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

by Unknown

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. 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 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. 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.