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:
[Illustration: FIG. 39. Acute Lobar (croupous) Pneumonia in a Child:
Recovery.]
[Illustration: FIG. 40. Acute Lobular (catarrhal) Pneumonia in a Child:
Recovery.]
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.
In children pneumonia is so frequently accompanied by marked nervous
symptoms that it may be mistaken for meningitis. Meningitis is
developed insidiously; has but slight febrile symptoms (102-103° F.),
which remit with comparatively great regularity; has a pulse which is
often slower than normal; has no thoracic symptoms, no dyspnoea nor
accelerated breathing; the face is pale and anxious; and the physical
signs of pneumonia are absent.
Sometimes a latent pneumonia with typhoid symptoms is mistaken for
typhus fever: especially is this the case when the latter is
prevailing. I frequently saw cases where such a mistake had been made
while in charge of the typhus-fever patients on Blackwell's Island
during a typhus epidemic. In these cases there will be active typhoid
symptoms, such as dry tongue, delirium, high temperature, etc. The
countenance in this pneumonia, although the cheeks may have a purplish
hue, does not exhibit that dull, heavy leaden expression so commonly
seen in typhus fever. Although there may be delirium in both instances,
the delirium in the former disease is of a milder type than in the
latter. The characteristic pneumonic expectoration is often absent in
this class of cases; therefore it cannot be relied upon as a point in
the differential diagnosis. If pulmonary consolidation is a
complication of typhus fever, it will not be developed until after the
sixth day of the fever, the time when the eruption is visible. If no
eruption is present, the pneumonic consolidation may be regarded as the
primary affection, and the symptoms which simulated those of typhus
fever may be regarded as secondary.
Pneumonia with typhoid symptoms is sometimes mistaken for typhoid
fever. It is called typhoid pneumonia. The differential diagnosis is
not difficult if one remembers that the pneumonia which complicates
typhoid fever does not come on until late in the fever, and the regular
history of typhoid fever precedes its development. On the other hand,
when the typhoid symptoms are present from the beginning or come on at
the end of the second stage of pneumonia, the physical signs of
pneumonia will attend or precede the typhoid symptoms. If a patient
over sixty years of age with this type of pneumonia is not seen until
the second or third week of his sickness, although evidences of
lung-consolidation may be found, it will be very difficult to decide
whether the pneumonia is or is not complicating a typhoid fever; and
under such circumstances a differential diagnosis may be impossible.
PROGNOSIS.--The mortality-rate of pneumonia is shown by the following
statistics: Of 12,421 cases treated in the hospitals at Stockholm, 11
per cent. died. In the Vienna hospitals 24 per cent. died. The Basle
hospital's report for thirty-two years gives 23 per cent. of deaths,
Grisolle reports 59 per cent. of deaths in those over sixty years of
age. In the United States medical reports from May 1, 1861, to July,
1866, of 61,202 cases which occurred among the white troops, 14,738
died, or a little more than 24 per cent.; and of 16,133 among the
colored troops (for the same period) 5233 died, or nearly 33 per cent.
The deaths from all other inflammatory diseases of the respiratory
organs for the same period were only one-seventh as many as from
pneumonia. The Confederate hospital reports give the rate of mortality
from pneumonia for twenty-five months of the same period as 33-1/3 per
cent. Of 255 cases treated in my wards in Bellevue Hospital during a
period of four years, the rate of mortality was 34 per cent.
{343} The statistics given of private practice differ remarkably from
those of hospital reports, and are somewhat contradictory. Of Lebert's
205 cases, 7-3/10 per cent. died. Ziemssen lost only 3-1/3 per cent. of
his cases. Bennett (mentioning, however, that no complication existed)
lost none of his 105 cases. Brundes of Copenhagen lost more than 21 per
cent. of his 142 cases. Wilson Fox gives to pneumonia the fifth, and
Walsh the third, place among fatal diseases. The mortality-average from
all the published reports to which I have had access gives 20.1 per
cent. of deaths.
From such facts it must be admitted that a disease in which death
occurs in 1 out of every 5 cases should be classed among the very fatal
diseases. But the death-rate varies very much at different times: it is
to-day the same as when Andral wrote, nearly fifty years ago. He stated
that it varied from 33 to 2 per cent. There can be no doubt but that
treatment somewhat influences the variations in the
mortality-statistics, but not to such an extent as to account for the
great differences in the reports of different observers.
The prognosis depends more upon the age of the patient than upon any
other single element. In infancy the mortality is greater than in early
childhood, in which period statistics give from 4 to 6 per cent. as the
ratio. The period of dentition seems to influence the prognosis in
children. Between the ages of forty and sixty the death-rate is from 10
to 25 per cent.; uncomplicated cases will recover. After sixty the
prognosis is exceedingly grave, and the greater the age of the patient
the less are the chances of recovery.
Statistics do not give pneumonia its proper place among the fatal
diseases of old age. My own experience leads me to believe that it is
the most fatal of all acute diseases at this period of life, for the
large number of autopsies in which it has been found to be the cause of
sudden death in individuals of advanced years, and the frequency with
which red or gray hepatization is found at the autopsy when pulmonary
disease was not suspected during life, must greatly increase the
statistical rate of mortality. Many modern authorities, who have had
large experience in the hospital practice of the aged, state that
nearly nine-tenths of those who die over sixty-five die of pneumonia.
Pneumonia is more fatal in females than in males, in the proportion of
about 3 to 2.
Statistics vary in regard to the influence of seasons on the prognosis
in pneumonia. In some years the proportion of deaths is far greater in
summer than in either the spring or winter. And it must be acknowledged
that certain as yet unknown atmospheric influences are of the utmost
importance in determining the death-rate in different years. Statistics
do not show that the mortality-rate is greatest during cold weather.
The prognosis is greatly influenced by the extent of the pneumonia.
Double pneumonia is not often recovered from, and pneumonia of an
entire lung is more dangerous than when only a single lobe is involved.
In pneumonia at the apex in infancy and old age the prognosis is
unfavorable. The more feeble the patient at the time of the attack, the
less are his chances of recovery. Previous attacks have no influence
over the prognosis.
Most authors make mention of certain diseases that complicate
pneumonia. Few give condensed statements of their influence on the
death-rate. In 255 cases of my own, 87 were fatal and 168 recovered. Of
these 255 cases, 124 were complicated and 131 were uncomplicated. Of
the complicated cases, 75 died; of the uncomplicated, 12. Of these
complications, alcoholism was present in 30 cases, pleurisy in 17,
Bright's disease in 13, pericarditis in 9, hypertrophy and dilatation
of the heart in 3, peritonitis in 2, fibrinous bronchitis in 1, and
rubeola in 1. Lebert in his statistical report on pneumonia states that
he lost only 5½ per cent. of his uncomplicated cases and all of his
complicated cases. Huss of Stockholm lost 6 per cent. of his
uncomplicated {344} and 20 per cent. of his complicated cases. Wilson
Fox says that, according to the reports of English physicians,
pneumonia complicated by endocarditis is fatal in 75 per cent. of the
cases; complicated by pericarditis, in 54 per cent.; by Bright's
disease, in 50 per cent.; and by alcoholism, in 25 per cent. Brundes of
Copenhagen in 120 uncomplicated cases lost only 6-2/3 per cent., while
of 22 complicated cases he lost all, or 100 per cent. Thus it is
evident from my own records, as well as from those of others which I
have given, that the rate of mortality in complicated pneumonia is much
greater than in uncomplicated.
By a careful study of these complications it is apparent that they all
exert a direct influence upon the heart, diminishing its power and
crippling its action by obstructing the blood-current from the right
ventricle toward the lungs. It is unnecessary to discuss these
complications in detail; it is sufficient to state that weakening of
the contractile power of the cardiac muscle is an essential feature of
endocarditis, pericarditis, Bright's disease, and alcoholismus. In all
acute infectious diseases such complications are regarded as dangerous,
because they increase the liability of heart-failure when such failure
is especially to be feared.
Other complications in addition to those already mentioned which
increase the mortality-rate in pneumonia are chlorosis, phthisis,
emphysema, laryngitis, oedema glottidis, bronchitis, pleurisy,
parotitis, pregnancy, erysipelas, and rheumatism. Bronchitis,
pleuritis, and jaundice do not seem to increase the mortality-rate very
much, although they certainly influence it; while pregnancy, parotitis,
and affections of the joints are very serious complications. Excepting
small-pox and cholera, abortion is more apt to occur during the course
of pneumonia than in any other acute disease.
A case of pneumonia may be called mild so long as the temperature does
not rise above 104° F.; an elevation of temperature above 106° F. for
two days renders the prognosis unfavorable. Wunderlich[48] says that a
gradual rise in temperature after the fourth day is always an
unfavorable symptom. A low temperature is dangerous only when the
respirations are very much accelerated.
[Footnote 48: In _Die Eigenwärme in Krankheiten_.]
When the pulse is 120 or 130 for two or three days, the prognosis is
bad; if the pulse reach 150 per minute, a pneumonia patient rarely
recovers. An irregular and intermittent pulse, and one whose tracing
exhibits dicrotism, has a most unfavorable prognosis. In children the
rapidity of the pulse is not of so much importance, while in old age
the pulse is seldom or never a reliable element in prognosis. A feeble,
irregular, and intermitted pulse is always an unfavorable symptom.
Prune-juice expectoration is also an unfavorable sign, as it indicates
extensive blood-changes or a depraved condition of the patient. If
there is an entire absence of expectoration in the second or third
stage of a pneumonia, or if it becomes scanty and difficult, the
prognosis is unfavorable. Any sudden suppression of the expectoration,
with coincident tracheal râles, in any period of the disease, indicates
impending death.
In adults delirium is an unfavorable symptom, except when it occurs at
the onset of the pneumonia. When delirium occurs late in one who is the
subject of chronic alcoholismus, it generally indicates a fatal
termination. Convulsions in children with great jactitation, and in old
age subsultus tendinum and a tendency to coma, are unfavorable signs.
Great exhaustion and signs of prostration, accompanied by a sunken,
pallid countenance and cold, clammy perspiration, are always attended
with danger. In children bronchial breathing after the seventh day,
numerous subcrepitant râles, copious and persistent diarrhoea, and
swelling of the veins of the hands, are unfavorable.
In old age a sudden rise or fall in temperature, apathy, somnolence,
and a {345} sallow countenance, are all symptoms indicative of great
danger. Any complication renders the prognosis unfavorable, and the
occurrence of pulmonary oedema or congestion in the unaffected parts of
the lung is to be regarded as a forerunner of death.
Purulent infiltration, the formation of an abscess, and the development
of gangrene are all attended with danger. Recovery from gangrene is
very rare.
Death does not result from heart-clot, for the conditions which favor
the forming of the clot precede its formation. The fibrin factors in
pneumonia are increased--often 400 per cent. more than normal. The
heart is so enfeebled that the right ventricle cannot empty itself; the
columnæ carneæ and the chordæ tendineæ whip up the residual blood
(already prepared for clotting). Heart-clot, it is well known, is the
rule when the death struggle is prolonged and the cardiac contractions
gradually become weaker and weaker. Such heart-failure is always the
beginning of death.
In seeking for the causes of death in pneumonia, observers have taken
the results of their post-mortems as a standard of their observations.
One finds oedema of the lungs at the majority of his autopsies, another
finds a clot in the heart in most of his fatal cases; hence the
conclusion is reached that pulmonary oedema and heart-clot are causes
of death in pneumonia. But it must be remembered that in every disease
there is a great difference between the cause and the mode of death.
If, as a result of the failure of heart-power during the last hours of
life, pulmonary congestion and oedema are developed and clots are found
in the heart-cavities, it ought not to be assumed that these conditions
are the cause of death. Jürgensen states that in fatal cases of
pneumonia oedema of the lungs is always present, and heart-clots are
frequently met with.