As the illness advances, and the nodules of consolidation grow larger and coalesce, more and more of the respiratory surface becomes involved, so that cyanotic symptoms are manifest. The face grows excessively pale, with a dusky tint around the eyes and mouth ; the expression is anxious ; the eyeballs are staring and suffused. The respirations may rise to 70, 80, or even more in the minute ; and the breathing grows more and more laborious. The child is painfully apathetic and dull. If an infant., he refuses his bottle, and can with difficulty be per suaded to swallow fluids from a spoon. His hands and feet are purple and often cold to the touch, although the internal temperature of the body is still febrile. At this period cough almost ceases, partly from exhaustion, partly from impaired irritability of the respiratory centre. In this state the child sinks and dies, the end being often preceded by a fit of convul sions. Before death, when this takes place from asphyxia, the internal temperature may be subnormal. In the case of a little rickety boy, aged thirteen months, with only two teeth, who died on the eleventh day from extensive catarrhal pneumonia of both lungs, the temperature at 6 R. on the evening before death had fallen to in the rectum.
At this stage of the disease percussion discovers more or less extensive dulness of the back on each side ; and the breathing is bronchial or tubu lar, especially about the angle of the scapula. The respiration is accompa nied by much fine metallic crepitation both in inspiration and expiration ; and this is often very superficial-sounding, as if generated immediately underneath the stethoscope. In the front of the chest there is seldom dulness, unless perhaps the resonance at the bases is diminished ; but usually a certain amount of coarse crepitation may be heard in the mam mary and infra-mammary region side. A curious feature at this time is the indifference of the child to the discomforts of the examination. He allows himself to be placed in any position without complaint, and seems to be quite careless what is done to him.
If the disease terminate favourably, there is no critical fall of temper ature, as is the case with the croupous variety of pneumonia. On the con trary, the diminution in the pyrexia takes place very gradually, and the improvement in the general condition does not occur until the local symp toms have given signs of amendment. Thus, the pulse and respiration are reduced in frequency, the breathing becomes less laborious, the pulse fuller, and the superficial veins less distended. The pallor and lividity of the face are less noticeable and the expression loses its distress. The tongue cleans, vomiting ceases, and the appetite returns. Still, the tem perature, although it continues to fall, is some days before it sinks to a natural level. The physical signs are also very slow to improve, and ab
sorption takes place very gradually. This variety of 'pneumonia, as has been said, is apt to leave behind it caseous unabsorbed masses in the lung which may lead to serious illness in the future. Still, under favourable con ditions these often become absorbed even although a period of months has elapsed since the attack was at an end.
If the disease do not prove fatal or show signs of resolution at the end of a week or ten days, it often takes on a subacute course. In some cases, espe cially where the catarrhal pneumonia occurs as a complication of measles or whooping-cough, the subacute character may prevail from the first. In this form the symptoms are less severe than in the acute variety, and the course of the disease is much longer. The temperature does not reach so high a level, remaining usually at about 102°, with morning remissions. Sometimes the pyrexia undergoes curious alternations. Thus, after being moderate for a few days (99°401°) the temperature suddenly shoots up to or 105°, and after a day or two sinks again to the same level as be fore. The pulse and respiration are both hurried, but their normal rela tion is comparatively little altered. As the disease advances the cough loses its hacking character and occurs in violent paroxysms almost indis tinguishable from those of pertussis. Their duration is, however, shorter, and inspiration is noiseless or less decidedly crowing. They may be fol lowed by vomiting. This character of the cough should lead us to sus pect considerable dilatation of the bronchi.
Vomiting and some looseness of the bowels are common symptoms. The tongue is furred ; the appetite is impaired ; the strength is diminished ; and the child wastes rapidly and becomes very feeble. In these cases, in addition to the physical signs of broncho-pneumonia which have been already described, we find very clear evidence of dilatation of bronchi. At each posterior base, but more pronounced on one side than on the other, cavernous breathing is heard with a coarse metallic ringing crepitation, sounding very close to the ear ; or the respiratory sound may be amphoric with tinkling echo. In many cases, too, the vocal resonance is broncho phonic, and the faintest laryngeal sound is conducted clearly to the end of the stethoscope.
These cases often continue for weeks, but under judicious treatment generally end in recovery. There is, however, a great tendency to imperfect absorption of the deposit ; and unless the child be placed under favoura ble sanitary conditions a chronic consolidation may be left which is after wards a source of danger. Sometimes, too, these cases pass into fibroid induration of the lung.