disseminated catarrhal pneumonia; but I would again ask attention to
the existence of a mild and circumscribed form of the disease, which
rarely if ever causes death of itself. In these mild attacks, which
occur frequently in adults, the part affected may be the base of the
lung, but more commonly it is the root, the apex, or the lower anterior
portion of the upper lobe. The anatomical condition is probably one of
congestion, with extension of catarrhal inflammation into the alveoli
without any preceding collapse, and with a varying degree of
implication of the walls of the vesicles and of epithelial accumulation
in the alveoli, though the process may not always go on to the
production of fully-formed pneumonic nodules, such as above described.
Yet it seems to me not only illogical, but eminently unsafe, to regard
such cases otherwise than as catarrhal pneumonia, since while under
proper treatment and in fairly healthy constitutions they uniformly
terminate in resolution, on the other hand, they will, if neglected or
if occurring in highly-vulnerable constitutions, run into a subacute
form, with more extensive implication of the alveolar walls and
peribronchial tissue, and will induce catarrhal phthisis. Allusion will
be made again to these cases when speaking of the symptoms and
diagnosis of catarrhal pneumonia.
In addition to the pulmonary lesions, the bronchial glands are, with
rare exceptions, swollen and congested. In cases of longer standing
foci of suppuration have been occasionally noted in them (Steiner),
though cheesy nodules are more common. Acute miliary tuberculosis is a
comparatively frequent complication. Oedema and congestion of the brain
and meninges occur {358} frequently, but are to be regarded as
secondary lesions without special significance. It is probable,
however, that more numerous examinations, in cases where death has been
preceded by grave cerebral symptoms, would reveal the occasional
occurrence of circumscribed areas of meningitis, with or without
miliary tubercles. The liver is congested in acute cases, while in
older ones there is apt to be fatty degeneration, which we have seen
occur in irregularly distributed patches, imparting a peculiar mottled
appearance to the organ. The kidneys also may be congested, but serious
changes in the epithelium are rarely met with. Vastly more common are
the lesions of catarrhal inflammation of the mucous membrane of the
stomach and intestine. While in acute cases they may be superficial and
slight, in those which have run a longer course Peyer's patches are
prominent, and the solitary glands are enlarged, and not rarely oval
ulcerations exist which may coalesce, so that I have seen quite
extensive destruction of the mucous membrane of the colon simulating
the effects of dysentery.
SYMPTOMS.--Before entering on a detailed description of the symptoms of
catarrhal pneumonia it must be premised that this disease presents a
far greater range in its degrees of severity than does croupous
pneumonia. In this latter disease, although clinical evidence shows
that its extent and course are less uniform than is often assumed,
there is a remarkable uniformity in the stages through which the
inflammatory exudation passes; but in catarrhal pneumonia, as in all
forms of catarrhal disease, it is a marked characteristic that the
process varies almost infinitely in different cases, both in the
location, the extent, and the degree of development of the lesions. It
is difficult to avoid the conclusion that a corresponding variety is
presented by the symptoms, and that a complete clinical picture of
catarrhal pneumonia must include cases of very mild character and of
short duration, as well as those of a more severe and fully-developed
type. I propose, therefore, to describe a mild form, an acute form of
the ordinary well-developed disease, and also a subacute and chronic
form.
The mild form is undoubtedly often overlooked, the attack being
regarded merely as a feverish cold or as an ordinary bronchitis. Yet
certain peculiarities in the symptoms, the course, and the tendencies
of the cases I refer to serve to distinguish them, and enable them to
be recognized as of more serious nature. More commonly the attacks
occur in young adults whose systems are abnormally sensitive either
from original weakness or in consequence of overwork, previous
sickness, or the action of other depressing and exhausting causes.
After some imprudent exposure there is a slight rigor, followed by
headache, flushed, feverish feeling, soreness in the chest, aching in
the limbs, and tight, dry, painful cough. A careful examination soon
after the onset would reveal the familiar signs of a bronchial catarrh,
though even now there might be noted a tendency for the affection to be
less diffused than is usual in ordinary bronchitis.
If the patient is not prudent and solicitous about his health, no
physician is summoned at once, and not rarely in the course of
forty-eight or seventy-two hours the general symptoms have subsided so
considerably that the patient feels able to move about, and may be led
by pressure of business claims to resume his occupation. He finds
himself so weak, however, and the cough is so much aggravated, that
medical advice is sought. Distinct fever of remittent type is found,
the morning temperature not exceeding 100° or 100½°, while in the
evening it rises to 102° or 103°. There is a tendency to perspiration,
especially on exertion, while exposure to a cool wind or draught causes
a chilly feeling; exertion soon fatigues; sleep is restless; appetite
is impaired; the tongue coated; the bowels irregular; and the urine
high-colored. Cough is troublesome and somewhat painful, and the chest
feels sore and weak. Physical examination will reveal, in the first
place, bronchitic {359} râles, dry and moist (sonorous, sibilant, and
mucous), on both sides of the chest, though not rarely much more
markedly on one side than on the other, or even limited to a portion of
one side.
In addition to this, careful auscultation, especially if conducted not
only during ordinary respiration, but during the strong inspirations
which follow cough, will detect in certain localities subcrepitant
râles, associated with feeble respiratory murmur and slightly prolonged
and blowing expiration. The percussion resonance or the vocal fremitus
or resonance may be only slightly impaired. These signs, which are
connected with an extension of catarrhal inflammation into the alveoli
and the consequent partial occlusion of certain lobules, may be met
with in the subclavicular spaces, at the lower anterior margin of the
upper lobes, at the roots of the lungs, or elsewhere. If the patient be
confined to bed and suitable treatment be employed, the local and
general symptoms will pass away in five to ten days. The cough grows
looser, and the sputa, which were at first very scanty and mucoid, grow
muco-purulent, and then diminish in amount. There follows a greater
degree of anæmia and of weakness than would have been expected from
what is apparently so slight an ailment, and especially there remains a
marked sensitiveness of the throat and chest, so that after any slight
recurrence of catarrh there may be a temporary return of râles at the
affected spot, until gradually the general health and the healthy tone
of the lungs are restored. But if, on the other hand, the patient
persists in keeping about and exposing himself, the febrile process of
remittent type will be prolonged, and though the disturbance of general
health will gradually subside, repeated renewals of catarrhal
irritation will occur, and the local disease will become more deeply
seated, will be attended with increased infiltration of the lobules,
and if the reaction of the system be greatly depressed will end by
becoming chronic. According to my observation, it is in this way--and
this fact confers its great importance upon the mild circumscribed form
of catarrhal pneumonia now under discussion--that very many cases of
pulmonary phthisis begin; and according to the power of resistance of
the tissues, and to the tendency of the system to become infected by
the products of unhealthy inflammation will be the disposition for the
disease to assume this unfavorable development. It is true that the
precise anatomical conditions present in the early stages of such cases
cannot be demonstrated, since death rarely if ever occurs at that
period; but it seems difficult to regard them as differing from those
found in partially developed patches of consolidation in more severe
and typical cases of catarrhal pneumonia. The constitutional symptoms,
the local signs, and the course and results of the affection all
indicate that it is not an ordinary bronchial catarrh, but that it is
properly to be regarded as a mild type of catarrhal pneumonia. Without
pretending to describe minutely all the clinical features of these
interesting cases, it may suffice to have called attention to their
frequent occurrence and great actual importance, and to the fact that
owing to the indifference of the patient or to the hasty examination of
the physician their true nature is often overlooked and the disease is
allowed to pass far beyond its original character of a local catarrhal
trouble.
Acute catarrhal pneumonia in its fully-developed form occurs most
commonly in children, especially as a complication of measles or in the
course of capillary bronchitis. It is evident, therefore, that the
passage from the stage of severe bronchial catarrh to that of alveolar
inflammation may be barely perceptible at first. This is especially
true because in such cases the development of the pneumonia is usually
preceded by a considerable amount of pulmonary collapse. The child is
already suffering with fever, rapid shallow breathing accompanied with
movements of the nostrils and possibly with inspiratory retraction of
the thorax, and with frequent painful cough. No rigor, as a rule,
occurs to mark the inception of the pneumonic complication. {360} The
fever, however, nearly always rises rapidly, and from 102° or 103°,
which has been the maximum during the preceding catarrh, it quickly
reaches 104° or 105°, or even higher. It will be promptly noticed also
that the respirations become even more accelerated, shallow, and
imperfect; in some cases they reach 100 in the minute. The alæ nasi
play violently; the elevation movement of the thorax is marked, while
expansion is but slight; there is retraction of the base of the chest
during inspiration, which is short and quick, while expiration is
prolonged and labored. Severe suffocative paroxysms occur from time to
time. The cough is frequent and painful, so that adults complain
severely of it, while in children it causes moaning or crying. Later,
when the nervous symptoms grow more prominent, the cough grows much
less frequent and severe, or even ceases. Sputa are rarely raised by
children unless with the act of vomiting; they are tenacious, but not
rusty colored, though they may be slightly streaked with blood. The
pulse soon grows very rapid, 160, 180, or even 200 in young children,
and loses force and volume. The appetite is lost, but thirst is
extreme. The tongue becomes brown and parched from deficient secretion
and from mouth-breathing. Diarrhoea is not uncommon, owing to the
frequent presence of intestinal catarrh as a complication. The urine
occasionally contains a small amount of albumen; and it is stated
(Bednär) that the chlorides persist. The nervous symptoms are
prominent. As the dyspnoea increases there is extreme restlessness, the
child tossing about incessantly, with slight delirium. Soon the flush
on the face yields to a distinct cyanotic appearance, with coolness of
the extremities. The restlessness subsides, and there is a tendency to
stupor, alternating with spells of active and restless delirium, and
finally deepening into coma, at times with rolling of the head, so that
there may be a close resemblance to the later stage of tuberculous
meningitis.
During the development of these symptoms the physical signs are for the
most part unsatisfactory and require great care to determine and to
interpret them. As already intimated, inspection shows inspiratory
retraction of the base of the chest, increased movement of elevation,
with defective expansion. Percussion does not usually give definite
results, owing to the fact that the lesions may be symmetrical in the
two lungs, and because the pneumonic process is complicated to a very
variable extent with the results of pulmonary collapse. In children
especially the most gentle and careful percussion is requisite to
detect and map out the affected areas. Some assistance may be rendered
by the fact that the dulness dependent on collapse is often found in
the form of symmetrical elongated areas in either intervertebral
groove. The results of palpation are even less satisfactory than those
of percussion. If the patches of consolidation are not extensive and
are scattered, no change will be detected; and it is only when
superficial areas of considerable extent are consolidated that distinct
increase of vocal fremitus can be determined. It may be remarked here
that, on the contrary, there is impairment of fremitus over areas of
pulmonary collapse.
Auscultation usually shows the continuance of the râles due to the
preceding bronchitis. In addition to these coarser dry and moist râles
there is also heard fine moist crackling over the area of pulmonary
consolidation; these fine subcrepitant râles are heard both during
inspiration and expiration. Pure bronchial breathing, such as is heard
in croupous pneumonia, is by no means constantly present. Over large
areas of catarrhal pneumonia, when the small bronchial tubes are
comparatively unobstructed, it may exist; but, on the other hand, there
may merely be weak diffused blowing breathing.
In adults an equally grave type of acute catarrhal pneumonia is not of
such common occurrence. Cases are met with, however, occurring
especially in subjects whose systems are depressed--as, for instance,
by overwork--in old or feeble persons, or in connection with
diphtheria, typhoid fever, or influenza. The {361} disease may then run
a course closely resembling that described above as found in children,
the rapidly developing interference with aëration of the blood, the
speedy failure of cardiac power, and the appearance of grave nervous
symptoms all being strongly marked. Such cases constitute a notable
proportion of what is commonly styled typhoid pneumonia, especially in
the aged, the disease being often in reality catarrhal instead of
croupous. I have also met with rapidly fatal catarrhal pneumonia
developed during the course of typhoid fever, particularly during the
later stages of cases marked by considerable bronchitis and great
nervous depression. In one instance the patient, a young man of
twenty-six years, who had been much exhausted by mental worry and
anxiety, passed through a well-marked attack of typhoid fever with
moderate pyrexia, but with decided nervous symptoms. Convalescence
seemed established on the twenty-first day, when he was carelessly
allowed to sit up in a chair, and while there was exposed to a draught
of air; he felt chilly, fever reappeared with cough, but no rusty
sputa; centres of catarrhal pneumonia developed in the lower lobe of
the right lung, then in the middle lobe; the fever varied from 101½° or
102° in the mornings to 103½° or 104° in the evenings. On the seventh
day there was a sudden fall to 99°, with a rise in the afternoon to
106°; centres of inflammation appeared in the left lung. For the next
five days there were remarkable fluctuations of temperature, the range
being from 100½° or 101° in the morning to 106° and 106½° in the
evening. The variations in the pulse-rate were not so marked.
Respiration was hurried and imperfect. Nervous symptoms of a typhoid
and ataxic nature developed, and death occurred on the twelfth day.
Considerable daily fluctuations in temperature, though rarely so
regular and extreme as in this case, are often noted in catarrhal
pneumonia, and are of some diagnostic importance. I have many tracings
to show the remittent though atypical course of the pyrexia of this
disease. Such grave cases of acute catarrhal pneumonia are very fatal,
even in adults, scarcely less so indeed than in children; and when
recovery occurs the convalescence is protracted, and often interrupted
by more or less serious renewals of catarrhal inflammation with
constitutional disturbance.
As already remarked, the pulse-rate, which soon becomes rapid, 110 to
124, does not vary as much as the temperature; and even during marked
remissions of the pyrexia the pulse usually continues rapid. The
appetite is greatly diminished or lost; the tongue is coated, often
heavily so; vomiting is not often present spontaneously, but may be
excited by the spasmodic attacks of cough. The respirations are hurried
and superficial, frequently rising to 40, 50, or 60 in the minute in
adults, and this rapidity persists during remissions of the fever just
as does the rapidity of the pulse. As a rule, it is not possible to
observe any marked difference in the movements of the two sides, owing
to the irregular distribution of the foci of disease. The cough is
frequent and may be painful. It is apt to occur in paroxysms, and the
spells may be so severe as to cause alarming interference with
respiration, and also to induce serious exhaustion.
The sputa are at first scanty and consist of tenacious mucus, which may
possibly show fine blood-points, but which are quite different from the
rusty-colored sputa of croupous pneumonia. Later the sputa become more
abundant and less consistent, being much affected by the amount of
bronchitis attendant.
The results of physical examination are much more satisfactory in
adults than in children, owing partly to the less frequency of
pulmonary collapse as a complication, and partly to the assistance
obtained from the more careful study of the vocal fremitus and
resonance possible in the former. Inspection will not show inspiratory
retraction of the base of the chest to anything like the extent seen in
children, owing to the greater rigidity of the thoracic walls. {362} In
the later stage of the disease, however, when considerable infiltration
and obstruction of the lungs has developed, such retraction and also an
inspiratory depression of the suprasternal space may be noted.
Palpation does not give such clear results as in croupous pneumonia,
yet careful observation will show relative increase of fremitus over
the affected areas. Auscultation of the voice usually gives valuable
results. They are not constant, however, nor is it common, even when a
considerable area is consolidated, to meet with such bronchophony as in
the second stage of croupous pneumonia. Still, it is nearly always
possible to detect some alteration of the vocal resonance by comparing
corresponding portions of the two sides; and this, as contrasted with
the negative results in bronchitis, possesses high value. The
respiratory murmur is usually feeble and blowing over the patches of
catarrhal infiltration. In some cases it is as intensely bronchial as
in the croupous form; but more commonly the greater or less obstruction
of the bronchioles renders it weaker and more distant and diffused. I
have observed considerable areas of consolidation due to catarrhal
pneumonia, over which the respiratory murmur was so feeble as to
suggest the presence of moderate pleuritic exudation. Râles are apt to
be present at all stages of the disease. Usually they are fine
subcrepitant or fine dry crackling râles, audible in both inspiration
and expiration; and even over consolidated areas these may be audible,
being doubtless transmitted from the fine bronchioles.
As the case progresses toward resolution the râles become larger and
looser. It often happens that the râles are variable, changing in
character, extent, and position from day to day vastly more than occurs
in croupous pneumonia.
Percussion gives valuable data if practised with care over symmetrical
areas of the two lungs. From such comparative study alone can
satisfactory results be obtained, since in many cases the areas of
disease are too small or not sufficiently superficial to yield more
than relative dulness. But it must happen rarely that spots are not
found where resonance is at least relatively impaired, while of course
in some cases actual dulness is readily detected. It has been stated
that collapse of the lung is a comparatively rare complication in
adults, yet careful study of the physical signs from day to day will
occasionally show its existence in a marked degree. It may occur in a
striking manner in the subacute catarrhal pneumonia of emphysematous
subjects; but in acute cases also considerable areas of the affected
lung may quickly pass into a state of collapse. In a fatal case of the
acute form in a young man I observed the abrupt development of the
signs of pulmonary collapse over the whole lower lobe of the right
lung, requiring care to avoid the error of supposing a considerable
pleuritic exudation to have supervened, but passing away in the course
of thirty-six hours with renewed expansion of the lobe and restoration
of the previously existing physical signs.
It is not necessary to give any detailed discussion of the other
symptoms of acute catarrhal pneumonia as occurring in adults--the
atypical remittent type of fever; the rapid pulse and breathing; the
digestive symptoms, anorexia, thirst, occasional nausea, and a
comparatively frequent tendency to diarrhoea; the nervous restlessness
and depression, with delirium supervening, at first slight, later more
active, and toward the close of fatal cases of such violence as to
require restraint, alternately with deepening stupor from exhaustion
and defective aëration of the blood. Albuminuria may be present in a
slight degree toward the close of severe cases. When death occurs in
these acute cases it usually does so from the tenth to the sixteenth
day. In children it may occur suddenly during or after a violent
paroxysm of cough, or an attack of convulsions may be the immediate
cause of death. More commonly death is preceded by evidences of
increasing intensity of interference with the aëration of the blood,
and with deepening stupor and nervous {363} disturbances such as have
been described. The degree of cardiac failure present is to be ascribed
rather to nervous exhaustion than, as in many cases of croupous
pneumonia, to the action of hyperpyrexia on the muscle of the heart.
The extreme interference with respiration in catarrhal pneumonia is
readily accounted for, not only by the extent of lung-tissue actually
involved in the process, but by the associated bronchitis with swelling
of the mucous membrane, by the accumulated bronchial secretions, and by
the frequent complication with collapse. When recovery is to follow,
the disease declines gradually and irregularly, slight recurrences of
fever and renewed catarrhal irritation being observed from time to
time. These exacerbations may not rarely be traced to atmospheric
influences or to trifling indiscretions on the part of the patient. The
pain declines gradually; and the pulse-rate also falls, but even after
the temperature has become normal some degree of rapidity of the pulse
is apt to remain for a considerable time. The physical signs gradually
disappear: the respirations, like the pulse, remain somewhat rapid, or
at least are for some time readily accelerated; and there is apt to be
some cough remaining, with gradually decreasing muco-purulent
expectoration. The digestive functions are also apt to be left in an
enfeebled condition, and the recovery of full nutrition and health is
often slow. A peculiar sensitiveness of the general system is
frequently noted after this disease, so that morbid processes,
especially of catarrhal type, are readily excited.
As would be expected, catarrhal pneumonia frequently presents much less
violent symptoms and runs a much less acute course than above
described, so that it may be said to assume a subacute or chronic form.