Laryngeal complications, which in adults, especially in the course of certain epidemics, are frequent and always serious occurrences, are rarely observed in the typhoid fever of children. They may appear as laryngitis, corresponding anatomically to an infiltration of the mucous membrane; or as ulcerations analogous to those described as occurring in the pharynx; or even as a laryngeal perichondritis, with cartilaginous necrosis and abscess formation. Clinically this complication is mani fest by aphonia, rasping croup-like cough, fits of suffocation, and, if it begins in the third or fourth week, by an increase of fever. A form of typhoid, beginning with laryngeal symptoms and occurring in children, has been described by Schuster as "laryngotyphus," the laryngeal symptoms continuing during the whole course of the disease. Fibrinous inflammation of the larynx and paralysis of the laryngeal muscles have been reported.
With respect to cardiac complications endocarditis and pericarditis may occur, but they are more rarely encountered in typhoid fever than in the course of other infectious diseases.
Of the symptoms on the part of the skin, the rose spots are the most conspicuous, equaling the enlarged spleen in diagnostic value. They appear five to ten days after the beginning of the fever, usually confined to the abdomen and back, less often except during infancy they are diffused over the entire body. The exanthem consists of pale-red slightly elevated papules of the size of a pinhead which disappear on pressure with the finger. The eruption comes out in several series and vanishes after a short time. The fact that the eruption cannot. always be easily demonstrated is distinctly indicative of typhoid fever, the often scanty efflorescences must he carefully looked for or they may be overlooked. In a case under my observation the eruption was con fined to a small group of lichen-like nodules in the right loin. From flea bites, which they resemble very much, these efflorescences are dis tinguished by the absence of a central point corresponding to the bite. Their number is no criterion of the course of typhoid fever; but a bluish color, instead of the customary rose, points to a serious infection. There are, however, cases in which the rose spots are wanting during the entire course of the disease.
While during the first clays of the disease the skin appears very dry, it is possible that later, especially at the initial remission of the fever, a profuse perspiration with miliaria may occur; this is devoid of any diagnostic or prognostic significance. Recently Auche and Letrelle have described cases of disseminated cutaneous gangrene which occa sions bluish red plaques with ecchymotic centres or abscesses of the skin. The same author and others have also observed pustules and
numerous cutaneous and subcutaneous abscesses. I have witnessed similar cases, the severest of which was that of the son of one of my colleagues, whose whole body was covered with numerous walnut-sized pus foci. It is evident that such complications aggravate and protract the disease. There occur also polymorphous erythemata, predomi nantly localized around the joints, and caused by a micrococcus closely related to the diplocoecus hasmorrhagicus (Leroux and Lorrain).
Decubilus, quite frequent and justly feared in adults, is rare in children, and is met with only in the severe and neglected cases. The decubitus is usually over the sacral bone, and never spreads extensively or deeply. Complications with erysipelas is an exceptional occurrence though it was observed by Escherich and myself, in a case where it started from the scrotum: this child also presented evidences of idiocy and aphasia. On the other hand, herpes labialis, which formerly was regarded as negative of typhoid fever, but indicative of pneumonia, is not at all rare in children.
Paresis of the lower extremities is sometimes observed. It retards convalescence, but as a rule, it disappears without leaving any perma nent traces. I have already mentioned a case of eclampsia with subse quent idiocy. In such a complication we have evidently to deal with a localization of the process in the meninges or in the cerebral cortex.
Several authors have spoken of the demonstration in cases of gitis of bacilli in the cerebrospinal fluid obtained by lumbar puncture.
Among the involvements of the organs of sense, apoplexy of the retina described by Bouchut may be mentioned, likewise otitis media, whose causation is evidently connected with the mouth infections which accompany typhoid and are rather frequent. During the period of con valescence deafness exists frequently, but is only transitory.
The blood exhibits hypolcucocytosis, reduction of the amount of haemoglobin and of the number of eosinophilous elements. These find ings may at tittles be utilized for purposes of differential diagnosis in initial pneumonia. I cannot substantiate the fibrin reaction as stated by Rosenthal that no fibrin network forms in the fresh preparation of typhoid blood, whereas in pneumonia, meningitis, and other affections with accompanying leueocytosis, a fibrin web may develop in the course of half an hour.