Complications.—In the more severe cases complications are frequently met with. In a large proportion more or less bronchial catarrh is present by the end of the first week. Fenwick states that in 87 per cent. of his cases signs of bron chitis were present at the end of the fourth day, and lobular consolidation was encountered in nearly 37 per cent. of his entire number. The onset of bron cho-pneumonia is often very insidious; the cough may be only slight, but the respirations will be observed to be un duly frequent, and the temperature shows a distinct rise. The physical signs are generally obscure, and most fre quently are localized at the base of the lungs.
Percussion may show only a slight deficiency in resonance, and on auscul tation we may find either a diminution of vesicular murmur or the presence of sibilant rftles. It is characteristic, how ever, of this form of infection that these signs are variable, and show a tendency to change from one place to another; it is exceptional to observe large areas of consolidation. The progress of the pul monary lesion is modified by the gen eral symptoms of the case; increased dyspncea is always a symptom of grave import.
Pleurisy is very seldom observed; when it does manifest itself, it tends rapidly to become purulent. Associated sometimes with the pulmonary infection, but occa sionally as a complication by itself, we meet with symptoms of cerebral conges tion, manifested in stupor, delirium, or epileptiform convulsions. Only rarely do we observe definite signs of local trouble; such as strabismus, inequality of pupils, and irregular pulse and res piration. Lesage makes reference to some forms of paralysis which disappear with returning health. Thrombosis of the cerebral vessels may take place in the final stages, and may, or may not mani fest its presence by special symptoms. Occasionally an attack of tetany may supervene. Should the drain of fluid from the tissues have been great, the de fective circulation may in itself give rise to many of the above symptoms. Infre quently the cerebral symptoms may be regarded as of a urfemic nature.
A true parenchymatous nephritis due to infection would appear to be a rare complication. Kjellberg states he met with it in 47 per cent. of his fatal cases; but competent observers, both English and American, have failed to meet with it, except very occasionally. Fenwick states that albumin in the urine was noted in 17 per cent. of his cases before
the fifth day of the disease; but in no instance did the urine show more than a trace of it. Under the microscope he never observed either blood-corpuscles or epithelial casts. Booker states that ne crosis of the epithelium in the convoluted and irregular tubules was found in nearly all his cases, and, in not a few, hyaline tube-casts were demonstrable. Infiltra tion with leucocytes was not seen in any case.
Various rashes on the skin may occa sionally be noted, usually of an erythem atous nature; and, unless great care is exercised, a mycotic ulceration of the mouth and throat may add greatly to the infant's discomfort.
The normal leucocyte-count in infants under 10 months is 13,500; but there is considerable individual variation. Mon onuclear cells predominate, the average number of polynuclear cells being 42 per cent. In dyspepsia, infantile atrophy, and gastro-enteritis there is no change in the proportion of the various kinds of leucocytes. In follicular enteritis and cholera infantum, with marked intesti nal lesions. there is an absolute increase in the total leucocytes, and a small rela tive increase in polynuclear cells. The existence of lymphocytosis described in intestinal diseases in infancy denied. Japhar (Jahr. f. Kinderh., B. 3, S. 179, 1901).
Diagnosis.—While there may be for the first two or three days some uncer tainty in reference to the character of a diarrhoea, a persistent high temperature beyond this period stamps the attack as of an inflammatory nature. After this date fluid evacuations of an offensive odor are characteristic of the toxic form; while small stools containing mucus in quantity and passed with much straining are met with in those cases in which the local inflammatory disorder is prominent. Typhoid fever is seldom met with during infancy; its onset is occasionally some what abrupt, but after the first few days its course becomes more characteristic. Widal's test should be applied in doubt ful cases. Several of the acute specific fevers are sometimes ushered in by an in testinal disturbance, which may for two or three days be misleading; of these scarlet fever and pneumonia are probably the most important. Intussusception develops rapidly and the stools always contain mucus and a considerable amount of dark blood, and are passed with straining; for the first few days there is no pyrexia.