Moderate inspiratory recessions occur, particularly in younger children. Ex piration is noticeably suppressed and is of a well-marked grunting and moan ing character. The grunting expiration is not so plain during rest as while speaking and crying, and sound inter rupted, suppressed, and painful. Con tinuous crying is avoided. If cough be present it is short and suppressed, and is often followed by crying in conse quence of the pain which is produced.
The clinical picture changes somewhat towards the end of the w-eek. The high, continuous fever, together with the lessened amount of nour ishment which has been taken, have already preeeptibly thinned the cheeks of the patient. The patient loses in strength and no longer at tempts to sit up alone. The facial expression is anxious and painfully distorted. The respiration has become somewhat more accelerated and is more laborious. The pulse becomes more frequent and softer. The tongue is heavily coated and dry, bowels are usually sluggish, and the urine is scanty and dark in color. The appetite is still more diminished. The physical signs in tbe lungs have become very plain by this time. From the fifth to the sixth day on, apathy, somnolence, occasionally also delirium and alarming weakness, often occur. Then, mostly at this time the longed-for crisis occurs which is frequently announced by the appearance of crepitant thles and by the skin becoming moist. The temperature which during the whole course of the disease has been con tinuously high, ranging from 30° and 40° to 40.5°C. (102°,104°,105° F.) drops to normal or somewhat below- norrnal within 12-24 hours. This decline in temperature occurs between the fifth and ninth day, mostly in the seventh day. Occasionally, during the ciisis the patient perspires very freely, and lapses into a quiet slumber. On awakening, the clini cal picture is very much altered. Many children are then very, bright, and ask for nourishment; others, who have been more ill are still very feeble and languid; but respiration has become much easier, slower, and noiseless, no longer grunting. The frequency of the pulse also diminishes rapidly. Dulness, bronchophony, and bronchial breathing, rapidly subside, and at the end of a week have usually entirely disap peared, leaving the patient fully convalescent.
Whenever the disease does not terminate favorably, and does not come to a crisis, perhaps because another lobe has become involved, the condition becomes constantly more serious from the eighth and ninth day on. The respiration becomes more labored, marked inspiratory recessions and cy-anosis appear. The pulse becomes very small and inter mittent, increasing to 200 and more. With increasing stupor and weak
ness or pulmonary (Aetna, death occurs, usually during the second week.
EY-en after resolution has taken place dangers may still threaten. In the first place from pleurisy (often purulent) or pericarditis, In rare eases, also, pneumonia terminates in atrophy. Termination in gan grene of the lungs which occurs exceedingly seldom is scarcely ever dependent upon a pneumonia per se, and may be more properly attrib uted to inspiration of particles of food. The same may be said of abscess of the lung which is rarely observed, and which, may, however, also develop from an encapsulated, purulent, pleuritic exudate.
Individual Symptoms and Complications.—From the beginning, respiration shows a marked increase in frequency. During the early years of life this often attains 50-60, yes, even SO; in older children 40-60-70. Since in the beginning, signs of dyspncea are frequently absent, one. is easily disposed to blame the fever solely on the increased frequency of respiration. On careful examination, however, the respira tion proves to be more rapid than the pulse, so that the ratio is less than 1:3. On expiration a moderate retardation or dragging of the affected side is shown. This, however, is never as marked as in exudative pleu ritis, and is particularly' absent in the beginning. In cases of involve ment of a lower lobe, mensuration may show a slight expansion of the corresponding half of the chest (Ziernssen).
The grunting, moaning and noisy expiration, is a particularly fre quent symptom in the subsequent course of croupous pneumonia. It is seldom found so outspoken in other diseases, or in bronchopneumonia, so that its appearance should at once arouse a suspieion of croupous pneumonia. Experienced mothers frequently make a proper diagnosis from this symptom alone. It is probable that the grunting expiration depends chiefly upon fill involvement of the pleura. This explains why in a central pneumonia (to which many apex pneunionias belong espe cially) it is so frequently absent. After the crisis the respiration rapidly becomes quiet and regular, tlysplicea disappears, and the number of respirations becomes normal within a few clays. In the beginning, dyspncea is often scarcely noticeable, and even later, especially in cen tral and apical pneumonias, it is but slightly marked. As a general rule, it is less marked than in bronehopneumonia and for this reason, cyanosis and inspiratory recessions are of a lesser degree. In extensive consoli dation and particularly in an attendant bronchitis the dysplitea may assume a very high grade.