoid of adults are a frequent and prognostically bad symptom, are rarely met with in children.
Swelling of the parotid, according to Biedert, is always indicative of a severe mouth infection and a malignant course; it usually occurs towards the end of the second week, and undergoes suppuration, pre vided the patient lives long enough.
Pseadontembranous anginas occur in severe typhoid fever develop ing during the course of the disease and rarely constituting the first symptoms, though I have observed this in three eases and it has been described by others. Of different significance is a pharyngeal affection described by E. L. Wagner as "angina typhosa," with the development of flat ulcerations on the palatal arches and likely to be regarded as a primary affection. In children this angina is net with relatively sel dom, but instead of it we frequently notice a circumscribed injection affecting the palatal arches and the epiglottis, with some adema of the mucous membrane. :Ilya, who studied more closely the nature of an gina mycosa, was able to cultivate typhoid bacilli from the ulcerations in the pharynx, which were not present in mere catarrhal forms.
Vomiting is more frequent than in adults, often inaugurating the disease or accompanying it. If associated with constipation,—an occur rence by no means rare in the typhoid fever of children,—it suggests meningitis. Abdominal pains are usually wanting or if present, not vio lent, which is in correspondence with the absence of intestinal ulceration. Gurgling in the ileocecal region is usually wanting, whereas it may be found in a large number of divers non-typhoidal intestinal affections, so that no diagnostic value can be attached to it. Meteorism is never very considerable, sometimes it is absent, and at times there may be retraction of the abdomen. Diarrhoea, as a rule, sets in rather late. In rare cases, some of which I have observed, the disease begins with the symptoms of a violent colitis, attended with tenesmus and bloody mucous stools. But, as already stated, in most cases the thin, fluid evac uations in moderate number (3 to 5 in 24 hours) and following a constipa tion, do not appear until the second week. Constipation, however, may continue throughout the course of the disease, as I have seen repeatedly.
The diarrkeal discharges have the characteristic, pea-soup appear ance, and if left standing in a glass vessel present a lower stratum con sisting of bright yellow and whitish flakes. From these, bacilli may be cultivated in doubtful cases according to the method of Drigalski and Conradi. An exceptionally profuse diarrhcca may cause the children to become very much emaciated, and it may continue at most 12 to 14 days, though the usual thin typhoid stools are replaced much sooner by solid evacuations or it may be that constipation occurs during conva lescence. Involuntary evacuations are always an unfavorable symp tom indicating an unusually severe course of the disease, especially when succeeded by deep stupor and paralysis of the sphincter so that the intestinal contents steadily ooze from the gaping anal orifice.