When the above symptoms and signs are noticed, the infant's condition is a very serious one ; and unless prompt measures are taken to excite ex pansion of the collapsed tissue and expel the obstructing mucus, death must inevitably ensue. The lividity increases or changes to an ashy hue, the breathing grows more and more shallow, and the child dies in a state of stupor from slow asphyxia, or expires in a convulsive attack.
In children over a year old, who are not the subjects of rickets, the symptoms are usually less severe, and the physical signs more nearly re semble those which exist under similar circumstances in the adult. If the ribs are, softened from rickets, the impediment thus raised to efficient in spiration greatly aggravates the effects of limitation of the respiratory sur face, and in children as old as two or three years the signs of suffering are well marked. If, however, the chest-wall preserves its normal rigidity, the symptoms are much less characteristic. The respiration may be hurried, although this is not always the case, and the complexion may show some signs of deficient aeration of the blood ; but the child is not prostrated by the lesion ; he can cry fairly loudly, and his cough is not suppressed. On examination of the chest, we find dulness of variable extent on one side, usually at the base ; the respiration is weak and harsh over the same area with absence of vocal resonance, and large moist riles are heard about the back. In some cases, as when the collapsed area immediately surrounds a large bronchial tube, the rhonchus may be metallic and ringing as if produced in a cavity.
If the lesion occupy the apex, the breathing is often loud and bron chial or blowing, and the dulness may be complete. In this situation col lapse is very likely to be mistaken for consolidation arising from other causes.
A rickety little boy, aged eighteen months, who had cut only sixteen teeth, was being treated in the East London Children's Hospital for chronic diarrhoea arising from ulceration of the bowels. The chest was not de formed and there was no softening of the ribs. An elder sister had died in the hospital from tubercular peritonitis. About a week after the child's admission he began to cough, and in a few days it was noticed that the percussion-note at the right supra-spinous fossa was decidedly high-pitched, and that the respiration there had a faint bronchial quality. There was a
little coarse bubbling about the back on each side. The temperature had been generally about 100° at night, sinking to 99° in the morning. The pulse was 96-100 ; the respirations 26-30.
Some days afterwards dulness at the right apex behind had become complete, and the breathing was bronchial with a click in the middle of inspiration. In front the percussion-note was quite healthy. The moist riles over the back persisted. Temperature in the evening, 99°400° ; pulse, 80-102 ; respirations, 20-30. All the time the diarrhoea continued and the child wasted rapidly. There was more or less general oedema. The urine was albuminous and contained renal epithelium. A few days afterwards the child died quietly.
On examination of the body, both lungs were found to be emphyse matous with scattered patches of lobular collapse. At the posterior part of the apex of the right lung was a patch of collapse which occupied the up per third of the lobe. Ulcers were found in the lower part of the sygmoid flexure and rectum. The kidneys were congested. There was no sign of gray granulations or of caseous nodules anywhere about the body.
This case was mistaken for one of acute tuberculosis with tuberculous ulceration of the bowels. The moderate pyrexia, the oedema, the albumi nuria, and the increasing signs of consolidation of the right apex seemed to justify this view, especially when considered in relation to the history of tubercular peritonitis in the elder sister.
In some cases of lobular collapse where the symptoms are not very severe, a considerable change all at once is found to occur. The tem perature rises, the breathing becomes laboured, and the lividity and signs of distress increase. These symptoms indicate the beginning of catarrhal pneumonia.
Sometimes after an attack of pleurisy the lung is left condensed and airless and adherent to the chest-wall, without any marked contraction of the side. This condition may produce very puzzling physical signs.