LECTURE XXI.

PNEUMONIA, ITS SYMPTOMS AND TREATMENT.-Symptoms of Pneumonia frequently present a mixed character when it supervenes on bronchitis-Idiopathic Pneumonia -approach of first stage generally gradual-characteristic peculiarities in mode of sucking and of respiration-attack sometimes sudden. Symptoms of second stage-results of auscultation-reasons for rarity of true pneumonic crepitus. Symptoms of third stage-convulsions often precede death-their import―occasional imperfect recovery-auscultatory phenomena of this stage.

Nature of modifications in symptoms produced by association with bronchitis. Diagnosis from bronchitis-pleurisy-hydrocephalus-remittent fever-intestinal disorder during dentition.

Treatment-Expectant treatment-Depletion-Tartar emetic-limitations as to its use. Mercury-its importance-danger of salivation very slight. Diet-antiphlogistic in the early stages-caution as to sucking-stimulants often needed in advanced stage. Blisters not desirable.

It was stated in the last lecture, that the supervention of inflammation of the substance of the lungs constitutes one of the chief dangers of infantile bronchitis. Pneumonia, however, is not to be regarded as being invariably a secondary affection; for, in some cases, while the disease of the air-tubes is but trivial, the pulmonary substance is the seat of serious inflammation; and in other instances the air-tubes are altogether unaffected, or at least are involved only in common with the other constituents of the lung. In either case, there are peculiarities enough, both in the symptoms observed and in the treatment required, to render the separate study of pneumonia indispensable.

When pneumonia supervenes, as it by no means seldom does, on previous catarrhal symptoms, the disease often comes on insidiously, and develops itself so gradually out of the preceding trivial ailments that it is not possible to determine the exact date of its attack. At other times, indeed, there is a sudden and well-marked increase of the fever and dyspnoea, and an aggravation of all the symptoms, sufficient clearly to point out the date of the supervention of the pneumonia. But, even though this should be the case, yet, if there were much bronchitis previously, the affection of the airtubes will often mask that of the lung to some degree; and the case not presenting the symptoms either of pure bronchitis or of

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SYMPTOMS OF THE FIRST STAGE OF PNEUMONIA.

unmixed pneumonia will assume some of the characters of each, and merit, both by the phenomena attending it during life, as well as by the appearances found after death, the name of bronchiopneumonia. Cases of this mixed character occur most frequently during the period of teething, when the mucous membranes are especially susceptible. We will return to notice some of these peculiarities hereafter, but we will first examine the symptoms that attend a case of idiopathic pneumonia, where the pulmonary substance has been affected from the outset, and has not merely become involved by the extension to it of mischief commencing in the bronchi.

In almost all of these unmixed cases, a condition of general feverishness, exacerbated towards evening, with fretfulness and pain in the head, precede the more marked symptoms. The child is either restless at night, or, if it sleep, its repose is unsound; it talks in its sleep, or wakes in a state of alarm. Sometimes from the very commencement, at other times soon after the appearance of these febrile symptoms, cough comes on; at first, short and hacking, frequently not causing the child any uneasiness, and so slight as scarcely to excite the notice, and not at all to awaken the anxiety, of the parents. Loss of appetite and increase of thirst are early observable: the bowels are usually constipated, and vomiting is not infrequent, especially in infants at the breast. The tongue and lips are at the same time of a florid red; the tongue is less moist than usual, and is generally coated in the middle with a thickish white fur. In these symptoms, indeed, there is but little to mark the real nature of the case, or to point to the organ whose disease has kindled the fever in the system; for the slight cough, if not overlooked, may yet be attributed to irritation of the bronchi, sympathetic with derangement of the stomach or intestines. The respiration too is not always much hurried at this early period; while, in the young child, both its frequency, and that of the pulse, are much modified by position; and the results of auscultation are not uniform, and may sometimes afford no information at all. Even now, however, there are some signs which to the attentive observer will convey much information, and information all the more valuable from our being furnished with it chiefly in those young infants in whom the diagnosis of the disease is attended with most difficulty. The seat of the mischief is shown to be in the respiratory organs by the child no longer breathing through the nares, while the tongue is applied to the roof of the mouth as in health; but by its breathing through the open mouth also, whence the

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tongue early acquires an unusual degree of dryness. This same inability to respire comfortably through the nares causes the child to suck by starts: it seizes the breast eagerly, sucks for a few moments with greediness, then suddenly drops the nipple, and in many instances begins to cry. As the disease advances, these peculiarities in the mode of sucking and of respiration often become more striking; but it is at its onset that they are most valuable, since then we have fewer indications to lead us right.

It is not, however, thus gradually that pneumonia always comes on; for sometimes a child who has gone to bed well, or merely a little poorly, wakes in the night in a state of alarm, refusing to be pacified, with a flushed face and burning skin, and hurried breathing and short cough. This sudden supervention of pneumonia is not so often met with among infants at the breast as among children from two to four years old. Often, though not always, this severe onset of the disease has appeared to depend on the pneumonia being associated with extensive inflammation of the pleura; but sometimes the symptoms which at first seemed so threatening soon subside, and the affection, in its subsequent stages, presents no peculiarity, and is not by any means remarkable for its severity.

This first stage of pneumonia passes, for the most part, by degrees into the second, in which the nature of the affection is generally obvious to all. The momentary cheerfulness which before existed has now passed away; infants now no longer wish to be removed from the cradle, or from the recumbent posture in their nurse's arms, and older children have quite lost all interest in their play; they become drowsy, ask to be put to bed, and cry if taken up. The hurry of the respiration is now abundantly evident; the ala nasi are dilated with each inspiration, the abdominal muscles are brought into play to assist in its performance, and any change of posture renders the breathing more laboured and more hurried. The cough has become much more frequent; it is still hard, sometimes is evidently painful, so that the child cries with each cough; at other times it is an almost constant short hack. The bright flush of the face, and the florid tint of the lips, are gone, but the heat of skin continues; for the persistence of an almost unvarying high temperature throughout its course is, as M. Roger has shown, one of the characteristics of the pneumonia of the child as well as of that of the adult. It is a pungent heat, which becomes more sensible the longer the hand is kept in contact with the surface; and so great is the elevation of temperature, that M. Roger found it average almost 104° Fah. in ninety-seven experiments, while in

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RESULTS OF AUSCULTATION.

some cases it greatly exceeded this degree. Though so intense, however, this heat is unequal at different parts--the extremities being cool, or even cold, while the body is hot; but there is no moisture on any part of the skin. The face now assumes a puffed, heavy, but anxious appearance, and when the child is very young, or the pneumonia very extensive, the lips put on a livid hue, which is also very evident around the mouth, while the face generally is pale. The thirst usually continues very urgent, but children at the breast still vomit the milk. This is apparently owing to their thirst being so urgent as to lead them to suck too greedily, and thus overload their stomach, since, while they generally vomit almost immediately after leaving the breast, they do not reject small quantities of fluid given them from a cup or a spoon. The disease of the lungs now betrays itself most strikingly in children at the breast, for as often as they attempt to suck, the respiration becomes at once greatly hurried; they drop the nipple, panting, from their mouth, or, having seized it, have not breath sufficient to make the vacuum necessary to bring the flow of milk.

The results of auscultation, though variable, are now sufficiently obvious. Crepitation is now heard, often in both lungs, and generally in their lower and posterior parts-seldom, however, the minute crepitus such as we hear in the pneumonia of the adult, but that sound known as the sub-crepitant râle. The comparative rarity of true pneumonic crepitus in inflammation of the lungs in infancy is a point not to be lost sight of: often, however, if you keep your ear to an infant's chest, and wait till it takes an unusually deep inspiration, you will hear the true crepitus of pneumonia just for a moment when the air enters the pulmonary vesicles; and then again you will lose it when the child breathes as it was doing before, and you will hear only the sub-crepitant râle. If the inflammation have attacked only one lung, you will perhaps be struck by the loud puerile breathing in the healthy organ, which is thus compelled to perform a double function. If both be involved, you may almost overlook the disease, since you have not the aid afforded by contrast; unless, as sometimes happens, the mischief on the one side is so far advanced as to cause bronchial breathing, while on the other side crepitation alone is audible. This bronchial breathing is sometimes heard associated with the sub-crepitant râle, or with large crepitation, while at other times the ear detects nothing but the whiff of air through the larger airtubes; and often this alone is audible on an ordinary inspiration, while on a deep breath being taken the sub-crepitant râle will be

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at once perceptible. In the child we lose all the information which, in the adult, is afforded by the different modifications of the voice sound: for the shrill or querulous tone of a suffering child, and the words often uttered in very different keys, afford, even when the child is old enough to talk well, results far too uncertain to be trustworthy.

Percussion sometimes yields a very manifest dulness on the affected side; and this dulness is usually most evident in the infra-scapular region. At other times, however, no such marked results are afforded, but the lower parts of the chest give a somewhat duller sound than the upper, and the impression communicated to the finger is that of greater solidity below than above the scapula. This last sign is often very valuable, since it may be perceived at a time when the ear cannot clearly detect actual dulness on percussion.

Death may take place in this, the second stage of pneumonia, if a very extensive portion of lung have been involved in the disease, or if it be associated with much inflammation of the pleura, or if the pneumonia have been grafted on severe bronchitis. The pneumonia which supervenes on measles, or which comes on in a child debilitated by previous illness, sometimes terminates unexpectedly in this stage, and on an examination of the body after death the lung is found scarcely to have passed beyond the first stage of pneumonia, except in a few portions of but limited extent; though still larger tracts will probably be found in the state of collapse, and to the sudden supervention of this condition the fatal event is probably in great measure due. It is important, too, to bear in mind that in weakly children, a pneumonia of even very small extent will often prove fatal: hence the great importance of watching most sedulously against all those intercurrent affections of the lungs which come on in the course of diarrhoea, measles, remittent fever, &c.

But the pneumonia may be free from any of the above-named complications, and then, if unchecked by treatment, it will pass into the third stage. The respiration now becomes more laboured, and though its frequency is sometimes diminished it will be found to have become irregular; several short and hurried inspirations being followed by one or two deeper, and at longer intervals, and these again by hurried breathing. The cough sometimes ceases altogether, or if not, it is less frequent, and looser, since it is now produced by the child's efforts to clear the larger air-tubes from the accumulating secretions. The voice is often lost, the patient