In many cases where nervous symptoms are prominent there is a sallow tint of the face, with tenderness over the liver, and a constipated state of the bowels. The symptoms of nervous excitement do not appear to be dependent upon undue elevation of temperature, for they do not neces sarily occur in cases where the pyrexia is most marked ; nor do they seem to have any connection with the ordinary reflex excitability of the nervous system so common in the young child.
A little girl, aged three years, was noticed to be very restless and irri table for a fortnight. At the end of that time she had a fit while at dinner. The child was brought to the hospital and remained convulsed for two hours. She was kept in the hospital for about a week, on account of twitchings in the muscles and a certain excitability of manner, although she had no return of the fits and seemed to be perfectly intelligent. The bowels were costive and had been much confined, otherwise no derange ment of organs could be discovered. After her discharge the child remained well for a fortnight, and was then brought back to the hospital with an attack of lobar pneumonia involving the lower part of the right lung. In this attack, although the temperature was high (about 104°, both morning and evening) the illness had not been ushered in by convulsions ; there was complete absence of nervous excitement ; and the disease ran an exceptionally mild course.
The breathing in pneumonia is hurried from the first. There is no actual dyspncea, for in an ordinary case we find none of the distress which is seen when a child is consciously suffering from shortness of breath. He lies down in his bed and requires no support by additional pillows. The Dares dilate widely, but the respiratory movements are merely increased in rapidity without being exaggerated in degree. The pulse is also quicker than normal, but is proportionately less hurried than the breathing. Con sequently there is a disturbance of the relation naturally° existing between the pulse and the respiration which is a very important symptom. The ratio from being 1 to 3.5 is reduced to 1 to 2.5 or even 1 to 2. Thus, a respiratory rate of 75 with a pulse rate of 140 is very commonly met with. Although the rapidity of breathing is not accompanied under ordi nary circumstances by a feeling of dyspucea, the child shows by his man ner that the supply of air to his lungs is a pressing necessity, for he will not willingly allow the process to be interrupted. He will bear much dis comfort without complaint, and indeed the passiveness of a young child under examination is a characteristic feature of the disease. If he begin to cry he usually ceases to do so very quickly. If he suck, he does so hurriedly, stopping at short intervals to breathe through his half-open' mouth, as air cannot be admitted in sufficient quantity through the nose.
The tongue is thickly furred, and in severe cases may become dry and brown. Vomiting often occurs at the beginning. The bowels are usually confined, but may be loose, and in exceptional cases there is profuse diar rhoea. The appetite is completely lost, and there is great thirst.
The urine is diminished in quantity. Its specific gravity is high, and it is often thick with lithates. The excretion of urea and uric acid is above the average of health ; but there is a great diminution in the amount of chlorides ; and at the height of the disease these salts may disappear altogether from the urine. Occasionally there is albuminuria ; and bile pigment is often noticed.
The pyrexia is high from the first, and the remission in the morning is often very slight, seldom exceeding a degree or a degree and a half. The temperature rises usually to between 103° and 105°, but may be higher. It often reaches its maximum on the third day. When the temperature falls it falls suddenly. Thus, in the case of a little girl, aged five years, on the evening of the fifth day the thermometer registered 104.2°. It then began to fall. At 10 P.M. it was 101.2° ; at 2 A.M. on the following morning it was ; and at 6 A.M. 99°. It remained all day at this level, being the same at 10 P.M.
Although in ordinary cases of pneumonia there is no actual dyspncea, in exceptional instances we find serious suffering from want of breath. It occasionally happens that when a large area of lung has become rapidly consolidated the heart's action is seriously embarrassed by the impediment to the pulmonary circulation. The over-distended right ventricle labours violently to force the circulation onwards ; but its walls soon become weakened and dilated by the pressure to which they are exposed. We find the child propped up in his cot struggling for breath with a pale or livid face. His Dares dilate widely at each inspiration ; the chest-walls are forcibly elevated, but expand only imperfectly ; and there is great recession of the suprasternal notch, the intercostal spaces, and the epigastrium as each breath is drawn. The child can hardly speak, but his expression in dicates terror and distress, and beads of sweat often stand upon his brow. On inspecting the chest the right auricle can usually be seen beating in the second and third interspaces to the right of the sternum ; the heart's action is violent, while the pulse at the wrist is so feeble as to be hardly perceptible. There is, indeed, little blood in the systemic circulation, but the pulmonary system is engorged. These cases are not so common in the child as they are in the adult ; but they are occasionally met with in early life, and unless prompt assistance be rendered may quickly prove fatal.