A system of practical medicine. By American authors. Vol. 3

by Unknown

Dyspnoea, although frequently accompanying accelerated respiration, is by no means a constant attendant of it. When urgent it is not in proportion to the amount of lung involved, since double pneumonia may be accompanied by less dyspnoea than when but one lobe is involved. It can be due only in small degree either to the diminution in the total breathing capacity, to the pain, or to the rapid and destructive tissue-metamorphosis; for on the day of crisis it ceases, although the lung at this time is not relieved of its obstructive exudation. The most intense dyspnoea usually occurs in those cases where there is extensive nervous prostration, and must always be regarded as a symptom of great gravity.

In secondary pneumonias, especially where there is coexistent disease in any part of the respiratory tract, the dyspnoea is usually more marked than in primary and uncomplicated pneumonia. It differs from the labored dyspnoea of general capillary bronchitis. A diagnosis between these two diseases can often be made by the character of the dyspnoea.

When the summit of the lung is involved, the dyspnoea is always greater than when the pneumonia is at the base. In pneumonia of the apex in children the dyspnoea is so great that the nostrils are widely dilated, the mouth is open, and its corners are drawn downward and outward. In senile pneumonia, even when the respirations are 70 per minute, patients do not complain of difficulty in breathing.

When persons over seventy who have been asthmatic or are the subjects of chronic bronchitis develop a pneumonia, they often suffer less from dyspnoea than before the pneumonic attack. They feel exhausted, are unable to move about, and on lying down to rest often suddenly expire.

Immediately after the initial chill pain is present in over 85 per cent. of the cases. It is of a sharp stabbing character, and is usually located over the seat of the pneumonia; it is intensified by coughing, sneezing, and deep inspirations. In some cases there is tenderness on pressure over the seat of the pain. The pain usually disappears after the third or fourth day of the disease; if it continues until the eighth day, it may be regarded as evidence of pleuro-pneumonia. If the pneumonia is central there will be no pain. In old age, even in a pleuro-pneumonia, pain is never severe. It is rather a dull, uneasy sensation referred to the whole chest, or if localized by the aged patient is referred to the pit of the stomach, the nipple, the loins, the hypochondrium, or even to the side opposite to the one involved.

Cough is generally present within twenty-four hours after the accession of croupous pneumonia. At first it is short, ringing, or hacking in character, and increases the pain in the side. It sometimes entirely ceases just before a fatal termination. In children a hacking cough is more constant than in adults. Within a few hours it becomes painful and urgent, and occasionally assumes a paroxysmal character, resembling whooping cough.

Old people with pneumonia often have no cough. When present it is slight, and may escape the notice of the patient as well as of the physician. When an aged person suffering from chronic bronchitis or asthma, who has had a chronic cough, develops a pneumonia, the cough generally becomes less severe, and may entirely cease.

Expectoration.—The sputum in pneumonia is characteristic. During the first forty-eight hours it is simply frothy mucus; then it becomes semi-transparent, viscid, gelatinous, and tenacious, but never opaque. Streaks of blood often appear early, mixed with the sputa. So tenacious is it that the cup which contains it may be inverted without spilling the mass. It can be drawn out between the thumb and finger into thin strings, and its tenacity undoubtedly is one cause of the difficulty in its expectoration. Its color varies: generally on the second day the brick-dust or rusty sputa are observed; still, there are numerous exceptions. The color is due to admixture of blood which extravasates from the capillaries of the alveoli. The rusty sputa are preceded in some cases by a transient brighter red expectoration. In other cases it is of a creamy-yellow color, resembling in this respect ordinary catarrhal sputa; or, again, it becomes dark and of a prune-juice color. A severe pneumonia may have none other than a purulent sputum.

Prune-juice sputa of an offensive odor are indicative of a depraved state, and occur only in grave forms of pneumonia. In alcoholismus and in those markedly septic forms of pneumonia which are to end fatally, the prune-juice or burnt-sienna sputum is usually present. In some instances prune-juice sputa appear before the physical evidences of hepatization.

A watery and blood-stained expectoration indicates pulmonary oedema and congestion, and is an unfavorable symptom. When a case is tending to a fatal termination, the sputa become scanty, less tenacious, more diffluent, and often of a greenish color. But a greenish color may be present during the stage of resolution, and may temporarily occur in the middle period of a pneumonia, without being indicative of serious changes. It is usually present in the so-called bilious pneumonia when there is jaundice.