Terminations.—In the large majority of cases in the child croupous pneumonia ends in resolution and recovery. In the primary form of the disease an unfavourable termination is very rare ; and even in cases of sec ondary pneumonia, unless the child be a new-born infant or in a state of great weakness, it is exceptional for him to die. When death takes place it usually occurs on the fourth or fifth day as a result of failure of the heart. It may, however, happen later as a consequence of abscess or gangrene of the lung.
When resolution occurs, the improvement is very sudden, and the dis ease terminates by crisis. The temperature, which had given little or no sign of reduction, falls suddenly in the course of twelve hours to the normal level, and remains low for four-and-twenty hours, even if it afterwards undergo a moderate increase. The crisis often occurs on the fifth day, but may be deferred until the eighth or ninth, and in rare cases until later. The violence of the onset, the height of the fever, and the severity of the nervous symptoms are not in proportion to the extent of surface in volved, nor are they to be taken as an indication that the course of the disease will be prolonged ; for cases in which the general symptoms are very pronounced may come to an end on the fifth day. The cessation of the pyrexia is followed by an immediate improvement in the child's con dition. The skin becomes moist ; the tongue cleans ; the pulse and respi ration fall in frequency and regain their normal relation to one another ; the cough is loose and less frequent ; the urine is more profuse ; and the appetite returns. The favourable change in the general symptoms precedes the improvement in the physical signs, and for a day or two the resonance may continue to be impaired, and the breathing to be bronchial or blow ing over the affected part of the lung.
In exceptional cases the termination by resolution occurs more gradu ally. The temperature perhaps falls suddenly, but almost immediately rises again ; so that for two or three days, a week, or even longer, the bodily heat may continue to be considerable at night, with a morning fall. Sometimes, after remaining low for two or three days the thermometer again registers a high degree of temperature and the child passes through a complete relapse of his illness. The relapse is, however, usually shorter
and less severe than the original attack.
The termination by abscess of the lung is not often seen except in cases where the pulmonary affection is secondary to pyannia. It does, however, occasionally occur in children of weakly constitution who are living in thoroughly insanitary conditions ; and may also be seen in cases where in flammation is set up in the lung as a consequence of impaction of a foreign body in one of the bronchi.
When abscess of the lung occurs in a case of secondary pneumonia the temperature remains high, or if it fall, rapidly rises again and assumes a hectic type ; there is great weakness ; the tongue becomes dry and brown, and the complexion dull and earthy in tint, with livid discolouration of the eyelids and lips. On examination of the chest the dulness is found to per sist, and the breathing to be bronchial or blowing, with much large bub bling or even metallic rhonchus. Unless the abscess burst into a bronchial tube, and its contents be evacuated, the physical sions are not characteris tic of the lesion. If, however, the purulent contents are discharged, caver nous breathing, whispering bronchophony, and the usual signs of a cavity may be detected at the seat of the disease. If the abscess be the result of pyEemic infection, the general symptoms are those of the constitutional state, and the local signs, not being the consequence of any extensive local inflammation, may be overlooked, more especially as the abscesses are small and are often completely surrounded by healthy lung-tissue.
Gangrene of the lung will be considered in a separate chapter.
Pneumonia is occasionally latent. This form of the disease is most commonly seen when the patient is a young child worn and wasted by chronic abdominal derangement, whose nervous irritability is almost com pletely lost. In such cases the ordinary symptoms of invasion are not no ticed. There is no sign of pain in the chest. Even the cough may be infrequent or absent. A slight rise in the temperature, increased rapidity of breathing, perversion of the pulse-respiration ratio, and indications of early prostration may be the only symptoms excited by the intercurrent malady.