Intestinal ltwinorrhages and perforations, with their sequoia', are met with almost exclusively in older children as in the young there is little anatomical alteration, necrosis and ulcerations being absent; but when these complications occur they have the same dangerous signifi cance as in adult life. The symptoms of intestinal haemorrhage are sud den collapse, with rapid depression of bodily temperature, cold sweat, pallor of face, cold nose and extremities, smallness of the pulse, followed in a few hours or by the next day by the passage of black or bright red masses per annul. Perforation takes place only in the later stages of the disease (third to fifth week); it begins with violent vomiting and singultus, to be soon followed by collapse and a rapidly developing, painful peritonitis. But peritonitis may ensue without intestinal per foration as a result of an extension of the process, by contiguity, to the serosa, and the prognosis in such cases is less unfavorable.
One of the most important symptoms and, in doubtful cases after the second year, of decisive aid in the diagnosis of typhoid fever, is swelling of the spleen, the frequency of which is about the same as in adults. The spleen enlarges at an early period and grows steadily with the development of the fever, becoming three or four times its original size, particularly in its long axis. However, meteorism or overlying by bowel may prevent its recognition by percussion, while the more relia ble palpation with the hand and fingers, flatly placed on the abdomen and pressing gently under the costal arch, may be valueless either on account of the softness of the spleen or the tension of the abdominal muscles. Certainly we must never content ourselves with a single exam ination for the determination of an enlarged spleen is of such decisive diagnostic moment. During the period of declining fever, the spleen becomes rapidly smaller, usually attaining its normal dimensions at the beginning of convalescence.
On the part of the respiratory organs we notice epistaxis relatively seldom and only in the early stages of the process; except, however, in those severe cases in which it is a phenomenon of the hremorrhagic dia thesis. Bronchial catarrh is a usual accompaniment of typhoid in children, and is localized mostly in the larger and middle branches of the bronchi. Where expectoration is scant and cardiac action slight, a hypostasis may result in the lower portions of the lung and, as a result of this, the percussion sound becomes duller and there are moist riles with soft bronchial breathing (so-called sub-bronchial respiration). At
the same time there occurs a slight cyanosis with increased frequency of pulse and respiration, dilatation of the alte nisi and a call upon the auxiliary respiratory muscles, symptoms all suggestive of an encroach ment on the respiratory area. A rise of fever would occasion the suspi cion of the development of genuine bronchopneumonie foci. Such an occurrence is a serious complication, at least protracting the disease, and often causing a fatal termination from asphyxia, pulmonary cedema or paralysis of the heart muscle. The development of a croupous pneu monia may likewise become a serious complication usually occurring at the height of the fever or at the beginning of its decline. In the latter case the temperature will again shoot upwards, and the pneumonia may become localized in different portions of the lungs, especially in the upper lobes and cause a loud bronchial breathing, typical crepitant riles, se vere dyspncea,, and intense general phenomena, or may as a migratory pneumonia successively affect adjoining portions of the lung. Pneu monia is a of typhoid. The form of typhoid fever described by Gerhardt in adults as "pneumotyphus," setting in under the aspect of a pneumonia, followed by typhoid symptoms, is very rare in children. It is only a few weeks ago that I had the opportunity to observe a case of this kind for the first time. The patient was a child twenty-one months old taken ill suddenly with rapidly ascending tem perature, and a small pneumonic focus developed in the left upper lobe, which some days later resolved without a fall in the temperature; rather the fever continuing with enlarged spleen, diarrhoea, roseola, in short with all the symptoms of a rather severe typhoid fever that terminated favorably.
Gangrene of the lungs is a complication that rarely occurs and only in intensely severe cases. More frequently we meet with pleuritis, with either serous or purulent exudation, caused either by the typhoid ba cilli or, more frequently, by a mixed infection. A latent tuberculosis, localized in the peribronchial lymph-nodes may be aroused by the fever and especially by the concomitant bronchial catarrh, and may mani fest itself by a continuance of fever, which usually presents irregular fluctuations at times of a hectic character, as well as by increasing cough, dyspncea, and evidence of foci of infiltration in the lungs.