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 consonant45 or ringing.46
45 Skoda.
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.