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).
[Illustration: FIG. 38. Croupous Pneumonia in the Adult, terminating in
Purulent Infiltration: Death on fourteenth day.]
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.