The appetite is often good, and although the child is pale as a rule, his nutrition, as has been said, unless interfered with by an intercurrent in flammatory attack, may be fairly satisfactory. During the attacks of ca tarrhal pneumonia, however, he wastes rapidly ; and if the disease has produced marked contraction of the side, the child is usually greatly emaciated. • Pyrexia is not a symptom of the uncomplicated disease. 'When pres ent, it usually indicates the occurrence of bronchitis or pneumonia, and is then 102° or 103°, or even higher. A more moderate pyrexia, may be the consequence of ulceration of the bronchial tubes. In these cases a microscopical examination of the sputum will discover the presence of fibres of elastic tissue.
In addition to the above symptoms others are present which are the consequence of interference with the pulmonary circulation. The right side of the heart becomes hypertrophied, and the systemic venous system is fuller than natural, so that the veins of the neck and chest, and often of the limbs, are abnormally prominent. The fingers are clubbed, and in advanced cases there may be a congested, turgid appearance of the face.
Amyloid disease of the liver, spleen, and kidneys is commonly present in advanced cases. If this be marked, there may be great anaemia and general dropsy.
Although in most cases fibroid induration of the lung is accompanied by marked contraction of the side, this symptom is not always present. In one of the most pronounced examples of the disease which has come under my notice—a child of five years old—the chest was well-shaped, and the affected half, although slightly flattened posteriorly and at the junction of the lateral and anterior thirds, was little inferior to the healthy side in actual measurement. In this case dissection of the body showed that the shrinking and condensation of the lung tissue was compensated for by enormous dilatation of the air-tubes, so that the space occupied by the or gan in the chest cavity was little diminished. Even if the lung be con densed so as to reduce its volume much below the standard of health, marked contraction of the chest may he prevented by the drawing into the affected side of movable organs in the neighbourhood. Thus, in a boy —aged eleven years—in whom the shrunken right lung was reduced to a mere mass of gristle, the enlarged amyloid liver was drawn upwards so that its upper border was at the level of the third rib. This displacement prevented the chest from falling in, and the contraction of the side was limited to a little flattening under the clavicle.
In cases where ulcerative destruction of lung ensues (fibroid phthisis) there is great interference with nutrition. The temperature is elevated, there is often hectic, and diarrhoea may occur with ulceration of the bowels. The symptoms are those common to the third stage of consump tion, and the physical signs are such as have been described as accompany ing confirmed pulmonary cirrhosis. In these cases the destructive process is soon followed by signs of deposit at the apex of the opposite lung.
Fibroid induration does not always go cn to fibroid phthisis. In children, at least, this is an exceptional mode of ending of the disease. As a rule the child succumbs to one of the intercurrent attacks of broncho pneumonia, or falls a victim to a secondary acute tuberculosis.
the early stage of fibroid induration of the lung a certain diagnosis is impossible. We may suspect that the process is proceeding if a child be subject to repeated attacks of inflammation of the lung, and if after an unusually prolonged attack of catarrhal pneumonia the percussion note remains high pitched, and the indications of dilatation of the bronchi are slow to subside ; but no positive opinion can be hazarded upon such insufficient data.
The diagnosis of the confirmed disease rests upon the signs of shrink ing and condensation of lung tissue combined with evidence of dilatation of the bronchi. There is great retraction of the affected side, indicated by falling in of the chest-wall, lowering of the shoulder, nipple, and inferior angle of the scapula, with curving of the spine—the concavity beinci towards the affected side. Neighbouring organs are displaced. If the right lung be diseased, the liver is drawn upwards, the heart is felt beat ing to the right of its normal position, and the resonance of the left limo. passes across the middle line of the chest. If the left lung be contracted, the heart is drawn upwards and the right lung encroaches upon the left pleural cavity.
On examination of the chest the percussion-note is wooden or tubular, with marked resistance, the breath-sound is weak or bronchial if the tubes much secretion, while after cough and expectoration loud blowing or cavernous breathing is heard, with large metallic rhonchus, and intense bronchophonic resonance of the voice. We find, bubbling indica tions of interference with the pulmonary circulation. The right ventricle is hypertrophied • the veins of the neck, chest, and arms are fuller than natural, and the fingers are clubbed.