The pleura participates regularly in croupous pneumonia as soon as the inflammation reaches it.* Friction is less frequently heard than in adults, very likely because the movements of the thorax are curtailed by the pain, a condition which the physician cannot increase at will. The most frequent and most important complication is exudative, and especially purulent, pleuritis, during which bronchial breathing and bronchophony may be very distinct and not only continue to be present but may even be increased.
The pulse is always very much increased in rapidity, and during the first years of life and during high temperature may reach 1S0-200 without causing an unfavorable prognosis. It is more unfavorable when the pulse becomes too small, intermittent, and easily compressible at the time of the crisis. After the crisis, the frequency diminishes rapidly, but often only becomes normal after several days. An irregular and slow pulse often occurs in older children during convalescence and is not a bad symptom.
The heart of the infant on account of its still unenfeebled condition, generally guarantees a favorable termination, the strong right ventricle contributing especially- thereto. A fatal collapse during the period of convalescence is an unusual event. A not very infrequent and a very serious complication is the occurrence of pericarditis, often fibrinous, purulent and causing a fatal termination. During life, pericarditis, which often develops with pleurisy, is frequently unrecognized (von Jaksch). Severe cyanosis, dyspnata, a bad pulse without sufficient rea sons, according to the condition of the lungs should lead one to think of this complication. Endocarditis is less frequent and not so serious.
From the first day. of the disease, the blood shows a marked leneo cytosis (instead of 10,000 leucocytes as high as 50,000 to mm.3), which increases until the crisis is reached and then rapidly decreases (v. Jaksch, Monti, Berggrun).
Leucocytosis is of prognostic value, since in fatal cases it is often relatively low or absent. Polynuclear cells predominate.
The digestire organs show nothing special except the frequent initial vomiting. The tongue is heavily coated, the appetite is poor, the thirst is great. Older children are frequently constipated; in infants cliarrhma occurs at times. A follicular tonsillitis sometimes precedes a pneumonia.
Tbe liver, and more frequently the spleen, may become enlarged to a mod erate degree. Exceptionally a purulent peritonitis may develop, which like most of the complications is caused by- pneumococci, the prognosis being comparatively favorable. Jaundice is less frequent than in adults.
The urine is scanty and high colored. It is deficient in sodium chloride, rich in urates, and also rich in urea which may still increase after the crisis (ming to the resorption of the pulmonary exudate. A febrile albuminuria is frequently present, less often a genuine acute nephritis which is at times luernorrhagic in character. Peptone, ace tone, anti acetic acid, are frequently present in the urine. Diazo re action is not frequent.
The nervous system frequently shows a serious participation of the brain which often dominates the entire clinical picture (cerebral pneu monia, etc.). In older children, delirium is often observed near the crisis, and postpneumonic melancholia. Aphasia and unilateral pal sies have also been described (Aufreeht). Genuine purulent meningitis is a rare complication. Pfaundler frequently found the patellar reflex diminished or absent, often even before the occurrence of the pulmonary symptoms. He regards this symptom of diagnostic value.
The Skin.—Ilerpes facialis is decidedly more rarely found than in adults (see Fig. S2). The statements regarding the frequency of the same vary considerably. Schlesinger found it in 18 per cent., Comby 10 per cent. of cases. Especially during the first years of life, when it would be desirable for diagnostic purposes, it is frequently absent. It may appear after the third or fourth day. An intense circumscribed redness of the cheek is often seen with the onset of the fever, and fre quently only disappears after the completion of the crisis. The redness of the cheek is frequently unilateral, but does not by any means always correspond to the seat of the pneumonia. In some cases, at the com mencement of' the disease, a general erythema of the skin mostly scar latina! in appearance occurs, but i.s of no consequence (Mace!).