, 1910 , Vol. 1 Pneumothorax. Character of expectoration dependent upon primary disease (tuberculosis, gangrene, abscess, etc.). Atelectasis. Dependent upon primary disease. Hypostatic Pneumonia. Mucoid, mucopurulent or, on account of complications, reddish-brown, or frothy and reddish, or bloody. SUBJECTIVE SYMPTOMS. Lobar Pneumonia. Sharp pain in affected side soon after initial chill lasting two to three days; commonly referred to region of nipple or axilla, occasionally to abdomen when appendicitis may be suspected; cough or deep inspiration aggravating it; absent in old people and in central pneumonia. Patient lies generally healthy side. on Cough frequent, short, repressed, associated with increased pain; may be absent in old people and alcoholics. Dyspnea nearly always present; respirations in adults from 40 to 60, in children from 60 to 100 per minute, shallow, brief inspiration as well as expiration; expiration often attended by audible grunt. Headache occurs early, may be present throughout. Acute Pneumonic Phthisis. Pain in side. Dyspnea supervenes early; respiration may soon be very labored. Cough invariably present; aggravates pain. Acute Pleurisy with Effusion. Pain usually sets in with febrile state; may not occur until some hours after onset of affection; is sharp, lancinating or dragging, aggravated by cough; its intensity no positive indication of severity of affection; commonly referred to nipple or axillary regions, not infrequently to abdomen or low down in back; diminishes as effusion appears; at start patient lies upon healthy side, later upon affected side. Cough occurs early; not as frequent or distressing as in pneumonia; may be absent in certain cases; increased during resorption of exudate. Dyspnea most pronounced when effusion develops rapidly; breathing frequent and shallow; when effusion accumulates slowly dyspnea may be absent except on exertion. Broncho-Pneumonia. Pain in affected side, gradual onset. Cough hard, distressing, often painful, accompanied by expectoration. Dyspnea constant and progressive; respiration rises to 50 or even 80 per minute. Hemorrhagic Infarct. Sudden appearance of lancinating pain in one side. Dyspnea supervenes with pain or even earlier; extremely distressing; struggle at breathing; mental anxiety. Sudden spells of cough. Hydrothorax. Pain absent. Dyspnea marked and constant, often orthopnea; asthmatic attacks. Cough irritative, invariably present at some period. Pneumothorax. Pain agonizing, appears suddenly at site of collected air in pleural sac; high degree of oppression. Dyspnea extreme, often attended by feeling of impending suffocation; frequent respirations. Atelectasis. Nothing characteristic. Hypostatic Pneumonia. No definite pain; oppression and sense of compression in thorax. Impaired respiration. DURATION. Lobar Pneumonia. Without complications generally not longer than eleven days. Acute Pneumonic Phthisis. Usually terminates fatally in from two to six weeks; some cases not before third month. Acute Pleurisy with Effusion. Longer than pneumonia; febrile period one to three weeks; stage of absorption widely varying duration. Broncho-Pneumonia. Considerable variation; fatal cases two to three weeks or less; cases recovering after from six to eight weeks, occasionally one to three weeks only. Hemorrhagic Infarct. Generally very brief, terminating lethally; at other times dependent upon resulting processes. Hydrothorax. Depends upon character of primary disorder. Pneumothorax. Depends mostly upon cause; tuberculous cases generally die within few weeks, occasionally even within first day; recovery at widely varying periods; chronic condition may continue for three or four years. Atelectasis. Very uncertain. Hypostatic Pneumonia. Depends upon character of associated condition. ETIOLOGICAL DATA. form Lobar Pneumonia. Primary "colds" and infection (mostly micrococcus lanceolatus of Fränkel); traumatism; more frequent in males; alcoholism predisposes. Secondary form in typhoid fever, influenza, measles. Acute Pneumonic Phthisis. Rapid infection; secondary form following localized pulmonary tuberculosis, tuberculosis of pleura, peritoneum or any other organ; much more frequently in males. Acute Pleurisy with Effusion. Primary form exposure to cold or wet; traumatism; primary tuberculosis of pleura. Secondary form (the most frequent) pulmonary tuberculosis; pneumonia; pulmonary abscess or gangrene; affections of osseous structures of thorax; diseases of mediastinum, bronchial glands, esophagus, abdominal viscera, metabolism. Broncho-Pneumonia. Primary form (mostly in adults) same causes as of pneumonia. Secondary form (the most frequent) following or associated with measles, scarlet fever, influenza, whooping-cough, diphtheria, tuberculosis; aspiration (deglutition) pneumonia. Hemorrhagic Infarct. Result of stasis. in presence of feeble circulation in pulmonary capillaries; thrombus in right heart (dilatation); mitral disease; venous thrombosis. Hydrothorax. Manifestations of general dropsy in diseases of heart, lungs, liver, kidney and in marasmatic conditions. Pneumothorax. Tuberculosis; bronchitis; empyema; malignant disease or ab HENRY HEIMAN, M. D., In considering the symptomatology of pneumonia in children we must differentiate between the two principal clinical varieties. of these affections, namely, lobar and broncho-pneumonia. Lobar pneumonia, is, according to our modern view, a general infection with localization of the inflammatory process in the lung tissue, whereas broncho-pneumonia is usually the extension of an inflammatory process from the upper respiratory tract into the bronchioles, alveoli, and adjacent tissues. In accordance with this difference in the pathological anatomy of the two diseases we find a distinct difference in the symptomatology. The onset of lobar pneumonia in children. is sudden as in adults. The disease is commonly at this period of life ushered in by high fever, vomiting, cyanosis or convulsions. The pathognomonic chill of the adult is replaced in children by cyanosis or convulsions. Within a short time of the onset we find a change in the pulse 1 Read before the Eastern Medical Society. respiration ratio, which gives us the first indication of pulmonary involvement. involvement. Normally this ratio is about 1 to 4, that is I respiratory movement to 4 pulse beats, whereas in pneumonia this ratio becomes changed to 1 to 3 or even to I to 2, so that with a pulse of 150, we may have respirations of 50 to 75. The temperature is as a rule of a continuous type running from 103 to 106 F. With this is usually associated the movement of the alae nasi, with respirations, and the well-known and characteristic expiratory grunt. One who is accustomed to see lobar pneumonia in adults, in which the condition can be often readily recognized at a glance, will not infrequently overlook this affection in children, on ac.count of the absence of dyspnoea and cough in not a few of the cases. The difficulty is enhanced by the late appearance of the physical signs. The time when these signs become demonstrable depends chiefly on the original site of the lesion, whether peripheral or central. In the peripheral pneumonia we can usually detect changes in the chest within 24 to 36 hours from the onset, whereas in a centrally located pneumonia signs of consolidation may not make their appearance before 3 to 5 days, or even longer. The earliest change is usually in the auscultation. The puerile breathing over the affected part becomes diminished or lost and the respiratory murmur is faint. The next change is in the voice and at this stage is the most characteristic and almost pathognomonic sign. When a child cries, coughs or is made to say moo, its name, the usual 99 or 1, 2, 3; you will detect a distinct increase in the vocal fremitus and also a change in its quality, that is, it acquires a nasal quality, the so-called bronchophony. The breathing soon loses its vesicular character and becomes bronchial in type. On percussion we at first elicit a hyperresonant note which soon becomes dull. If the consolidation is in the neighborhood of a large bronchus, we obtain on percussion a tympanitic note, the so-called Skodaic resonance. Fine crepitant rales are usually heard over the area of consolidation, but are by no means as frequent or constant as in the adult. Promptness in the early detection of these signs, demands frequent and careful examinations of the chest and especially of certain regions, where these signs usually make their earliest appearance. These areas are the supra and inclavicular regions, upper axillae, and the bases of the lungs. It is important to recognize the existence in the child of certain normal variations in the physical signs of the chest, which might confuse the physician in his examination. In not a few children the auscultatory murmur over the right apex possesses normally a broncho-vesicular type. Posteriorly over the right base we often find a distinct dulness due to the situation of the liver and also to the overlapping of the middle and lower lobes of the lung. To diagnosticate the existence of pulmonary consolidation in these regions we must not only have dulness or change in auscultatory signs, but also change in the voice or the existence of fine crepitant rales. The usual duration of the fever is five to nine days and as in the adult falls by crisis, in the majority of the cases. However in some children we observe a pseudocrisis or the so-called precritical drop. It is assumed that this first drop in the temperature is due to the formation of almost sufficient antitoxin in the blood, and the subsequent rise in temperature during the next day, represents formation of new toxins, which the body readily overcomes by renewed production It is Complications. The complications of lobar pneumonia are quite frequent and play an important role in the prognosis of the disease. They are attributable either to the action of the pneumococcus and its toxins on various organs and tissues of the body, or to the secondary invasion of other organisms. The most frequent and important complication of lobar pneumonia at this period of life is empyema. It is almost always due to the invasion of the pleura by the pneumococcus. This usually takes place by means of the lymphatics. Even if at first the fluid is not purulent, it soon assumes that character, if the pneumococcus itself is present in the pleural cavity. Our experience at the Mt. Sinai Hospital in Dr. Koplik's wards has been, that if the fluid withdrawn from the pleural cavity, though clear, showed the pneumococcus, invariably empyema developed within a short time. Although the usual site of the accumulation of pus is at the base we should not forget the occasional occurrence of interlobular, sacculated, and apical empyema. In these regions the diagnosis is not so readily made, and if suspected we should not hesitate to introduce an exploratory needle. Aside from the well known physical signs, this complication should be suspected, if after the crisis there is a gradual rise of temperature, accompanied by pallor, sweats, and nonappearance of the expected convalescence. In apical and central pneumonias, there is often present a serous meningitis, giving such marked symptoms on the part of the central nervous system, that the erroneous diagnosis of a purulent meningitis is made in the beginning. This condition has been called meningism, but is in reality a serous. meningitis, the result of the action of the pneumococcus toxins on the central nervous system and the meninges. When the pneumococcus itself invades the nervous system, then we have a purulent pneumococcus meningitis, which is a much rarer and more fatal complication. Otitis media is frequently seen, and is equally as frequently not seen because of lack of examination of the ears. Other complications which have been observed are too well known to merit extended consideration. Some of these are gastro-enteritis, pneumococcus peritonitis, nephritis, endocarditis, pericarditis, arthritis, mastoiditis, parotitis, etc. Prognosis. As a rule lobar pneumonia in children terminates in complete recovery. Fatal cases are seen during the first year of life and in older children in the presence of such complications as empyema, mastoiditis, meningitis, pericarditis, and peritonitis. The previous condition of the patient plays an important role. In uncomplicated cases the mortality is usually from 5 to 8%. A high temperature associated with a high leucocyte count and high percentage of polynuclears is a favorable prognostic sign. Marked prostration, cyanosis and dyspnoea, extensive lung involvement, and a low leucocyte count render the prognosis unfavorable, but even in the apparently most hopeless cases, recovery may take place. , 1910 , Vol. V. Broncho-Pneumonia. Broncho-pneumonia is usually secondary to the acute infectious diseases, or to acute diseases of the upper respiratory tract. Being secondary, the clinical course is much less definite than that of lobar pneumonia and its onset and duration more variable. In most of the cases the onset of broncho-pneumonia is preceded by a bronchitis. When the inflammation extends into the bronchioles and alveoli, the first symptoms of bronchopneumonia appear. These are, rise in temperature, increased respiration, dyspnoea and rapid pulse. In addition to the signs of bronchitis we now discover the presence of fine rales scattered over various areas of the chest, mostly over both infrascapular regions. The extent of lung involvement is very variable. In some cases we find no other physical signs than that of bronchitis. In others we have in addition smaller or larger areas of dulness with bronchovesicular or bronchial breathing and bronchial voice. In extensive involvement of many contiguous lobules the signs may closely resemble those of lobar pneumonia. In other cases, only signs of diffuse bronchitis are present throughout the entire course of the disease and we are here only enabled to diagnose the existence of a broncho-pneumonia by the general condition and symptoms. The usual duration is from one to three weeks, but may be considerably longer. Relapses are frequently and the termination is usually by lysis. A polynuclear leucocytosis is present here as in lobar pneumonia, the average is about 34,000, the maximum being 73,000, and the minimum 13,000. While lobar pneumonia is frequently seen in the adult, broncho-pneumonia is much more common in infants and children. seen of Complications. The complications broncho-pneumonia are chiefly due to the local extension of the inflammation. Empyema is not as frequently seen as in lobar pneumonia. Interstitial pneumonia, pulmonary and lymph node tuberculosis are not frequent sequelae of this affection. Prognosis. Broncho-pneumonia is a much graver disease than lobar pneumonia, as it usually affects infants and children whose resistance has been lowered by previous disease. The mortality varies from 10 to 30%. In young infants it is very often fatal. Extensive pulmonary involvement, prostration, marked dyspnoea, and cyanosis are very unfavorable signs. Although these two diseases have been considered together tonight, they are in reality two distinct affections. Distinct in their pathogenesis, pathological anatomy and clinical course. In fact their only relationship is, that they both involve the lung tissue. We may express the hope that future bacteriological studies will enable us to place their classification on a firmer basis. than is possible at present. DISCUSSION. Dr. William P. Northrup said, I have regretted very much that I could not hear the first and all of Dr. Heiman's paper. I was lost in darkest Brooklyn until quite late in the afternoon and I had to have dinner and I got here as early as I could. I have been sort of an understudy of Dr. Hymanson. He gets the pneumonia case first and the consultation fee and I come in when he cannot be found, so incidentally we have seen quite a number of cases this winter together and ripping bad ones. I am sorry his paper could not be discussed with the other because some features interested me very, very much. It was very obvious to me as Dr. Heiman's paper was going on that we are thinking of different ages of children. Do we mean a child a year old or one three years old or five when Dr. Heiman speaks of the voice sounds, of 1, 2, 3, and moo? The patient I think of is not old enough to say moo or 1, 2, 3. So when we discuss |