Chapter XXII: Part 22

In children the temperature rises very rapidly, sometimes reaching 106° F. within the first twelve hours. The highest recorded temperature in the pneumonia of children, with recovery, is 106°-107° F. The average temperature {326} of pneumonia at this period of life is 104° F., the range being higher than in adult pneumonia.

In children the day of crisis is oftener the seventh than the fifth day. The fall of temperature during the crisis is somewhat remarkable; it often falls two and a half degrees below the normal, and this exceedingly low temperature may be maintained for two or three days, and yet the child recover.

The accompanying charts show ordinary temperature-curves from children with pneumonia (see Figs. 35, 36).

In old age it is often difficult to determine the exact day of the invasion of pneumonia except by the temperature. The rectal temperature rises to 103° or 104° F., or even higher, on the first days, and continues at about the initial point for three or four days, with daily morning and evening oscillations of a degree or a degree and a half. The temperature-rise does not begin for several hours after the initial chill, if a chill occur (see Fig. 37).

Relapse in pneumonia is a rare event; it is quite phenomenal for it to occur four days after the crisis. The temperature suddenly rises, but usually returns to normal in three or four days.

Pulse.--The pulse in pneumonia varies with the type and extent, as well as with the stage, of the disease. In an ordinary mild case the pulse-rate is usually between 90 and 120 per minute. When the pulse-rate for any length of time is above 120, the case must be regarded as an exceedingly grave one.

{327} The pulse at the onset of croupous pneumonia is usually full and soft. As the disease progresses it becomes small and feeble. In severe cases, and when the nervous system is markedly implicated, it is rapid, and may be 130 to 140, or even 160, at the onset of the disease. In such cases it will also be small and feeble.

A high temperature is usually accompanied by a rapid pulse, and a low temperature by a moderately frequent, full pulse. At the day of crisis, when the temperature falls, the pulse will fall; and this occurs in the severe as well as in the mild cases.

Subsequent to the third or fourth day in severe cases the pulse, in addition to its frequency and feebleness, may exhibit dicrotism, or it may be jerky, very compressible, and intermittent. Sometimes just before death the pulse becomes markedly slow. The feebleness of the pulse is ascribed by some to cardiac depression, the result of the high temperature; by others it is claimed that the afflux of blood to the left ventricle obstructs, and causes a deficiency in, the aortic circulation. In other words, hepatization is adduced as a cause of the feeble pulse. In chronic wasting diseases, in feeble, weak individuals, or in those already suffering from cardiac disease, weakness of the pulse is a very marked symptom.

I cannot regard a feeble pulse in pneumonia as due to the pulmonary hepatization, for it is not that pneumonia which is most extensive that is accompanied by the greatest heart-flagging. Heart-failure may exist before, or just as, consolidation is beginning. In many pulmonary affections the obstruction to the pulmonary circulation is greater than in pneumonia, and yet there is no heart-failure. The pneumonia with the highest temperature-range is not necessarily the pneumonia in which heart-failure is most marked {328} or earliest to develop. There are many diseases in which there is a much higher range of temperature and yet no evidence of heart-failure occurs.

If a prolonged high temperature is the cause of feeble heart-power by the parenchymatous changes which it induces in its muscular fibres, such a high fever is not met with in pneumonia, and the heart is rarely found at post-mortem to exhibit such changes. May not the heart-failure, as indicated by a rapid, feeble, and intermittent pulse in pneumonia, be due to the presence in the blood of a morbific agent (as in certain infectious diseases) which so affects the nerve-centres which supply the heart that its contractile power is diminished and its rhythm disturbed? The pulse early shows commencing heart-failure by each cardiac pulsation producing a variable filling of the arteries with blood; hence the beats first vary in force, then waves occur, then true intermissions. I have been able to detect this heart-insufficiency by these variations of the pulse within twenty-four hours after the onset of a pneumonia, and occasionally during the initiatory chill.

In children the pulse-rate is greatly increased; it may reach 200 in a minute. It is very small, unequal and irregular, but never intermittent.

In senile pneumonia the pulse is not a reliable indication. The pulse may be only 50, and yet this would be a rapid pulse for the particular case in which it occurs.

In old age, both in health and in disease, the pulse has a fictitious hardness on account of arterial changes. The pulse may not be intermittent or irregular, yet the heart may be very irregular and intermittent in its action. Again, the pulse may be feeble and intermittent and the heart be acting regularly.

Remittence of the pulse is quite common in senile pneumonia independent of cardiac changes. The action of cold upon the surface in the aged is very quickly indicated by the radial pulse lessening its volume and strength, so that if the pulse at the wrist is taken it should be from the arm which has been covered. To avoid error, the pulse in senile pneumonia must be counted at the heart.

The surface of the body may be pungently hot and dry until the crisis is reached, or it may be bathed in perspiration from the onset of the disease. A moist surface has been regarded as a very favorable sign, but when in the height of the disease the parched skin becomes moist and the patient is not relieved, it is an unfavorable rather than a favorable symptom, and is met with more often in fatal cases than in those that recover.

In most cases of croupous pneumonia the expression of the countenance is characteristic. It is one of anxiety, and over the malar bones is a mahogany flush--not, as in typhus fever, diffused, but well defined and circumscribed, so that it is sometimes called the pneumonic spot. While the cheeks exhibit a spot of this dusky hue, the rest of the face may have an earthy pallor. Bouillard states that the pneumonic flush on the cheek is most marked when the pneumonia has its seat at the apex of the lung. Some authorities state that the cheek flushes most or solely on the affected side, while others[35] have shown that the cheek on the side opposite to that affected is the one that is usually flushed. In this connection it is interesting to mention the case of Jaccoud, who, suffering from an attack of pneumonia himself, noticed for twenty-four hours preceding the pneumonia signs a flush and a burning sensation in the cheek opposite to the side affected. Usually one cheek is more flushed than the other, and this is undoubtedly due to disturbance of the vaso-motor system.

[Footnote 35: Barthez and Rilliet.]

When the impediment to the circulation is excessive, or when vaso-motor disturbance is marked, the lips become cyanosed. At the time of crisis the face becomes paler.

In about one-half the cases pneumonia is attended by an herpetic {329} eruption upon the lips, nose, cheeks, or eyelids. It rarely appears before the second or third day. It may not appear until the crisis is reached. Herpes occurs with varying frequency in different years, but is more commonly met in pneumonia than in any other febrile state. One winter nearly every case of pneumonia in Bellevue Hospital was accompanied by herpes labialis. When sweating exists and involves the entire body, it is very frequently accompanied by sudamina, which are either abundant or sparse, and seem to have a critical significance.

In children, while the surface of the body is hot and dry the extremities are cool. The pneumonic flush instead of having a mahogany tint assumes a bluish-white tint. Cyanosis of the extremities is more frequent than in adults, and herpes labialis more common. All the cutaneous symptoms are exaggerated in children.

In old age the pneumonic flush is often the first objective sign of pneumonia. The eyelids alone are cyanotic. If the face is dusky at first, it subsequently assumes a sallow hue, and the surface-heat, which is greatest in the morning, is succeeded by a cold, clammy perspiration.

Cerebral Symptoms.--The cerebral symptoms in the early stage of pneumonia are not very significant. Headache is usually present at the onset, and may continue throughout the disease. It usually steadily diminishes after the third day. If it is severe in the evening, there will be slight delirium at night--so slight as often to escape notice. Delirium and convulsions rarely occur except in debilitated subjects and in persons of enervating habits. It is most frequently met with in alcoholic subjects, and then it assumes the character of delirium tremens. It is an active, busy, restless delirium: the patient is constantly talking, but seldom in a coherent manner. Sometimes, in those who are not alcoholic subjects, the delirium may assume an active and violent character. Whenever active delirium is present, it is important to make careful and diligent search into the previous habits of the patient.

Pneumonia of the apex is more apt to be accompanied by severe cerebral symptoms than when it has its seat at the base.

Delirium may pass into coma. When delirium and headache are marked symptoms, muscular tremors (subsultus tendinum) are very apt to occur, with insomnia and frightful hallucinations. Indeed, these cerebral symptoms are often so prominent in alcoholic pneumonia, and occur so early, that the pneumonia may be wholly masked, and will only be discovered by the temperature-range and by a careful physical exploration of the chest.

When delirium is present in feeble patients, it assumes a low muttering typhoid type, and a state of stupor is soon reached.

Among the rare nervous symptoms met with in pneumonia may be mentioned photophobia, disturbances of vision, and deafness.

In children the cerebral symptoms are more prominent than in adults, and they do not seem to be influenced by the extent of lung involved. Stupor and restlessness on the one hand, or headache, delirium, and convulsions on the other, may usher in pneumonia in children without any prodromata.

Sometimes children pass rapidly into a semi-comatose condition which has not been preceded by delirium or convulsions. Convulsions are as common in children as they are rare in adults, and occur with greatest frequency and severity during dentition. The convulsions may be general and resemble those of epilepsy (pneumonie éclamptique of Barthez and Rilliet), or they may attack single muscles or groups of muscles, the child occasionally passing into a tetanic or opisthotonic condition.

If convulsions do not occur until late they are quickly followed by a deep and fatal coma. A very rare occurrence is partial paralysis of the muscles which were involved during the convulsive period. Such paralysis is often {330} permanent. Again, the cerebral symptoms may closely resemble those which attend cerebro-spinal meningitis--viz. headache, constipation, great prostration, delirium, convulsions, opisthotonos, and strabismus. As in meningitis, there is a peculiar cry, and all the symptoms may point directly to the brain. These symptoms are most likely to be present in the pneumonia of the apex in children from five to seven years of age.[36]

[Footnote 36: This form is the pneumonie méninges of Barthez and Rilliet.]

In senile pneumonia headache may persist throughout the entire attack; it is usually accompanied by delirium of a mild type, especially when the apex of the lung is involved. These patients are very loquacious and have a constant desire to get out of bed.

Alimentary Tract.--The symptoms referable to the digestive apparatus are neither diagnostic nor important. Nausea and vomiting are not infrequent, and in about 15 per cent. of all cases are among the initial symptoms. Gastric symptoms, when severe and persistent, greatly endanger life. There is no characteristic appearance of the tongue: it may be normal throughout, or covered with a creamy-white fur, which becomes dry and brown as the disease advances. In severe cases and toward the end of the disease the lips and tongue become brown, dry, and cracked, and sordes collect on the teeth. Anorexia is marked at the onset, and the thirst is intense. When convalescence commences the tongue becomes clean and the appetite returns. Occasionally there is a catarrh of the oral mucous membrane. Diarrhoea may occur as one of the initial symptoms. It is most apt to be present when there are nausea and vomiting. As a rule, the bowels are constipated and the stools dry. In young children nausea and vomiting are more common, and in 50 per cent. of the cases usher in the disease. They usually cease on the second day, although they may persist until the crisis occurs. Excessive and violent diarrhoea may precede a fatal termination.

In senile croupous pneumonia the tongue early becomes dry, shrivelled, and covered with a thick brown coating, and is protruded with difficulty. Although these patients do not complain of thirst, they take with avidity fluids that are placed to their lips. As the period of crisis is reached critical diarrhoea is of frequent occurrence.

Loss of strength occurs earlier and is more marked in pneumonia than in any other acute disease except typhus fever. Pneumonia patients become very weak within the first five days. The recovery of strength during convalescence is rapid.

Urine.--The urine at the onset of pneumonia is scanty, high-colored, and of high specific gravity. The amount of urea excreted is twice or three times more than the normal. The excess of urea increases until the crisis, and then suddenly diminishes with the fall in temperature, often below the normal standard.[37]

[Footnote 37: The daily amount of urea normally excreted is subject to great variations: it ranges between 355 and 460 grains. Parkes gives the result of 25 different observations: the lowest estimate was 286.1 gr. and the highest 688.4 gr.]

Uric acid is also increased, and follows the same course as that of the urea. The inorganic salts of the urine, especially the sodium chloride, are diminished, and during the height of the pneumonia may be wholly absent. Much has been written concerning this diminution, which is by no means peculiar to pneumonia, but in no other acute disease is its diminution so constant and marked a symptom. Sodium chloride is probably retained in the system, for when the salt has been administered in large quantities none has appeared in the urine. The reappearance of the chlorides in the urine marks the approach of convalescence, and when the crisis occurs they appear in excess, following an opposite course to the urea and uric acid.

Although these last two ingredients are in very rare cases retained, the {331} same as the chlorides, to appear when the crisis occurs, their retention is usually accompanied by a critical diarrhoea, which is followed by a prolonged convalescence. The diarrhoea is undoubtedly due to the irritation caused by the urea.

Parkes[38] states that sulphuric acid is increased and phosphoric acid is diminished, but Huss affirms that both acids are diminished. With the increase of the urea and uric acid, and diminution of chlorides, biliary pigment will appear in the urine, and occasionally the biliary acids.

[Footnote 38: _On the Urine._]

Slight albuminuria is an ordinary phenomenon of pneumonia, and, though usually met with in the second stage, it may appear at any time. This symptom is present in 35 per cent. of all cases. Its presence is a point of resemblance between pneumonia and other acute blood diseases. The more severe the pneumonia, the more marked is the albuminuria. Some have ascribed its presence to passive hyperæmia the result of the pulmonary obstruction. This is questionable, except in those rare cases where venous engorgement is indicated by cyanosis, enlargement of the liver, jugular pulsation, etc.

In children the amount of urine corresponds to the quantity of fluid taken.

Critical Phenomena.--At the end of the first week, during which all the symptoms have increased in severity, the continued fall of temperature tells us that convalescence is established. As the temperature falls, profuse (critical) sweating occurs. Both of these phenomena may occur to such an extent that for hours the condition of the patient is one of collapse.

In rare cases death has occurred in the midst of these symptoms. The respirations and pulse-rate are diminished in frequency, the pulse being small and frequently exhibiting dicrotism. The cough becomes loose, the dyspnoea abates, the flush disappears from the cheek, the sputum is more copious, and is expectorated with less difficulty; it loses the rusty color from metamorphosis of its hæmoglobin, diminishes in viscosity, and no longer adheres to the side of the vessel, but becomes more opaque, of a creamy consistency, and resembles that of simple bronchial catarrh. When resolution is retarded, the creamy-yellow tint may give place to an almost black hue, on account of the excessive amount of pigment present. As convalescence advances, the sputa become scantier, more mucous, watery, transparent and colorless. At the time of crisis the intense thirst diminishes, the appetite returns, pain in the side subsides, and the patient passes into a quiet, natural sleep, to waken fully convalescent, suffering only from extreme exhaustion.

Epistaxis, hæmaturia, and hemorrhage from the bowels sometimes occur at the critical period, and may be regarded either as accidents or as the result of the defervescence. After the crisis the amount of urea in the urine (which during the height of the disease was augmented) falls to normal or nearly to normal. Sodium chloride appears in the urine as soon as the crisis occurs.

The critical phenomena in children are the same as in adults, and frequently the fall in temperature is so great that for hours after the crisis they lie half unconscious, with a cold surface covered with a colliquative sweat. With the critical sweat there is often a catarrhal flow from the nose. When children have been extremely restless or delirious the crisis is marked by the patient passing into quiet sleep.

In old age, when recovery occurs, it is generally by crisis, and a critical diarrhoea is much more frequent than a critical sweat.

In adults and in children the recovery of strength and flesh is rapid; in the aged the period of convalescence is very prolonged, and often does not begin (when the pneumonia is of the asthenic--typhoid--type) until the fourteenth or fifteenth day; still, complete recovery may be reached.

Symptoms indicating Danger.--When croupous pneumonia is to terminate fatally, dyspnoea is greatly increased; the patient suddenly sinks; the pulse {332} becomes extremely small, rapid, irregular, intermittent, and dicrotic. Large moist râles are heard over the larger bronchi and trachea, while the auscultatory signs of pulmonary oedema become more and more apparent. The sputa become frothy, liquid, and blood-stained, or are entirely suppressed. The respirations become more and more hurried, the face is sunken and livid, the extremities are cold, and the superficial capillary circulation is more and more interfered with, as is indicated by the cyanosis. The body is bathed in a profuse cold perspiration. The fatal issue is usually preceded by coma.

The temperature may steadily rise up to the time of death, or death may occur in the defervescence. In alcoholic pneumonia death is preceded by cerebral symptoms, such as somnolence, numbness of the limbs, a sense of formication, and slight convulsive attacks.

In children death is often preceded by convulsions or coma. If the disease is protracted, death may be preceded by extreme exhaustion and collapse. Cyanosis and extreme rapidity of the pulse are usually present in children just before the fatal issue.

Senile pneumonia may end fatally within a few hours after its onset in a most unexpected manner. The aged patient walks apathetically about, totters to the bed, lies down, and dies. If the pneumonia has existed for a number of days, the signs of a fatal termination are sallowness of the face, a cold clammy skin, expansion of the alæ nasi, and a sudden rise or fall of the temperature. The inspirations become mere gasps, and, following the apathy, the patient gradually lapses into complete coma.

Symptoms which attend the Termination of Pneumonia in Abscess.--Acute pneumonia terminates in abscess in from 1 to 2 per cent. of all the cases. It is therefore a rare termination. It is most frequent in debilitated, weak subjects and in those who have received a depressing plan of treatment. The expectoration is exceedingly copious and fetid, and the sputa are yellowish or yellowish-gray in color, consisting almost wholly of purulent matter. Pigment is usually found in the expectorated masses, and when shreds of pulmonary tissue are present the diagnosis is established. The fever assumes a hectic type and is accompanied by rigors and sweats.

After these symptoms have continued for a time, the patient grows weaker and emaciated, and death results from exhaustion, from asphyxia (when a large bronchus is plugged with pus), or from the discharge of the abscess into a neighboring cavity.

DaCosta states that "pulmonary pneumonic abscesses are at the base of the lung;" Fox locates them "at the apex;" Green, "on the upper lobe;" I have found them in both situations.

The physical evidences of a lung-cavity are the most reliable signs of pneumonic abscess. Abscess is a very rare termination of croupous pneumonia in children. In old age the formation of abscesses is never evinced by any well-marked symptoms. The finding of elastic fibres in the sputa with the physical signs of a cavity are the only diagnostic signs.

Symptoms which attend the Termination of Pneumonia in Gangrene.--Gangrene as a termination of pneumonia has been found in about 14 per cent. of cases.[39] This must be regarded as an exceptionally high percentage. Its occurrence is usually accompanied by symptoms of sudden collapse. The pulse becomes rapid, feeble, and intermittent, the face is pale and of a deathly hue, and there is a profuse expectoration of blackish-green masses containing shreds of decomposed and decomposing lung-substance of an exceedingly fetid odor. The breath is fetid and the whole body emits a cadaverous smell. The rapidly-increasing prostration is sometimes accompanied by hemorrhage.

[Footnote 39: In 28 out of 200 cases (_Guy's Hospital Reports_, Sec. vii., 1848).]

The sickening and indescribable odor of pulmonary gangrene is most perceptible after an attack of coughing. Gangrene has its most frequent site in {333} the lower lobes of the lung, and it is here that a careful search must be made for the rather ill-defined physical signs which attend its development. In old age, when a pneumonia is to terminate in a gangrene, typhoid symptoms appear very early, and death occurs with symptoms of the profoundest collapse within five days from the initial chill.

Symptoms which attend the Termination of Pneumonia in Purulent Infiltration.--The symptoms of purulent infiltration differ but slightly from those of the third stage of pneumonia. When resolution does not take place at the period of crisis, and the temperature remains high, accompanied by symptoms of prostration and profuse putrid expectoration, with none of the physical signs of resolution, purulent infiltration is to be suspected. Death may result from exhaustion, or recovery take place after a prolonged convalescence (see Fig. 38).

Mild delirium is a frequent symptom during the stage of purulent infiltration. The sputa contain a large number of cells in various stages of fatty degeneration. The temperature has regular evening exacerbations, and often ranges higher than during any preceding period of the disease. The tongue becomes brown and dry, sordes collect upon the teeth, and the patient passes into a typhoid state.

Typhoid pneumonia is a term which has been applied to a variety of croupous pneumonia which is attended by typhoid symptoms. It has also been called asthenic, low, or nervous pneumonia. There are symptoms of extreme prostration from its onset. After well-marked pneumonic symptoms have been present for a few days, the patient passes into a condition of extreme prostration.

There is little or no expectoration, no dyspnoea, no pain, no cough. Sordes collect on the teeth and gums; the tongue becomes thickly coated with black crusts; the pulse becomes small, feeble, and rapid, and there is a tendency to the formation of bed-sores; and then occur stupor, somnolence, and a continuous low muttering delirium. This form of pneumonia is met with most frequently in the aged. In some cases there is marked disturbance of the special senses.

Tremors and subsultus tendinum frequently coexist. It may be accompanied by glandular swellings, by sharp and darting muscular pains, by arthritic symptoms, or by great gastric disturbance. It is not infrequent in epidemics, {334} and it may follow or accompany erysipelas, Bright's disease, alcoholismus, or phlebitis. It is always a grave condition, but recovery is possible. Convalescence, which is very tedious, may commence as early as the twelfth or fourteenth day. Sometimes a modification of typhoid pneumonia accompanies dysentery, intestinal catarrh, or a phlegmonous gastritis. There are great sweating, profuse diarrhoea (colliquative), and high fever. The odor of the sputa resembles that of gangrene of the lungs. Such cases commonly end fatally.[40]

[Footnote 40: _Cyclo. Pract. Med._, iii., art. "Gastritis."]

Bilious or Gastric Pneumonia.--Croupous pneumonia occurring in malarial districts, accompanied by gastro-enteric or hepatic symptoms, is known as malarial or bilious pneumonia. It has all the characteristic symptoms of pneumonia of a very severe type, but the fever is paroxysmal. The tongue is heavily coated; nausea and vomiting are common, and may persist throughout its entire course; the epigastrium is distended and tender; the skin is jaundiced; the liver is enlarged, and there is usually an exhausting diarrhoea, attended by greenish, black, viscid, and inodorous stools. The hepatic congestion and jaundice are due to a coincident gastro-duodenal catarrh.

Bilious pneumonia may be of a sthenic or asthenic type. The theory that the liver becomes inflamed by extension from the lung is untenable.

The symptoms of bilious pneumonia have frequently led to a diagnosis of typhoid gastric fever or some severe acute affection of the intestinal tract. But a reference to the physical signs will remove all doubts.

Bilious pneumonia runs a more protracted course and has a much longer period of convalescence than ordinary croupous pneumonia. In old age this form is not infrequent. The vomiting is distinctly bilious in character, and at this period of life somnolence and stupor are quite common, and are exceedingly unfavorable symptoms.

Latent Pneumonia.--Pneumonia in adults is seldom latent unless it complicates some disease whose symptoms are so severe, and the attending prostration is so great, as to obscure the characteristic signs of the pneumonia. Intercurrent senile pneumonia is always latent, and Grisolle says that an exploration of the thoracic organs in the majority of such cases gives negative results. If, then, an intercurrent senile pneumonia runs its course without expectoration, without dyspnoea, without the pneumonic flush, and without any of the physical signs of pneumonia, its diagnosis must rest--first, on the extreme frequency of pneumonia in old age; secondly, on the fact that of all the phlegmasiæ of advanced life pneumonia is the one which is oftenest latent; thirdly, that of all the acute diseases in old age pneumonia is attended by the highest range of temperature and the greatest prostration. When an old person has a slight rigor followed by febrile movement, with great prostration, for which no explanation can be found, pneumonia may be suspected, even though all its diagnostic signs are absent.

Intermittent or remittent pneumonia, which is described by some authors as a distinct type, is a form of acute pneumonia in which a malarial element is so pronounced that all the pneumonic symptoms, even the physical signs, undergo distinct intermission, returning each day with increasing severity. Occasionally, instead of the quotidian it assumes the tertian type. During the intermission the temperature may fall to normal. Severe chills and sweating are often present, and the pneumonia is not infrequently double.

The malarial conditions which give rise to this type of pneumonia occur more frequently in our Southern and Western States than in any other part of the world.

PHYSICAL SIGNS.--By studying the physical signs of croupous pneumonia in connection with the different stages of its morbid anatomy, their importance as elements in diagnosis and prognosis can best be appreciated.

{335} Stage of Engorgement.--The physical signs indicative of the first stage of croupous pneumonia are usually present within twenty-four hours after its invasion. If the pneumonia is central, their appearance may be delayed until the third day.

Inspection.--On inspection the movements of the affected side are noticed to be more or less restricted, while the unaffected side moves as in health. In double pneumonia the respiratory movements will assume a costal type, attended by an increase in the abdominal breathing.

Palpation.--On palpation there is more or less increase in the vocal fremitus on the affected side. The degree of increase corresponds to the extent of the engorgement. It must always be remembered that normally the vocal fremitus is more marked on the right side than on the left.

Percussion.--There is slight dulness over that portion of the chest-wall which corresponds to the affected portion of lung: its extent varies with the amount of lung involved. It is never well marked until the end of the first stage, although the pulmonary capillaries are engorged with blood from the commencement. Even at the end of this stage the intensity of the percussion sound, although diminished and muffled, has a slightly tympanitic quality, due to the fact that the exudation has not completely displaced the air in the distended alveoli. Very extensive central pneumonia may fail to give either increase in vocal fremitus or dulness on percussion until the second stage is well advanced. Absolute dulness during this stage is of rare occurrence.

Auscultation.--During the dry stage, which according to some[41] is said to precede the exudation stage, there will be noticed a feebleness and unnatural dryness of the respiratory murmur. Sometimes it is harsh, at others feeble and loses the peculiar breezy, rustling quality of the normal respiratory sound. If it is less intense over the affected portion of the lung, it is exaggerated over the unaffected portion. These changes are apt to pass unrecognized unless auscultation is practised frequently and early in the disease. As soon as the engorgement is well marked and exudation takes place into the air-cells, fine crackling sounds are heard at the end of inspiration. These sounds are called crepitant râles, and are regarded as the characteristic sign of the first stage of pneumonia. They resemble those produced by throwing salt on live coals or rubbing the hair in the neighborhood of the ear between the fingers. These râles do not necessarily depend upon the presence of fluid in the alveoli, but may arise from the sudden separation of the alveolar walls at the end of inspiration when they have been agglutinated by a tenacious exudation. They are as numerous as they are minute, are unaffected by coughing, and remain audible over a circumscribed space from twelve to twenty-four hours. Whenever the pneumonic stages follow each other in rapid succession, the crepitant râle may not be heard. It is rarely present in a pneumonia which is developed during an attack of acute articular rheumatism. With the crepitant râle the respiratory murmur is feeble or assumes a broncho-vesicular character.

[Footnote 41: Stokes.]

When, as often happens, pneumonia has been preceded by or complicates any other thoracic affection, the crepitant râle will be mingled with the sounds arising from that particular condition. It is said[42] that bronchial breathing is sometimes heard in this stage of pneumonia. The voice-sounds undergo slight increase in their intensity over the seat of the pneumonic engorgement.

[Footnote 42: Traube, _Annal. der Charité_, i. 286.]

In children the crepitant râle is frequently absent, and, though it may be heard at the end of a full inspiration after coughing, it is never so fine or distinct as in adults. In children there will be no increase in vocal fremitus if, as often happens, a large bronchus leading to the inflamed spot is plugged with mucus.

{336} In old age the physical signs of adult pneumonia are modified by certain physiological changes which occur in the lungs and chest-cavity of the aged. The more complete bony union of the chest-walls, the curvature of the spine, the rigidity of the bronchial tubes, the rounded form of the chest, and the senile rarefaction of the lungs, give rise to extra resonance on percussion as compared with an adult chest. On account of the great arching of the sternum and the deposition of carbonaceous material at the apex of the lung, the clavicular region near the median line gives a dull percussion sound. The scapular and supra-scapular regions are less resonant than in the adult, on account of the tilting of the scapulæ due to curvature of the spine. There is a loss in the vesicular element of the respiratory murmur, and it resembles the sound produced by a forceful expulsion of air from the compressed lips. When the septa or the alveoli are torn and greatly distended, it has a bronchial character. Its intensity varies: at one moment it is loud, at another hardly perceptible; the variation occurs not only in the same individual, but in different individuals of the same age. The vocal sounds are loud and bronchophonic in character, and have a vibration closely resembling oegophony. It is also to be mentioned that it is almost a physiological condition for old people to have bronchorrhoea; hence mucous râles may be present during the whole period of advanced life, and if one relies on the usual crepitating râles of adult pneumonia for a diagnosis he will be misled.

Inspection and palpation in the first stage of senile pneumonia furnish little positive information. Percussion will give little dulness until the lung has reached the stage of red hepatization, and even then it may be so slight as to pass unnoticed. Very early in the disease the respiratory murmur is feeble and indistinct over the affected portion, while the portion of lung that is not involved assumes, for the time, all the characters of a normal adult respiratory murmur. Again, the breathing over the pneumonia may be intensely puerile and interrupted.

The crepitant râle is rarely present in the first stage of senile pneumonia, but subcrepitant râles and large moist râles resembling those of bronchitis are heard during the whole of this stage. The explanation of the absence of the crepitant râle is to be found in the physiological condition of the air-cells just referred to. Sometimes, on a deep inspiration after violent coughing, fine crepitation is heard, but upon careful examination it will not be found to differ from the râles of capillary bronchitis. It may be stated as a general rule that the feebler and more superficial the respirations the less distinct will be the adventitious sounds.

The physiological rigidity of the bronchi in old age favors the early development of bronchial breathing, which is often the first physical sign of senile pneumonia. One of its peculiarities, when occurring in the stage of engorgement, is that it is most distinct at the root of the inflamed lung.

Stage of Red Hepatization.--The physical signs of the second stage of croupous pneumonia are more diagnostic than those of either of the other stages.

Inspection shows the expansive movements of the affected side to be more markedly diminished than in the first stage, while those of the healthy side are increased. Frequently there is absolute loss of motion over the inflamed lung.

Palpation.--By palpation the vocal fremitus is usually increased on the affected side over the consolidated lung-tissue. In some instances it may be only slightly increased, and in rare instances it will be found less marked upon the affected side than upon the healthy. Palpation may also reveal slight displacement of the heart from the pressure of the distended lung; and in rare cases well-marked pulsation is felt over the affected lung.[43]

[Footnote 43: Skoda, Stokes, and Graves regard this as the result of increased pulsation of the arteries in the inflamed spot; and Walshe and Fox rather admit it, but Grisolle denies it.]

{337} It is evident that the vibrations of the vocal cords can be transmitted from the trachea through the bronchi and lung to the chest-wall, and there is no reason why the cardiac impulse may not likewise be transmitted through a solidified lung to the chest-wall.

If the pneumonia is central, the vocal fremitus may not be increased. It is diminished when there is an abundant pleuritic exudation over the pneumonic lung.

Percussion.--On percussion there will be marked dulness over that portion of the lung which is the seat of the pneumonia, while over the healthy portion, as well as over the opposite lung, there will be exaggerated resonance. The nearer the hepatization approaches the surface of the lung, the more marked will be the dulness. There is a peculiar sense of resistance on percussion over a completely airless hepatized lung which is not present in solidification from other causes. The exact outline of an hepatized lobe can often be traced on the chest-wall.

The tympanitic quality which is sometimes present during the stage of engorgement may continue anteriorly during the second stage, and yet posteriorly the dulness will be complete. A tympanitic percussion sound is sometimes elicited over that portion of lung which is adjacent to the consolidated lobe. When an upper lobe is consolidated, forcible percussion may elicit a tympanitic sound, for the column of air in a large bronchus will vibrate under forcible percussion. The cracked-pot sound (bruit de pot fêlé) is occasionally met with over those relaxed and permeable parts of the lung in the immediate vicinity of the consolidation. When this sound is present over the consolidated portion, it is due to the sudden expulsion of air from one of the larger bronchi. It is most frequent in young persons with thin, elastic chest-walls. The cracked-pot sound in pneumonia is not increased in intensity when the patient's mouth is open.

In basic pneumonia the subclavicular percussion note may be distinctly amphoric in character. Dulness may appear within twelve or twenty-four hours after the onset of a pneumonia, or it may be delayed until the fourth day.

Auscultation.--As soon as the air-cells are completely filled by the pneumonic exudation, the crepitant râle ceases and bronchial respiration is heard over the affected lung. The bronchial breathing is due to the fact that the vesicular element of the respiratory sound disappears on account of the complete consolidation of the vesicular structure, and the tracheal element of the respiration is conveyed to the chest-walls through the consolidated lung. It often has a metallic element, or may sound like the tearing of a piece of linen. Bronchial respiration is more intense in pneumonia than in any other disease.

Laennec taught that bronchial respiration was due to the superior conducting power of condensed lung. Skoda combats this view, and says that bronchial respiration is generated or magnified in caverns and in the bronchi of condensed lung-substance by the air in these cavities and in the bronchi vibrating in consonance with that within the trachea. The condition necessary for this consonance is provided in the circumstance that the air is pent up in confined spaces whose walls reflect the sonorous undulations.

The more complete the consolidation, the more intense is the bronchial respiration. At the commencement of this stage the tubular breathing only attends expiration, while later it accompanies both acts. Pleuritic exudation may mask or render this sound very indistinct. It may in rare instances be absent even when extensive consolidation exists and the pleura is perfectly normal. This can be accounted for in most cases by the plugging of a large bronchus. There are cases in which its absence is inexplicable.

The vocal sounds are increased in intensity and bronchophony is heard {338} over the consolidated lung. The physical conditions of the lung which give rise to bronchophony have the same diagnostic significance as the bronchial respiration, and in all instances its occurrence, its distinctness, its temporary disappearance, and its reappearance are dependent upon precisely the same conditions as are the changes in the bronchial respiration. If the pleural cavity is partially filled with fluid, bronchophony will be indistinct or absent below the level of the fluid, while at its level the voice-sounds will be either bronchophonic or oegophonic.

During this stage the heart-sounds are transmitted to the surface over the hepatized lung with greater intensity than normal.

In children dulness is especially marked in the infra-scapular region of the affected side. Some authors[44] speak of a feeling of greater solidity below than above the scapula, which can be detected before the ear can detect actual dulness on percussion. Vocal fremitus may be increased, but it is not reliable on account of the changes in the voice.

[Footnote 44: West.]

In old age, inspection and palpation give negative results. Dulness on percussion in old age would be regarded as normal resonance in the adult; hence the percussion sound in senile pneumonia may be only relatively dull. The tubular or bronchial breathing in the second stage of senile pneumonia is more intense than in adult pneumonia. Small gurgles or mucus râles generally persist throughout this stage. Bronchophony is not well marked. On causing the aged patient to cough and expire violently, tubular breathing may be heard where it was before absent.

Stage of Gray Hepatization.--There is no abrupt transition from the second to the third stage of pneumonia, so that the physical signs of the early part of gray hepatization are the same as those of the second stage.

Inspection.--As resolution progresses, expansive motion on the affected side becomes more and more apparent.

Palpation.--On palpation the vocal fremitus will be found approaching normal, its intensity diminishing as resolution occurs.

Percussion.--Dulness on percussion becomes less and less marked, but of all the signs this is the last to disappear. Rare cases are mentioned where it has disappeared in twenty-four hours after the commencement of resolution by crisis. As the percussion sound approaches the normal, a tympanic note is again present in circumscribed spots.

Auscultation.--The bronchial respiration that was present in the second stage gives place to broncho-vesicular breathing. This soon becomes blowing, then indeterminate, and finally approximates to, and merges into, normal vesicular breathing. Bronchophony gives place to exaggerated vocal resonance in connection with the changes in the respiratory and vocal sounds. The crepitant râle returns, but is soon obscured by larger and moister crepitating sounds, "the resolving subcrepitant râle of pneumonia," called also the râle redux. Large and small mucus râles, sibilant and sonorous, accompany the subcrepitant râles, to disappear only when resolution is complete. Not infrequently the bronchial râles that are developed during the stage of resolution are of that character called consonant[45] or ringing.[46]

[Footnote 45: Skoda.]

[Footnote 46: Traube.]

The physical signs of this stage are all retrogressive, and they disappear in the opposite order to that in which they appeared. In rare instances resolution is so rapid that the subcrepitant râle is not heard. In this class of cases dulness on percussion and bronchial breathing continue for some time after the crisis.

In children, bronchial breathing rarely disappears before the seventh day. It is often accompanied by the subcrepitant râle. When resolution takes place, bronchial breathing and the subcrepitant râle will disappear at the same time.

{339} In old age, inspection, palpation, and percussion give similar results as in adult pneumonia. On auscultation coarse crepitating sounds and loud gurgles are often heard at a distance from the site of the pneumonia. The râle redux is not distinctive of or peculiar to the third stage of senile pneumonia. The sounds heard during this stage are called mucous crepitations, by which is meant liquid crepitating râles produced in tubes intermediate between the bronchioles and the larger bronchi.

If pneumonia terminates in purulent infiltration, the temperature remains high and symptoms of great prostration are developed. The bronchial breathing continues, and becomes more intense, dulness on percussion persists, and sharp, high-pitched râles resembling fine gurgles are abundant.

The occurrence of abscess or gangrene is indicated by the physical signs which attend the formation of cavities in consolidated lung-substance.

No one of the physical signs which is present in the different stages of pneumonia is sufficient for a diagnosis, but the manner and order of their occurrence, and their relation to the symptoms which mark the different stages of the disease, enable one to reach a positive diagnosis in all typical cases. The only symptom of croupous pneumonia which can be regarded as diagnosticated is the sputum.

The physical signs of pulmonary abscess in the aged are very generally wanting. Distinctly localized gurgling and cavernous respiration may, when taken in connection with the rational signs, suffice for an approximate diagnosis, but the great rarity of abscess in old age should make one cautious in its diagnosis. The sputa will greatly aid in such cases.

The physical signs of senile pneumonia are subject to greater variations than ever occur in pneumonia in the adult, and often they do not even follow the course, irregular as it is, which has just been described.

Gray hepatization or abscess may be reached without any distinctive auscultatory signs, even after repeated and careful examination. The râle redux of resolution may be absent, dulness and bronchial breathing being immediately followed by normal (senile) resonance without crepitation. This occurs most frequently in the typhoid variety.

DIFFERENTIAL DIAGNOSIS.--In typical cases of croupous pneumonia (except in childhood and old age) the diagnosis is not difficult. The prolonged chill of invasion, the rapid rise of temperature, the accelerated, panting respiration, pain, cough, characteristic sputum, increase in vocal fremitus, dulness on percussion, the crepitant râle, bronchial breathing, and bronchophony are sufficient to establish the diagnosis.

Croupous pneumonia may be confounded with acute pulmonary congestion and oedema, capillary bronchitis, pleurisy, hypostatic congestion, catarrhal pneumonia (in children), pulmonary apoplexy, meningitis, and typhoid fever.

Pneumonia begins with a chill, while pulmonary oedema has no chill. Pneumonia is a febrile disease, while in pulmonary oedema there is no rise in temperature. In pneumonia there is pain in the side; there is no pain in pulmonary oedema. The sputum in pneumonia is viscid, rusty, and microscopically pathognomonic; pulmonary oedema is accompanied by a profuse watery expectoration. Pneumonia is commonly unilateral, and can occur in any part of the lung, while pulmonary oedema is bilateral, and usually occurs in the most dependent portion of the lung. In pneumonia we have the crepitant, dry râle, while in pulmonary oedema we have subcrepitant râles, larger and more liquid than those in pneumonia. Bronchial breathing and bronchophony occur in pneumonia, and are absent in pulmonary oedema. Percussion dulness is more marked in pneumonia than in pulmonary oedema, and the diseases with which the latter condition is apt to arise will aid us very much in the diagnosis. Urinary symptoms are negative in pulmonary oedema, while in pneumonia the chlorides are diminished or absent.

{340} The stage of resolution in pneumonia is not infrequently mistaken for general capillary bronchitis, but, though the subcrepitant râle is present in both, it is heard all over the chest in capillary bronchitis, while it is confined to a comparatively small space in pneumonia. The expectoration is muco-purulent in bronchitis, and viscid and fibrinous in pneumonia. The temperature is lower in bronchitis (100°-103°) than in pneumonia (104°-106°). Capillary bronchitis is bilateral, pneumonia usually unilateral. Capillary bronchitis does not commonly begin with a chill, like that which occurs in pneumonia, but comes on more insidiously and without pain. Capillary bronchitis gives an exaggerated percussion note, while there is dulness on percussion in pneumonia. There is bronchial breathing in pneumonia, and a feeble vesicular murmur in capillary bronchitis. In capillary bronchitis the cyanotic appearances are very much more marked than in pneumonia, and there is no perversion of the pulse-respiration ratio. The breathing is labored in capillary bronchitis, and panting in pneumonia. In capillary bronchitis there are several slight attacks of chilliness; in pneumonia there is usually only one chill, at the onset.

The chief points in making the diagnosis between pneumonia and pleurisy are the pain, sputum, and percussion note. Pneumonia is ushered in by a distinct chill, followed by a rise in temperature to 104° to 105°, while pleurisy begins with chilliness or a number of slight rigors, and the temperature is lower, rarely above 100°. The dry hacking cough of pleurisy may be accompanied by slight mucous expectoration, while in pneumonia the expectoration is characteristic. In pleurisy the breathing is catching; in pneumonia it is panting. In pleurisy the face is pale and anxious; in pneumonia the cheek bears a dull mahogany-colored flush. In pleurisy the pulse is firm, small, tense, and wiry; in pneumonia it is full and bounding. The amount of chlorides in the urine is not altered in pleurisy, but in pneumonia they are diminished or absent. The pulse-respiration ratio is not affected in pleurisy, while in pneumonia it may fall as low as 2:1. There are no critical days in pleurisy, while in pneumonia crisis occurs about the fifth or seventh day. In pleurisy with effusion there may be bulging of the intercostal spaces, and the heart may be displaced; these phenomena never occur in pneumonia. The vocal fremitus is feeble or absent in pleurisy, while in pneumonia it is much increased. In pneumonia there is dulness on percussion, while percussion over a pleuritic effusion elicits flatness, which changes with the position of the patient. In pleurisy the grazing, rubbing, or sticky friction-sound may be heard with both respiratory acts; in pneumonia we hear the crepitant râle. In pleurisy the respiratory sounds are feeble or absent, as are the vocal sounds, while bronchial breathing and bronchophony are marked in pneumonia. It may be remembered, however, that if adhesions from an old pleurisy bind the lung to the chest, vocal fremitus may be increased in pleurisy. Again, bronchophony and bronchial breathing may exist in pleurisy, but they are always diffuse, never sharp and tubular, as in pneumonia, and are usually confined to the scapular region.

Hypostatic congestion of the lungs is accompanied by copious, watery, blood-stained expectoration. In pneumonia the sputa, though bloody, are rarely watery. Pneumonia occurs anywhere in the lung, and has well-marked rational symptoms; hypostatic congestion occurs in the most dependent portion of the lung, disappears when the patient sits up, is accompanied by no rational symptoms except dyspnoea and expectoration, and usually can be traced to a long-continued recumbent posture in those who are suffering from extensive blood-changes.

It is often difficult to decide whether a child has catarrhal or croupous pneumonia. It is to be remembered that catarrhal pneumonia is always secondary, while croupous is primary. Catarrhal pneumonia usually follows {341} a bronchitis, croupous pneumonia rarely. In catarrhal pneumonia both lungs are involved; in croupous but one, and often only a single lobe. Catarrhal pneumonia is accompanied by a catarrhal sputum, while croupous pneumonia has a viscid, rusty, fibrinous expectoration. There is no day of crisis in catarrhal pneumonia, while croupous pneumonia in children almost always ends in well-marked crisis. In catarrhal pneumonia dulness on percussion is generally confined to the posterior dorsal region, and does not extend so far forward as in lobar pneumonia. Again, the extent of the physical signs and the rapidity of their development in catarrhal pneumonia are in contrast with those of croupous.

The range of the temperature is a most valuable guide in their differential diagnosis, since not only the height of the fever is greater in croupous, but the temperature-curve is different, as seen in the accompanying tracings:

Pulmonary apoplexy is rarely met with independent of valvular disease of the heart or pyæmia. It is a non-febrile disease, while pneumonia has marked pyrexia at the onset. In pulmonary apoplexy dyspnoea is very intense and comes on abruptly; in pneumonia it comes on slowly and progressively increases. The expectoration in pulmonary apoplexy consists of small, black sooty-looking coagula, while in pneumonia the viscid fibrinous mass contains numerous cell-elements other than blood-corpuscles. In apoplexy the dulness is distinctly circumscribed, and around it moist râles are heard, while in pneumonia the area of dulness is more extended and râles are heard over the seat of the dulness. The urinary symptoms are negative in pulmonary apoplexy; in acute pneumonia the chlorides are diminished or absent. There is a peculiar acid odor to the breath--an odor like that of tincture of horseradish--in pulmonary apoplexy, never found in pneumonia.[47]

[Footnote 47: Guéneau de Mussey.]

When croupous pneumonia has its seat at the apex of the lung, it may be {342} confounded with the first stage of phthisis. But the history of a chill followed by the characteristic pneumonic symptoms will generally enable one to make the differential diagnosis. Besides, the fever in phthisis is irregular and is subject to irregular exacerbations and remissions. If the signs of consolidation persist with little or no change, if the temperature at no time falls to normal, if there are night-sweats, if emaciation is progressive,--then the case is to be regarded as one of phthisis, even though there may have been pneumonic consolidation complicating it.