The urine usually is scant, often contains albumin, less frequently casts and renal epithelia. Sometimes it exhibits the character of nephritic urine, and there is a form of the affection designated as renal-typhoid in which these symptoms manifest themselves at the very beginning and dominate the disease. As already stated, typhoid bacilli frequently occur in the urine. Ehrlich's diazo reaction usually proves positive at the height of the process. From the time of its appearance, its intensity, and duration we may, with certain precaution, draw prog nostic conclusions. On the part of the sexual organs we observe rarely in girls a pseudomembranous inflammation of the vagina and gangrene (soma) of the labia.
Having described the course of light, medium and malignant cases of typhoid fever in childhood with their complications and sequeke, there remains to give a short survey of some particular and peculiar features of the disease. Foremost among these are the abortive cases, distinguished from ordinary typhoid by their short duration, and accom parried either by light or severe symptoms. Next come protracted cases in winch without complications or sequehe, the fever may persist for five weeks and longer. Finally we have feverless or afebrile cases, by all means the rarest anomaly of the morbid process. These forms, frequently overlooked or falsely interpreted, play a role in spreading the infection that must not be underestimated. Their recognition has been materially facilitated by the modern methods of cultivating the bac teria from the dejeetions and by \Vidal's agglutination reaction.
Relapses in children are scarcely rarer than in adults. They may occur during the period of defervescence, forcing the temperature again upwards; or set in after a brief afebrile interval. The relapse may equal in intensity and duration the first onset or exceed it, or be less, or repeat itself many times (see temperature curve in Fig. 106) thus protracting the duration of the disease considerably. In a ease reported by Comby, the fever relapsed six times and lasted fully four months.
Typhoid fever in infancy occupies, in a certain sense, a separate position. On the strength of my own experience I can not confirm the assertion made on various sides that the affection is exceedingly rare during the first half of life. True, the symptoms are of a rather vague nature; yet the course of the temperature curve, which in point of con stancy and regularity, is not encountered in other febrile intestinal affec tions of this age, will lead to the right scent, and the usually profuse eruption of roseola should remove any doubt. Alarfan, Gerhardt, and recently Forget, consider the prognosis of the affection at this age as especially bad, its mortality, according to the last-mentioned author, being 50 per cent. The latter claim, however, is contrary to my obser vation, for in a dozen cases of typhoid fever in infants there was only one with fatal termination. True, these infants were all breast-fed, which may have a certain influence on the prognosis. Likewise, the
extensive intestinal alterations advanced by various writers, which may lead to perforation, I have never been able to observe in the necroscopic material at the Prague Pathological Institute.
The course and termination generally speaking is likely to be shorter and more favorable than in adults, but they exhibit great varia tion. The height of the fever indicates the gravity of the case to a lesser extent than the tempestuous beginning of the phenomena with sharp ascent of the temperature, rapidly developing disturbance of the sen sorium, pallor of the face, dryness and fuliginous coating of the tongue and teeth, fissured lips, intense prostration, feeble and frequent pulse, etc. But even in such cases the conditions are not quite so unfavorable as in later life the two most dangerous contingencies, intestinal hremor rhage and perforation, being of rare occurrence. Ambulatory typhoid in children, especially from the lower strata of society, is by no means rare, yet. I have had repeatedly patients from the better classes brought to my office who had been feverish for sonic time and in whom I was able to determine the fully developed disease. Many cases of this kind may suddenly terminate unfavorably, as Biedert and others have observed.
The diagnosis, on account of its mild course and the vague symp toms during the first week, is usually quite difficult and may be estab lished only by exclusion. The course of the temperature, which should be taken every three or four hours, the steadily increasing size of the spleen, and the eruption of roseola, both of which symptoms are scarcely observable before the end of the first week of fever, finally clear up the diagnosis. However, very frequently—and any practitioner of average experience will agree with me—a differential diagnosis from other feb rile conditions of childhood may be exceedingly difficult. Foremost. among these I mention miliary tuberculosis, which may equally stealth ily set in, at first presenting no local symptoms and with a similar temperature curve. In such perplexing cases irregular fluctuation of the fever (the variation between morning and evening being several de grees), the absence of diarrha-a, the presence of dyspnom with almost negative pulmonary findings, the relatively long duration of the process, its stationary character, hereditary taint, demonstration of tuberculous products in the region of the glands or in the osseous system, and finally the development of the disease after measles or whooping-cough, are suggestive of tuberculosis, whereas enlarged spleen and roseola point to typhoid fever. But even in such cases mistakes are by no means im possible. I, myself, for instance, observed a case in which, immediately succeeding measles, a severe typhoid fever developed. A positive diag nosis of it was made possible only after long hesitation and principally on the basis of its recovery.