Even when the fibroid overgrowth has increased to such a degree as seriously to impair the usefulness of the lung as a respiratory organ, the influence of the disease upon general nutrition may be comparatively slight so long as the chest is free from intercurrent attacks of bronchitis or ca tarrhal pneumonia. Special symptoms arising from contraction of the lung and consequent obstruction to the pulmonary and systemic circulation are to be noticed ; but if no secondary disease of organs has been induced by his illness, the child is often fairly stout and strong. Therefore, in warm and settled weather, which brings with it freedom from catarrh, his health may afford little subject for complaint ; but in changeable seasons, and es pecially during the winter months, he wastes rapidly and exhibits all the symptoms of " consumption." When the disease occurs as a sequel to an attack of pleurisy, the early symptoms vary according as to whether the pleuritic effusion and conse quent compression of the lung have been moderate or excessive. In the first case, unless a local catarrh be present the general symptoms may be insignificant ; and a physical examination may only detect dulness at the extreme base behind, with very weak bronchial breathing and some coarse bubbles with respiration. The child may be subject to paroxysmal cough, but need not for a long time necessarily suffer in his nutrition through the condition of his lung. If, however, effusion have been copious, and the lung be bound down by thick bands of lymph, the symptoms and physical signs are those of pleurisy with retraction, combined with paroxysmal cough, profuse expectoration of offensive muco-purulent sputa, and the other phenomena which attend a case of pronounced cirrhosis of the lung.
In the fully established disease we find the following signs : On account of the diminution in size of the affected lung, the chest-wall corresponding to the shrunken organ is retracted. The ribs are flattened over the seat of disease, and the respiratory movement is impaired or sup pressed. If the lung is much reduced in size, the shoulder, the nipple, and the inferior angle of the scapula are lowered, the ribs are approxi mated, and the circumference of the chest on that side is diminished to the measuring tape. An outline of the chest drawn from the cyrtometer shows this 'difference between the two sides very clearly. In addition a certain displacement of soft parts in the neighbourhood is to be noted. The mediastinum is drawn towards the affected side, and the opposite lung is found on percussion to project across the middle line of the chest. The heart is also displaced, unless adhesions between the pericardium and ad joining pleura retain it in its normal position. If the upper part of the left lung be the seat of disease, the heart is drawn upwards. If the right lung be affected, the heart is pulled towards the right side, and in extreme cases may be felt beating to the right of the sternum. Vocal vibration is
sometimes plainly perceptible over the indurated organ, although it is ab sent from the sound side. In other cases no fremitus may be perceived over the affected half of the chest when the child speaks, although it can be felt over the healthy lung. The percussion-note is of wooden or tubular quality, and there is usually marked resistance of the chest-wall. This in crease of resistance is especially noticeable when the diseased lung is the seat of an intercurrent attack of bronchopneumonia ; and the percussion note at this time may be as completely dull and toneless as in cases of pleuritic effusion. The breath-sound is found to vary according to the amount of secretion retained in the tubes at the time of examination. If the dilated tubes are full of muco-pus, the breath-sound is weak and bron chial, with little rhonchus ; and resonance of the voice when the child speaks is faint or suppressed. If the air-passages are comparatively empty, the respiration is loud and blowing, often intensely cavernous, or even amphoric, with metallic echo ; and large, crisp, metallic bubbles, with dry, creaking sounds, are heard with both inspiration and expiration. These signs are in most cases limited to one-half of the chest.
The symptoms noted in a case of pronounced cirrhosis are in part clue to the condition of the lung itself ; but in part they are the consequence of the obstructed pulmonary circulation.
The cough is a very characteristic symptom. Owing to retention of secretion in the dilated tubes, and to loss of elasticity in their indurated walls, cough is severe and spasmodic. It occurs at comparatively rare in tervals, and consists in a rapid succession of loose-sounding hacks which often continue for many minutes. The child's face becomes congested and his eyelids suffused, and his whole body often shakes with the vio lence of the paroxysm. After lasting a variable time the cough ends in spasmodic contractions of the diaphragm, and enormous quantities of offensive purulent matter are retched or expectorated. The unpleasant smell of the morbid secretion is due partly tb its retention and consequent putrefaction in the dilated tubes, and partly to the presence in it of gan grenous shreds of mucous membrane. The same causes communicate a fetor to the child's breath, :which can be perceived at a considerable dis tance from his cot. Sometimes the expectorated matters are tinged with blood ; but heemoptysis from this cause is not common in the child. Epistaxis may, however, occur, and the blood from the nose may be swal lowed and retched up again at the end of a cough, so as to appear as if brought up from the lungs.
The respirations are usually from 30 to 35 in the minute. If broncho pneumonia be superadded, the breathing becomes much more hurried, and the pulse-respiration ratio is perverted.