LOBAR PNEUMONIA. 
BY 
ANDREW H. SMITH, 
NEW YORK. 
Vol. XVI.—1 LOBAR PNEUMONIA. 
Synonyms.—Croupous pneumonia, Fibrinous pneumonia, Pneu- 
monitis, Lung Fever. 
The lung differs from all other structures in having two separate 
circulations: the nutritive, supplied from the left side of the heart 
through the bronchial arteries, and the functional, supplied from the 
right side of the heart through the pulmonary artery. This doable 
circulation underlies all the phenomena of pneumonia, and must be 
recognized in any definition of the disease, as without it the disease 
itself could not exist. 
Definition.—Lobar 'pneumonia is an acute disease in ivhich a specific 
parasite invades the air cells of one or more pulmonary lobes, where it 
grows in a fibrinous medium exuded from the functional capillaries, and 
generates a toxin that infects the system at large. 
The local process causes consolidation of the affected area by fill- 
ing the air cells with the effused material, which, material is after- 
wards removed, leaving the structure of the lung intact. 
The general infection is marked by fever, which, in a typical case, 
begins with a chill, and after a duration of from four to nine days ends 
abruptly by crisis. 
In most cases a local dry pleuritis is excited, the phenomena of 
which are added to those cf the pneumonia proper. 
Death may take place from the virulence of the infection, from 
loss of respiratory surface, from exhaustion of the right heart, from 
consecutive asthenia, from complications, or from a combination of 
two or more of these causes. 
Symptoms. 
A brief sketch of the principal clinical features of the disease will 
be useful as affording a preliminary view of the field to be examined. 
The attack may be preceded by prodromes to be hereafter de- 
scribed, but as a rule the first complaint of the patient is of a pain 
in the chest, usually in the mammary region. This is often very 
severe, and by restricting the movements of the ribs renders the res- 
piration superficial and rapid. A chill more or less severe follows, 4 
SMITH—LOBAR PNEUMONIA. 
or in many cases precedes, tlie pain. The chill varies from a mere 
creeping sensation to a heavy and prolonged rigor, as severe as in a 
case of intermittent fever. Coincident with the chill there is a rise 
of temperature. The thermometer shows from three to four degrees 
Fahrenheit of fever during the first twelve hours, rapidly rising until 
the temperature reaches from 103° to 105° F. or even more. Then 
there is a period during which the temperature is maintained with 
slight variations until from the fifth to the eighth day, when a crisis 
occurs and the temperature falls abruptly, until within a few hours it 
becomes normal. 
Cough is an early symptom, but it is repressed as much as possi- 
ble to avoid the severe pain it causes. The expectoration is apt to be 
frothy at first, and mixed with florid blood; later it becomes viscid 
and very tenacious, so that it is spat out with difficulty and adheres 
like thick mucilage to the vessel containing it. Its color at this 
stage varies in different cases. It may be a light yellow, a pale green, 
or a cliocolate-brown, or a mixture of these colors. It is often likened 
to prune juice. Sputa of this character may be considered pathogno- 
monic of this disease. As resolution progresses the expectoration 
becomes less colored, less sticky in consistence, and more catarrhal 
in its character, and the quantity gradually diminishes until it ceases 
altogether. 
The respirations are early increased in frequency, and this quite 
out of proportion to the increase in pulse rate and temperature. With 
a pulse of not more than 90 the respirations will number 30 or more 
to the minute. In nearly every severe case there will be a time when 
the respirations will go up to 40 or 50, and they not infrequently reach 
60 or more per minute, when the consolidation is extensive or pul- 
monary oedema takes place. The pulse is usually full and strong in 
the early stages, numbering from 90 to 100 when the temperature is 
103.5° to 104°, and becoming weaker and more frequent as the dis- 
ease advances. When the respiration is greatly embarrassed the 
pulse is apt to be small and creeping, unless affected by stimulants. 
The skin is hot and dry at first, later there is a tendency to per- 
spiration which may be profuse. The face is pale, with often a 
dusky red patch on either cheek. The lips are inclined to a bluish 
hue in proportion to the degree of pulmonary implication. They are 
often the seat of an herpetic eruption. 
After the first forty-eight hours the chlorides in the urine are 
greatly diminished in quantity, or entirely absent. In severe cases 
a moderate degree of albuminuria is common during the height of the 
fever. 
The physical signs begin to be appreciable as a rule within from SYMPTOMS, 
5 
twelve to twenty-four hours after the initial chill. Usually the first 
to be noticed is a fine crepitant rale, heard only with inspiration, 
though in some cases this is preceded by a diminished clearness of 
the respiratory murmur. Duluess on percussion succeeds, increas- 
ing in intensity as the consolidation becomes more complete. Ulti- 
mately the respiratory murmur is wholly replaced in the affected area 
by a peculiar whiffing sound heard most distinctly towards the close 
of expiration, the so-called tubular breathing. If the pleura is in- 
volved there may be a rubbing or creaking sound in addition. There 
are increased vocal resonance and vocal fremitus. 
As resolution progresses the auscultatory signs reappear and again 
disappear in the reverse order of their original sequence. At the 
crisis, while the temperature falls and the pulse and respiration be- 
come less frequent, there is no immediate change in the physical 
signs, showing that the condition of the affected area remains the 
same. 
In a large proportion of cases of pneumonia there is decided leu- 
cocytosis, the white cells numbering 20,000, 30,000, 40,000 or more 
to the cubic millimetre. 
This being a general picture of the disease we will examine its 
features more in detail, noting as we proceed the variations more or 
less frequently observed from the typical course of the affection. 
Prodromes.—In about twenty-five to thirty per cent, of the cases 
of pneumonia there are prodromes. In the aged the proportion is 
higher, reaching to sixty per cent.1 There may be for several days 
before the seizure a general feeling of malaise, headache, loss of ap- 
X>etite, dull pains in limbs and back, perhaps diarrhoea or epistaxis. 
The skin may have a sallow appearance suggesting slight jaundice. 
Chilly sensations alternating with flashes of heat may be experienced. 
These symptoms, leading up to the fully developed attack, are ac- 
cepted as a part of the seizure, an initial stage of the pneumonia de- 
pending upon the specific infection. 
Andral3 relates a case in which the general symptoms of head- 
ache, debility, duluess of the intellectual faculties, flushed face, in- 
jected eyes, and a frequent pulse appeared at least six days before 
the physical signs could be detected. 
The Initial Pain.—This is usually sudden in its onset. Not infre- 
quently the patient is awakened in the night by a sharp pain in the 
chest, much aggravated by every movement of respiration. This 
pain may be felt in any part of the thorax, but is most often referred 
to the region of the nipple on the affected side. Instinctively the 
respiratory movements are restricted in amplitude, and to compen- 
sate for this become more frequent. It will be observed that the 6 
SMITH—LOBAR PNEUMONIA. 
sound side of tlie cliest expands more than its fellow. There are 
cases, however, in which there is only a dull heavy aching, and some- 
times no complaint of pain whatever is made. When the pain is 
sharp it is no doubt due to accompanying pleuritis, while the dull 
aching has its seat in the pulmonary parenchyma, the pleura not 
being involved, and the dull pain not being masked by the more severe. 
In some instances the pain is referred to a point entirely outside 
of the chest. Thus, I recall a case in which the pain, which was 
very acute, was felt in the abdomen, and attention was thus diverted 
for a time from the real seat and nature of the disease. In many 
cases the pain is felt with great intensity some hours or even a day 
or two before there is any considerable rise in temperature or before 
the physical signs can be recognized. That the pleura should be 
thus irritated before there are any other symptoms or signs of pleu- 
risy, and while the pneumonic process is still undeveloped, would seem 
to indicate a special susceptibility of the serous membrane to the 
very early local action of the toxin. It has been suggested that the 
pain was due to the stretching of the inflamed pleura by the swelling 
of the subjacent lung,3 but this is at variance with the facts above 
mentioned. 
The duration of the pain does not often exceed two or three days. 
As consolidation becomes more complete the movements of the lung 
nearly cease, and the friction of the pleural surfaces upon each other 
being less, the pain is diminished in proportion. 
The Chill.—This is not uniformly present. It was absent in 
35 per cent, of 223 cases observed at the Presbyterian Hospital. 
Eisner found it absent in 30 out of 150 cases.4 It marks the 
moment at which the system feels the brunt of the infection, and 
from what we now know of the infectious diseases as a class, its 
occurrence alone would raise the presumption that pneumonia was 
such a disease. It varies greatly both in intensity and duration; in 
one case scarcely attracting the notice of the patient, and in another 
occurring as a severe rigor lasting for an hour or more, and leaving 
after it a sense of profound depression. Its severity generally bears 
a relation to the severity of the infection as expressed by the effect 
upon the nervous system rather than upon the temperature, and it 
has a prognostic significance which will be dwelt upon in another 
section. 
It is sometimes, though not often, repeated when a fresh invasion 
of lung occurs. Usually the cases in which it is absent are mild, or 
they have the type of bronchopneumonia rather than of the distinc- 
tively croupous form. 
The relation of the chill to the local condition is not clear. By SYMPTOMS. 
7 
many it is considered as marking a general infection of wliicli the 
lung changes are a subsequent expression. In proof of this view it 
is put forward that the physical signs are often not developed until 
some time has elapsed after the chill. Indeed, Syers5 reports five 
cases of pneumonia entirely without physical signs of lung consolida- 
tion. In each case the illness began suddenly; the temperature was 
high and fell by crisis; there was labial herpes; and the pulse-respi- 
ration ratio was typically that of pneumonia. Still no evidence of 
lung consolidation was detected in the physical examinations, which 
were repeated and most thorough. Now while such cases would 
seem to support the view’ that pneumonia is primarily a general 
infection with a secondary local lesion of varying intensity and im- 
portance, or which may remain absent altogether, it seems impos- 
sible from a careful consideration of all the phenomena to resist the 
conviction that the disease begins in the lungs. 
The evidence to the contrary is based on the general assumption 
that there is no disease in the lungs unless, and until, there are 
physical signs indicating its presence. But a moment’s reflection 
will show that as the local disease causes the signs, it must 'precede 
their appearance, and that it must progress to a certain extent before 
it can manifest itself in a way to be appreciated through all the in- 
tervening tissues by the coarse and insensitive methods of ausculta- 
tion and percussion. That bacteria are developed to a considerable 
extent during this time, and are actively engaged in the production 
of toxin, is a priori a reasonable inference from the toxaemia which is 
already present. If we reject this inference we must fall back upon 
the assumption that some other form of toxin from a microorganism 
in some other situation exists first, and in some unexplained way 
ultimately induces the growth of the specific organism in the lungs. 
Such an assumption is unreasonable in itself, and requires more for its 
support than the mere absence for a time of the physical signs. More- 
over, we find that when rigors occur in other infective diseases, they 
often appear before there is any local manifestation at all commen- 
surate with the general disturbance. This is especially true of puru- 
lent infection. The chill generally precedes any palpable local change, 
and its appearance is often the first indication that a pus focus is 
about to develop. Yet we must believe that the initial step is a local 
infection which even at its inception, so far as we can distinguish, is 
competent to poison the general system. Just how much toxic ma- 
terial lias to be taken up in order to provoke an explosion we do not 
know, but there is nothing in analogy to forbid the inference that, in 
pneumonia, a local process going on in the air cells may furnish 
enough toxin to excite a general reaction without giving rise as yet 8 
SMITH—LOBAIt PNEUMONIA. 
to recognizable physical signs. Besides, under the title of pro- 
dromes certain symptoms have been mentioned which in a consider- 
able proportion of the cases precede the chill. Granting them to be 
a part of the disease, we have to admit that there is toxin in the 
blood at a very early stage, often as long as two or three or more 
days before the physical signs begin to be discoverable. But if there 
is toxin in the blood, there must be germs somewhere, and where if 
not in the lung? Hence the inference already drawn seems to be in- 
evitable. 
In this connection it is to be noted that different specimens of 
pneumococci produce toxins differing enormously in virulence, so 
that in one case a comparatively limited local action may give rise 
to an intense general infection, while in another case a much greater 
accumulation of cocci in the lung may have a mild infection as the 
result. 
The Pulse.—In sthenic cases the pulse is at first full, bounding, 
and incompressible; such a pulse as in former times was held to de- 
mand blood-letting. Its frequency bears about the normal relation 
to the temperature, but less than the normal relation to the res- 
piration. As the disease progresses the pulse tends to increase in 
frequency and to become less firm. When the pulmonary obstruc- 
tion is considerable and the blood current is retarded in the lungs 
the arterial system is left but partly filled and the pulse becomes 
small and thready. Under these conditions it is often observed to 
fluctuate in strength with inspiration and expiration, being feebler 
when the blood is aspirated towards the thorax by the expansion of 
the chest, and stronger when the contraction -of the latter is added to 
the force of the cardiac systole. 
As a rule the pulse decreases in frequency with the fall of the 
temperature at the crisis. But this is not always so, and a frequent 
pulse with a low temperature is an association of serious import. It 
indicates that the system has become deeply infected, and the heart 
muscle proportionately weakened. In an adult a pulse as high as 
120, if maintained from day to day, may well cause serious appre- 
hension. On the other hand, especially in elderly persons, there 
may be little or no increase in the frequency of the pulse. In young 
children it often reaches a very high figure, which may even be diffi- 
cult to count, and yet the danger is not proportionately greater. In 
fact the pulse is subject to so great variations in sympathy with the 
disturbance of the nervous system that its indications taken alone are 
extremely unreliable. 
The respiration early assumes a frequency which is very charac- 
teristic, and is sufficient of itself to excite a suspicion of the nature SYMPTOMS. 
9 
of the disease. This increased frequency is due to several causes. 
Probably there is from the very beginning a specific irritation which 
is felt in the affected territory in the lung and which excites to greater 
functional activity. 
Hughlings Jackson6 mentions a case in which the intercostal mus- 
cles acted in voluntary, but not in involuntary, respiration. This 
was one of several cases of pneumonia in which the knee-jerk was 
absent. 
Such cases serve to show the profound effect which the toxin is 
capable of exerting upon the nervous system, and which extending 
to the respiratory centre would suggest a partial explanation of the 
great rapidity of respiration while as yet the respiratory surface is 
scarcely diminished. In confirmation of this, Washbouru found that 
mice injected with Fninkel’s pneumococcus suffered from dyspnoea 
even in the absence of pneumonia. 
Next, the pain which is felt in most cases tends to prevent a full 
expansion- of the thorax, and there is consequently an effort to make 
up by frequency of breathing what is lost in amplitude. This is 
evidenced by the superficial character of the respiration, and the fact 
that even before the expansion of the lung is lessened by solidifica- 
tion the affected side of the chest may often be seen to move less 
freely than the other. Then comes the influence of the fever, which 
of itself should give about one additional respiration for each increase 
of four beats of the pulse, or one degree Fahrenheit of temperature. 
Lastly there is added, as congestion and consolidation become factors 
in the case, the effect of reduced respiratory surface. 
These causes combined result in a frequency of the respiration 
out of all proportion to the pulse and temperature. Thus seventeen 
cases of pneumonia observed with reference to this point at the Pres- 
byterian Hospital gave as the average maximum of temperature, pulse, 
and respiration, 104.4°, 131, and 57 respectively. It will be noticed 
that the usual ratio of the pulse to the temperature, viz., increase of 
ten beats for each degree of rise, is very closely maintained, while 
the usual ratio of one respiration to four pulse beats is changed to 
about one to two and two-tliirds. 
At the crisis the respiration falls with the pulse and temperature, 
but not in equal degree, running usually between 20 and 25, while 
the temperature is normal or subnormal, and the pulse about 80. 
This fall of the respiration without a corresponding change in the 
available breathing surface is often cited as a proof that the pul- 
monary conditions have very little share in making up the gravity 
of the case. But, it is not to be overlooked that after the crisis 
the respiration maintains its comparatively low rate only in the 10 
SMITH—LOBAR PNEUMONIA. 
absence of all muscular effort, and when there is no accession of 
temperature. Should the patient attempt any exertion, or should 
the temperature rise again from any cause an immediate quickening 
of the respiration to a disproportionate degree would show the crip- 
pled condition of the lung. There is normally a wide margin of re- 
spiratory surface which can be drawn upon without greatly disturbing 
the breathing. But, with this margin exhausted the slightest tax 
upon the respiration either by muscular effort or by rise of tempera- 
ture makes itself felt at once. 
Pregnancy, rachitis, Pott’s disease, pulmonary emphysema, and 
all conditions that interfere mechanically with the movements of res- 
piration, add to the dyspnoea, and must be taken into consideration 
in estimating the degree to which the lungs are affected by the pneu- 
monia itself. 
Grisolle insists upon the distinction between real and apparent 
dyspnoea in pneumonia. The nervous patient, tormented by the 
stitch that limits the excursion of the ribs, and by an incessant 
cough will breathe 75 to 80 times per minute. Yet he is really less 
asphyxiated than the prostrated cyanotic patient who breathes only 
24 to 28 times in the same period. The prognosis is determined 
more by the peripheral cyanosis, the distention of the jugulars, and 
the state of the pulse and heart than by the apparent dyspnoea.7 
In pneumonia in the aged, which, however, is apt not to be strictly 
lobar or croupous, this frequency of respiration together with a mod- 
erate degree of fever is often almost the only evidence of the serious 
character of the attack, and is sufficient to establish the diagnosis in 
advance of the appearance of the physical signs, which latter are often 
delayed or imperfectly manifested. 
Very frequently the respiration is interspersed with grunting 
sounds at intervals or perhaps with every expiration. This is most 
marked during the stage when the pleurisy is at its height, and is 
usually associated with a more or less soporous condition, the sound 
ceasing when the patient is aroused. 
In cases in which the respiration is labored the ala3 of the nose 
will be observed to expand with each inspiration. This is an auto- 
matic movement, and indicates that the respiratory centre is receiv- 
ing an unusual stimulus. As a prognostic sign it has no special 
value. 
The temperature begins to rise from the moment of the attack, 
and increases with slight fluctuations until the maximum is reached. 
In cases that pass the crisis the highest point is usually a few hours 
before the decided fall takes place, the temperature often declining a 
degree or so, to rise again before the final drop. When death occurs SYMPTOMS. 
11 
before the crisis the highest point often immediately precedes disso- 
lution, when the thermometer may indicate 107 \ 108°, or even 109 \ 
Very high temperatures, however, may be recovered from. Francis 
Hawkins" gives a case of hyperpyrexia with double lobar pneumonia, 
in which, upon the fifth day of the disease, the temperature rose to 
108.4° F. (42.4° C.) as 
recorded by two differ- 
ent thermometers. The 
temperature fell by ly- 
sis, and became normal 
on the twenty-ninth day 
after admission. Pa- 
tient discharged recov- 
e r e d. The treatment 
was cold sponging and 
packing with iced water. 
When defervescence 
occurs by crisis, which 
is usually from the fifth 
to the eighth day, the 
temperature falls within 
a few hours almost or 
quite to normal. This 
is apt to occur during 
the night, and it often 
happens that the patient 
is left at the evening 
visit with no sign of an 
approaching decline in 
temperature, yet the 
next morning is found 
in an almost afebrile 
condition. 
The accompanying 
chart (No. 1) is of a case admitted on the eighth day of the disease. 
Pack at 75° F. repeated every four hours produced very little effect, 
but at the crisis on the ninth day the temperature fell 51° F. in four 
hours. 
A day or two before the actual crisis there may occur a sudden 
and considerable drop of temperature, followed promptly by a rise 
to its former height. This is known as pseudo-crisis. On the other 
hand, the crisis may be preceded by a brief but marked accession of 
temperature, the so-called critical perturbation. 
Hour. 
Temp 
C. F. 
41.1° 106° 
40.5° 105° 
40. 104° 
39.4° 103° 
38.8° 103° 
38.3° 101° 
37.7° 100° 
37.3° 99° 
36.6° 98° 
36.1° 97° 
96° 
Coccgjbtifk 'ff* 
One hour & tter -.L 
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One Ttour 
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On? hour otfer 
rtf*M?% 
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To 07 
To 3o 
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rr a 
Chart No. 1.—Defervescence by Crisis. 12 
SMITH—LOBAR PNEUMONIA. 
An increase of temperature following a decline suggests the in- 
volvement of a fresh portion of lung, though it may be due to other 
causes. 
As will be seen later under the head of Prognosis, the severity of 
the attack is not necessarily in proportion to the temperature; indeed, 
the greatest danger may be present when the thermometer shows but 
a moderate rise. Especially in the aged, it is possible for the attack 
to be afebrile throughout, aud to go on to a fatal termination without 
rise of temperature. 
It is to be borne in mind that the temperature of the surface may 
be but little increased, while that of the interior of the body is alarm- 
ingly high. Hence the rectal temperature may be greatly in excess 
of that observed in the axilla or in the mouth. This is not seldom 
the case in elderly persons, in whom the peripheral circulation is 
sluggish. It is also occasionally the result of extreme intensity of 
the initial infection. Especially in children this high internal tem- 
perature may coincide with coldness of the extremities. 
At the crisis the face becomes paler and calmer, restlessness and 
delirium disappear, the skin becomes moist, or there may be profuse 
sweating, and there is a tendency to sleep. An attack of diarrhoea at 
this time is not rare. The temperature may fall in from twelve to 
eighteen hours to 98° or 97° F., but may rise again on the following 
day to 99° or 100°. 
Fowler gives the following as the days of crisis in the order of 
their frequency: “22 per cent, on the seventh day; 16 per cent, on 
the fifth day; 12 per cent, each on the sixth and eighth days; and 10 
per cent, on the ninth day.” 
Instead of a complete crisis there may be a considerable and rapid 
decline of temperature, followed by a rise, and this succeeded in turn 
by a gradual lysis. Agaiu, there may be a complete well-marked 
crisis, but the lung remains solid; there is renewed pyrexia and the 
case goes on to a fatal termination. 
In a considerable proportion of cases there is no such sudden fall 
of temperature as constitutes a crisis, but the temperature, while fluc- 
tuating more or less, gradually becomes lower until the normal line 
is reached. This defervescence by lysis may be complete at any 
time between the third and the fifteenth or twentieth day (see chart 
No. 2). 
The cough is seldom a marked feature. It is accompanied by se- 
vere pain in most cases, due to accompanying pleuritis, and for this 
reason is superficial and catchy. Usually it begins within the first 
few hours, or in some instances it precedes the distinctive symptoms 
of the attack. Sometimes, particularly in persons past middle life, it SYMPTOMS. 
13 
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Chart No. 2.—Defervescence by Lysis. 
Hour. 
Temp... 
C. F. •• 
41.1° 106° 
40.5° 106° •■ 
40° 104° •- 
39.4° 103° v 
38.8° 102°.. 
38.3° 101° - 
« 
37.7° 100° • 
37.2° 99° _ 
36.6° 98° 
36.1° 97° 
96° 
_R_ 
_P_ 14 
SMITH—LOBAR PNEUMONIA. 
is entirely absent. Severe cougli occurring in paroxysms shows that 
the bronchial surface is involved. Such a cough is usually limited to 
the early stage of the attack. While it lasts it is the source of con- 
siderable distress from the pleuritic pain excited by it. 
The expectoration is at first frothy and tinged with blood. Oc- 
casionally it is almost pure blood. Later it becomes more dense and 
takes on a yellow, or brownish, or rusty color—according to the 
amount of blood it contains. The color is not often uniform, but 
more or less marbled from the aggregation of differently stained 
masses, varying in color from dark reddish-brown to pinkish or am- 
ber, or a greenish tint. With all these colors there is, however, a 
vitreous, semitranslucent appearance, which is not lost until the 
abundant admixture of leucocytes at a later stage renders the expec- 
toration opaque. The quantity is not great, seldom exceeding two or 
three ounces in twenty-four hours.- The expectorated material is 
composed of mucus mixed with leucocytes, red blood cells, epitlielia 
(both columuar and pavement), fibrinous casts of the air cells, for- 
merly described as pneumonic globules, and occasional casts of the 
bronchioles. Cursclimann’s spirals are sometimes found in the spu- 
tum, but their presence has no diagnostic significance. 
The sputum abounds in microorganisms, especially the diplo- 
coccus lanceolatus, which, however, diminish rapidly after the crisis. 
Chemically, it is found to contain a large amount of sodium chloride, 
while the alkaline phosphates are absent. The extreme adhesiveness 
of the expectoration has been already referred to. Owing to this it 
is difficult to eject it from the mouth, as it adheres to the tongue and 
teeth, often requiring the aid of a handkerchief for its removal. 
Later it assumes a more creamy appearance and becomes some- 
what less tenacious. At this stage it contains a larger proportion of 
leucocytes, many of them in a state of fatty degeneration. 
Occasionally, instead of this thick sticky material we find a thin 
fluid deeply stained with a dark coloring-matter derived from the 
blood. This so-called prune-juice expectoration is supposed to de- 
note a specially unfavorable condition. Probably it depends upon 
a serous exudation into the air passages, and indicates that the blood 
is less rich in fibrin than in cases yielding the tenacious sputum. 
Now and then we meet with a case of pneumonia in which there 
is no expectoration from beginning to end. In these cases the exu- 
date is removed by absorption alone. The process of freeing the lung 
and restoring its permeability is not materially longer than when a 
part of the effused material is coughed up. Indeed, when we con- 
sider the large amount of material to be removed, it is evident that 
the quantity represented by the expectoration must count for very SYMPTOMS. 
15 
little in tlie process. In fact, the bulk of the expectorated material 
in any case is furnished by the coincident bronchitis. 
An expectoration such as is described above is fairly pathog- 
nomonic. In no other affection do we have these sticky, tenacious, 
variously colored sputa. In bronchitis occasional isolated masses 
somewhat resembling them in character may be found, intermixed 
with watery and frothy material, but they lack the adhesive quality 
by which the whole contents of the cup are bound together, and they 
assume rather more of a nummular form. 
The 'posture in pneumonia is indicative of a chest affection. The 
patient lies at first on the back, as rendering the respiration less 
painful; but as consolidation progresses, the increased weight of the 
affected lung makes the decubitus on that side more comfortable than 
any other position, as there is less pressure upon the sound lung, 
and the .breathing is therefore easier. There is not the frequent 
change of posture so common in simple pleurisy; the patient having 
found the position that suits him the best, is likely to maintain 
it pretty steadily. Ortliopnoea is rarely observed, unless there is 
fluid in the pleural cavity or a considerable degree of pulmonary 
oedema. 
The face is apt to have a more or less dusky hue, in proportion 
to the respiratory involvement, and the lips are pale with a bluish 
tint in most of the severe cases. The countenance has a pained and 
anxious expression and the aspect is that of a person seriously ill. 
There is often evidence of great weakness and a tendency to slip 
down in the bed, which may be quite as marked as in typhoid fever. 
This, however, is far from being a constant feature, some persons 
retaining a remarkable degree of strength throughout the whole 
attack. The difference in this respect will be referred to again in 
another connection. 
The Blood.—From the outset the number of leucocytes in the 
blood is usually considerably increased, reaching sometimes as high 
as 40,000 to 60,000 per cubic millimetre. According to Stienon,9 
during the pyrexia the polynuclear cells are very abundant and the 
eosinophiles very rare. After the crisis the former diminish, and the 
latter increase. The subject of leucocy tosis will be further considered 
under the head of Prognosis. 
It has long been known that in pneumonia the proportion of fibrin 
in the blood is greatly increased. This increase may amount to as 
much as two hundred and fifty per cent. 
The Urine.—The absence of chlorides from the urine is a pretty 
constant condition after the first two or three days. The quantity 
becomes less as the process of consolidation advances, and, as the 16 
SMITH—LOBAR PNEUMONIA. 
exudate in the lung is enormously rich in chlorides, it seems a fair 
inference that they escape into the alveoli in place of being excreted by 
the kidneys. This inference is strengthened by the fact that during 
the absorption of the exudate the quantity of chlorides thrown out 
by the kidneys is abnormally great. In obscure cases this disap- 
pearance, partial or complete, of the chlorides from the urine may 
have considerable diagnostic value, although it may occur in other 
diseases. 
F. Pick 10 calls attention to a change in the urine in pneumonia not 
described hitherto. In from twenty-four to forty-eight hours after 
the crisis there is a decided decrease of acidity, the urine becoming 
neutral or alkaline. This condition continues for from twenty-four to 
thirty-six hours and then the acidity returns. 
The phenomenon is of pretty constant occurrence, Pick having 
observed it in thirty-one out of thirty-eight cases. He ascribes it 
to the absorption of the exudate, which is rich in sodium. It may 
be due, however, to sodium being excreted in the urine as bicarbo- 
nate, which under normal conditions would have been neutralized by 
pneumic acid in passing through the lungs (see page 44). 
In a considerable proportion of cases of pneumonia albumin is 
found in the urine. Owen found it in all but four of twenty-six 
cases.11 The amount bears some relation to the severity of the case. 
The albuminuria is probably the result of several contributing causes. 
The infection itself, like other acute infections, has a tendency to pro- 
duce this result, the pneumotoxin probably irritating the kidneys as 
so many other toxins do. Secondly, the interference with the pulmo- 
nary circulation results in more or less tension of the venous system, 
congesting the kidneys; and lastly, the imperfect metabolism conse- 
quent upon incomplete hsematosis leaves material in the blood to be 
thrown out by the kidneys, which material normally would be de- 
stroyed by oxidation. 
Besides albumin, blood and fibrinous casts of the uriniferous tubes 
are occasionally found in the urine. 
According to Sternberg,12 secondary infection of the kidneys by 
the micrococcus pneumoniae crouposae is probably not infrequent. 
The micrococcus is not ordinarily found in the blood in pneumonia, 
though sometimes present in small numbers. Fraenkel and Reiclie 
(1894) found this micrococcus in the kidneys in twenty-two out of 
twenty-four autopsies upon cases of pneumonia, and had a bacterio- 
logical examination of the urine been made during life, it is probable 
that the pneumococcus would have been found there. 
In a certain number of cases, undoubtedly, the kidney disease is 
due to the presence of the pneumococcus itself in the kidney. Such SYMPTOMS. 
17 
a condition could be demonstrated during life only by finding the 
organism in the urine in a case presenting symptoms of renal irri- 
tation. 
The most recent observations go to show that cases in which sec- 
ondary infection by the coccus itself occurs in organs other than the 
lungs usually prove fatal, and it is probable that these secondary in- 
fections very often determine the issue of the primary disease. The 
albuminuria in the simple form begins to clear uj) after defervescence, 
except in cases in which the respiratory embarrassment continues 
after the fall of the temperature. 
Associated with the albumin haemoglobin may appear in the 
urine. Nash 13 mentions a case in a girl of sixteen ill four days with 
pneumonia. The crisis occurred on the seventh day, after which no 
more coloring-matter or albumin could be detected. 
An early appearance of albumin in the urine, before the pulmo- 
nary circulation is materially obstructed, may be interpreted as indi- 
cating a high degree of infection, and therefore as likely to be fol- 
lowed by severe depression. Usually its first appearance is when 
the disease is at its height. 
The prognostic significance of albuminuria in this affection is 
important in proportion to the degree of renal implication present. 
This is judged of by the quantity of albumin on the one hand and 
the associated symptoms on the other. A large amount of albumin 
in a scanty urine containing epithelial casts and perhaps blood discs, 
the fever at the same time being high, the stomach irritable, and the 
mental faculties clouded, creates a presumption that organic change 
is present in the kidney. Such change alone constitutes a grave ele- 
ment in the prognosis, but when we consider that lying back of it 
there is likely to be an infection of the kidney by the organism itself 
as well as by the toxin, and that in this case the germ being in the 
blood, other organs also will be involved, it gives an extremely seri- 
ous aspect to the case. Should an examination of the blood show the 
presence of active pneumococci, the prognosis would be almost hope- 
less. Sturges and Coupland found that of twenty-seven cases in which 
albuminuria of all grades was present five were fatal, while of sev- 
enty-one without albuminuria all but two recovered. From these 
figures it would seem that pneumonia with albuminuria is more than 
six times as fatal as without it. It would be wrong, however, to infer 
that such an increase of mortality is due to the kidney affection by 
itself. We should rather note the fact that this affection is prone to 
appear in cases that are otherwise bad, and more likely, therefore, 
to prove fatal. 
Regarded as a complication, acute parenchymatous nephritis is 
Vol. XVI.— 2 18 
SMITH—LOBAR TNEUMONIA. 
not uncommon. Osier'4 found marked interstitial changes in the kid- 
neys in twenty-five per cent, of the cases that came to autopsy at the 
Montreal General Hospital. It is very rare that it is the foundation 
of permanent disease. 
A further effect of the disease upon the renal function is a remark- 
able diminution of the toxicity of the urine. According to researches 
by Roger and Gaume,13 the toxicity is only one-fourth of the normal 
during the pyrexia, but rises to the normal or beyond it at the crisis. 
It would seem from this that either the disease so acts upon the 
chemical processes that the usual amount of toxins is not formed, or 
that the kidneys fail to eliminate the toxins in full measure from the 
blood. While it is not at all impossible that the latter is the case 
in some degree, and that the retained toxins may play a part in pro- 
ducing the general condition, still as the lessened toxicity is not nec- 
essarily accompanied by evidence of kidney implication it seems more 
probable that it depends upon a fault in the chemical processes by 
which the toxic material is formed. 
Throughout the febrile stage the quantity of urea is abnormally 
great, the urine is scanty, and the specific gravity is excessive. 
After the crisis the urine becomes more abundant, but the excess 
of urea persists for some time, and may be greater even than when 
the pyrexia was present. This is probably due to the formation of 
urea from the exudate absorbed from the lung. According to Herter, 
the uric acid also is greatly increased. 
Delirium.—'The mental condition is more or less disturbed in a 
majority of cases. As the pyrexia increases delirium is pretty fre- 
quently observed. It may take the form of simple incoherence of 
speech, or it may be of the active, busy sort. Occurring early and in 
persons who naturally show a tendency to cerebral derangement in 
the presence of fever, it may have but little significance. Even the 
moderate pyrexia attending a severe cold will sometimes cause a pass- 
ing delirium in such patients, and if attacked with pneumonia they are 
likely from the outset to appear more ill than they really are, so far 
at least as the mental condition indicates. But in other cases the 
delirium is a part of the general nervous perturbation to which the 
infection gives rise, and it then points to a condition of considerable 
gravity. For some reason not yet explained, it is more prone to 
occur in apical pneumonia than when the lower lobes are involved, 
though this is denied by some observers. 
Old persons are especially liable to a quiet delirium resembling 
that of typhoid fever. 
Persons delirious from pneumonia require special watchfulness 
on the part of nurses and attendants. Occasionally the patient be- SYMPTOMS. 
19 
comes maniacal, and seeks to escape from imaginary enemies. Thus 
a young man, not alcoholic, in the service of the writer in the New 
York Presbyterian Hospital, during a momentary absence of the 
attendant, dashed across the ward and through the sash of a closed 
window, and fell from the second story to the ground. He recovered 
from his pneumonia and from the injuries sustained from the fall. 
In alcoholics this sudden frenzy is of frequent occurrence. 
The delirium is not always proportioned to, or dependent upon, 
the temperature. It may be present when the pyrexia is very mod- 
erate. When this is the case it is of evil omen, as it indicates cere- 
bral exhaustion. It may be a question whether the brain symptoms 
in a given case are the result merely of disturbed cerebral nutrition 
as in many other forms of disease, or whether they depend upon the 
direct local action of the microbe. The frequency with which the 
pneumococcus is found in the fluid of meningitis, even when pneu- 
monia is not present, shows that it has a special predilection for that 
locality, and it is perhaps more frequently present than we are in 
the habit of admitting. If autopsies in pneumonia more generally 
included the cranial cavity, it is probable that more cases of men- 
ingitis would be discovered; its distinctive clinical features being 
masked by those of the primary disease. 
When the aeration of the blood is seriously interfered with, we 
have in this condition alone a sufficient cause for some degree of men- 
tal disturbance, which shows itself more particularly in somnolence 
or coma. 
According to Potain,18 of Paris, the delirium of pneumonia is the 
result of varied conditions of the cerebrum; ranging from simple ex- 
citement, through the meningitis state, to true meningitis. Follow- 
ing the excited stage there is a period of quiet that deepens into 
coma, at times associated with signs of compression of the basilar 
cranial nerves. The meningitis may be apoplectic in character. 
Aside from the occurrence of delirium there are other evidences 
of nervous implication. The most striking, perhaps, is the extreme 
prostration that marks certain cases even in the early stage. It is 
not uncommon that a patient is stricken down in a way that at once 
suggests the agency of a powerful infection. His strength leaves 
him, he takes immediately to his bed, his limbs shake, his tongue is 
tremulous, his head and bones ache, he is nauseated and perhaps 
vomits. All this is in addition to the chill and to the stitch, and 
seems at a stroke to deprive the patient of half his vitality. It is in 
striking contrast to the comparatively slight impression upon the 
nervous system which is often noted in cases in which the tempera- 
ture may be higher and the pulmonary condition much more serious. 20 
SMITH—LOBAR PNEUMONIA. 
Sleeplessness is another condition not at all uncommon. Some- 
times for nights and days there is no sleep, unless the patient is 
overwhelmed with hypnotics. This condition should always suggest 
a careful inquiry into the previous habits of the patient, for while it 
is by no means confined to those with alcoholic antecedents, it is 
much more frequent in such persons, and in the absence of delirium 
the key to the problem might be overlooked. In subjects not alco- 
holic, the condition seems to be one of cerebral irritation at first, and 
later, perhaps, of cerebral exhaustion. 
In children often, and very rarely in adults, convulsions take the 
place of the initial chill. As the disease progresses, and particu- 
larly in cases in which lifematosis is seriously interfered with, somno- 
lence, deepening into coma, is a very frequent condition. As this 
tends to favor the occurrence or aggravation of hypostatic congestion, 
frequent efforts should be made to arouse the patient that he may be 
excited to more vigorous respiration. Life may hinge upon the ob- 
servance of this precaution at a critical juncture. Sponging the face, 
neck, and between the shoulders with ice water is an efficient means of 
recalling the patient to consciousness under these conditions. 
Causes of Death.—In fatal cases death may occur in a variety of 
ways. First, there are cases in which the patient is overwhelmed by 
the intense virulence of the infection, death occurring within from 
thirty-six to forty-eight hours after the chill. It would seem as if all 
the vital functions were overpowered by the toxsemia. There is ex- 
treme muscular and nervous prostration, the heart’s action becomes 
rapid and feeble, digestion is suspended, the kidneys act imperfectly, 
delirium and coma supervene, and death occurs from acute asthenia. 
In other cases death is caused by exhaustion of the right heart. 
The muscle tires out from overwork, being enfeebled already by the 
action of the poison. Later, dilatation takes place, perhaps to the 
extent of producing incompetence of the tricuspid valves. Finally, 
it becomes so overdistended that it cannot recover itself and asystole 
results. 
Still another cause of death is loss of respiratory surface. This 
is rarely the result of simple pneumonic consolidation, but there is 
added to this congestion an oedema of other portions of the lung. In 
these cases the lungs fill up more and more; the breathing becomes 
more and more rapid and superficial; and death by asphyxia takes 
place. 
Plicque17 lays much stress upon this mode of death, declaring that 
nine patients succumb to it for one dying from the infection. 
In a considerable proportion of cases death comes from exhaus- 
tion of the vital powers, after a protracted and intense struggle which PHYSICAL SIGNS. 
21 
tlie system is unable longer to continue. This is common in feeble 
and old persons, and is marked by a gradual giving out of the forces. 
It usually does not occur until after the febrile period. 
Lastly, death may be caused by one or more of the many compli- 
cations to be described hereafter. 
In addition to the foregoing, sudden death may occur at any stage 
of pneumonia, with no previous warning. 
As remarked by Wells,17 cases of this kind caused by heart clot, 
paralysis of the heart, and apoplexy may be readily explained, but 
there are cases in which no gross anatomical lesion can be found, and 
which with our present knowledge cannot be accounted for. Wells18 
quotes a number of such cases. The essay referred to contains a 
great amount of material that cannot be presented here, but which is 
extremely interesting. 
Physical Signs. 
Usually, even before there is notable (fulness on percussion, and 
sometimes within three or four hours after the beginning of the at- 
tack, we have a fine crepitant rale over the seat of the lesion. This 
is a sign commonly regarded as peculiar to pneumonia. It is heard 
only during inspiration, and often is confined to the last third of the 
inspiratory act. It has been likened to the crackling of salt thrown 
upon a heated surface, or to the sound produced by rubbing a lock 
of hair between the thumb and finger. A still more accurate compari- 
son is with the crackling of a static electric machine when the poles 
are almost in contact. It is supposed to be produced by the burst- 
ing of minute air bubbles in the bronchioles or alveoli. It is not to 
be confounded with the subcrepitant rale, which is coarser, and is 
heard in expiration as well as inspiration. The crepitant rale ceases 
when consolidation takes place, the exuded material then occupying 
the alveoli and excluding the air. The crepitant rale is absent in a 
small proportion of cases. It sometimes disappears for a time and 
then returns, to disappear finally as the solidification becomes com- 
plete. This sign is accurately limited to the affected portion of the 
lung, not being heard outside of the pneumonic area, although not 
always present in all parts embraced within that area. Indeed, in 
most cases we fail to find it over a large surface at any one time, 
though repeated examinations will reveal its presence at different 
points. This is due to its dependence upon transient conditions that 
vary within narrow limits with the changes going on in the lung, and 
to the crepitation not being a sound of sufficient intensity to be heard 
at any distance from the point at which it is produced. 
It may be reproduced when the exudate begins to resolve. Re- 22 
SMITH—LOBAK PNEUMONIA. 
cur ring during resolution it is known as the crepitus redux or rdle 
redux. It then is coarser than the true crepitant rale, and partakes 
rather of the character of the subcrepitant. 
As consolidation proceeds the crepitant rale is replaced by a new 
sound, bronchial or tubular breathing. The French call this the 
pneumonic souffle. It is a high-pitched, whiff-like sound, and may be 
closely imitated by stroking the coat sleeve lightly with the tips of 
the fingers. Often it is heard only in expiration, during which the 
current of air is more rapid than during the slower movement of 
inspiration. It is produced by the passage of air through the finer 
tubes, the vibrations being conducted with especial clearness by the 
solid tissue of the surrounding lung. It simply indicates consolida- 
tion, and therefore is not distinctive of pneumonia. At first it merely 
modifies the vesicular murmur, giving rise to bronchovesicular respi- 
ration, but as the alveoli become more completely filled it excludes 
vesicular respiration completely in expiration, and imparts a de- 
cidedly bronchial character to the inspiratory sound, which sound is 
at the same time shortened and incomplete. It is a sound of consid- 
erable intensity, and may be transmitted to some little distance be- 
yond the consolidated area, and even over the contiguous portion of 
the sound lung. In children this is especially the case. When fully 
developed, bronchial respiration is usually a persistent sign, being 
found at each examination during the whole period of consolidation. 
If temporarily absent from a locality where it was formerly found, 
the absence is due to a transient obstruction of a bronchial tube. 
If a considerable area of lung is consolidated and therefore with- 
drawn from action, a compensatory increase of expansion of the un- 
affected portion is necessitated, and as a result we have exaggeration 
of the normal respiratory murmur, the condition known as puerile 
respiration. This may be very marked, not only in the sound parts 
of the affected lung, but also throughout the other lung as well. 
The vocal resonance is modified by the greater density of the me- 
dium through which it is conveyed. The sound becomes loud, harsh, 
and metallic, reminding one of the voice as heard through a tele- 
phone. To this sign the term bronchophony is applied. In eliciting 
this sign it is important to cause the patient to speak as much as 
possible from the chest. As this is difficult in the case of women, the 
vocal signs in them are much less marked and conclusive than in men. 
Much depends upon the words the patient is required to pronounce. 
The usual one, two, three will illustrate this, the first giving much 
more decided results than the second and third. It is to be borne 
in mind that the normal vocal resonance is more pronounced on the 
right side than on the left. In some cases pectoriloquy is developed, PHYSICAL SIGNS. 
23 
that is, the words spoken are heard as distinct articular speech, when 
the ear is applied to the chest. Bronchophony is not developed until 
the second stage, as it depends upon solidification of the lung. In 
the normal condition the sound vibrations formed in the bronchial 
tubes are greatly softened, or almost suppressed, by the spongy lung 
tissue interposed between the tubes and the chest wall. When this 
tissue becomes solid by the filling up of the air cells, the bronchial 
sounds are transmitted directly to the surface, and seem to be formed 
immediately under the ear of the auscultator. This apparent near- 
Fig. 1.—Stethoscope for Auscultation of the Posterior Portion of the Chest, the Patient Being in a 
Recumbent Position. 
ness of tlie sound, wliich is sometimes almost startling, is quite as 
characteristic of bronchophony as is the modified character of the 
sound itself. 
Like tubular breathing this sign is merely significant of solidified 
lung, and therefore does not necessarily indicate the presence of 
pneumonia. In connection with other signs and symptoms, however, 
it is of great diagnostic value. 
Along with bronchophony goes increased vocal fremitus. This 
may be appreciated by placing the palm upon the chest, or more 
delicately by pressing lightly with the finger tips in the intercostal 
spaces. In cases in which there is abundant pleuritic exudation over 
the pneumonic lung, the fremitus is less exaggerated. 
Yery often the sounds of the heart are heard over a greatly in- 
creased area, being conveyed to a distance by the consolidated lung. 
In pneumonia it is often difficult to auscultate the posterior por- 
tion of the chest. To turn the patient so as to bring the affected side 
uppermost will frequently cause extreme respiratory distress; and 
with a weak heart it is not wise to raise him into a sitting posture. 
To meet this difficulty I have devised a stethoscope (Fig. 1) that, by 
pressing down the mattress with the left hand, can be slipped under 24 
SMITH—LOBAR PNEUMONIA. 
the patient on the fingers of the right. The cup of the stethoscope is 
flat and shallow, in shape like the cover of a pill box; and the rubber 
tubes instead of coming off from the top, come off from the side at 
points but little removed from each other. The thickness of the cup 
is about half an inch. With this instrument the auscultatory signs 
can be obtained with scarcely any disturbance of the patient. 
Very early in the progress of the case a degree of 'percussion dul- 
ness is observed. At first it is very slight, and is appreciated only by 
comparison with the note obtained over the corresponding location 
on the sound side. But it soon becomes more pronounced, and when 
the consolidation is fully developed the percussion note is but a 
shade removed from absolute flatness. Beginning in a portion of 
the lobe, it spreads usually until the entire lobe is included. Often 
it is pronounced at first only at a central point, from which the dul- 
ness fades away in all directions, but as time goes on the area in- 
creases until it accurately represents the contour of the lobe. If 
a second lobe becomes involved it is rarely by continuity, most com- 
monly by the formation of a second distinct focus. 
In some instances, however, the vesicular resonance is replaced 
by a sound which is more or less tympanitic, skodaic resonance. It 
is high-pitched and wooden in character, as when one taps with the 
fingers on a table. The contrast is marked with flatness on the one 
hand, and with the sonorous resonance of pneumothorax on the other. 
This type of resonance is produced in the bronchial tubes within the 
consolidated area, the air within these tubes being caused to vibrate 
by the impulse conveyed to it through the solidified lung, and the 
vibrations being transmitted in turn through the same medium to 
the surface. Over the larger bronchi the cracked-pot sound may 
occasionally be elicited, the shock of the percussion stroke being 
transmitted in the same manner. 
Along with the dulness on percussion, or the peculiar form of 
tympany, as the case may be, there is a well-marked sense of resist- 
ance imparted to the finger over the consolidated area. This will 
serve to correct any erroneous inference that might be drawn from 
an unexpectedly resonant percussion note. This sense of resistance 
is often more appreciable than the actual percussion dulness. 
With regard to all these physical signs, however, it is to be borne 
in mind that when the consolidation begins centrally in the lobe it 
may not be possible at once to obtain the usual results of ausculta- 
tion and percussion, the intervening normal lung preventing the ab- 
normal sounds from reaching the ear, and at the same time giving 
out a clear note on percussion. In such cases we have to depend for 
a while on the rational symptoms for a diagnosis. But it is not as PHYSICAL SIGNS. 
25 
a rule more than one or two days before tlie physical signs begin to 
be apparent, and in the end we may have them as clearly presented 
as under the usual conditions. This central beginning with the de- 
layed physical signs is very apt to occur in patients advanced in age, 
or in whom, from any cause, the vital powers are not active. 
In the aged the physical signs lose somewhat of their distinctive- 
ness. There is a tendency to increased resonance on percussion due 
to the rigidity of the bony framework of the chest, the greater depth 
of the thorax, and the backward curvature of the spine. The calcifi- 
cation of the rings of the trachea and bronchial tubes makes both the 
percussion note and the voice sound more sonorous, while it impairs 
the distinctive character of vesicular breathing, substituting a some- 
what bronchial quality. The excess of the bronchial secretion, which 
is almost physiological in old age, is likely to obscure the crepitant 
rale, which, in any case, is frequently absent in senile pneumonia. 
Auscultation of the Right Heart.—In a considerable proportion, 
perhaps more than half, of the cases of pneumonia, we have sooner or 
later to confront what may become a very serious mechanical condi- 
tion—the overfilling of the right heart and the venous system. This 
condition has its appropriate signs and symptoms, in speaking of 
which I shall use to a considerable extent the language of a former 
communication.10 
Whenever there is obstruction of the pulmonary circulation, the 
labor of the right heart is necessarily increased. In proportion to 
its inability to overcome the obstruction, there will be an accumula- 
tion of blood in the venous system. Excess of blood in the veins 
implies deficiency in the arteries, and hence this class of cases is 
characterized by an unequal divison of the blood between the venous 
circulation and the arterial. 
This condition has extremely important consequences, especially 
in acute pulmonary affections. In these w'e study the pulse with the 
greatest solicitude to judge howT the heart, as we say, is supporting 
the struggle. But the arterial pulse gives no indication of the imme- 
diate peril, for it is not the left heart that is bearing the brunt of the 
battle. The pulse tells its story only at second-hand. It may be 
small and weak, but it is chiefly because the left heart does not re- 
ceive enough blood from the lungs to fill its chambers and to distend 
the arteries. The trouble is not in a lack of propelling power so much 
as in deficiency of blood to be propelled. 
But if, instead of feeling the radial pulse, we could lay our finger 
upon the pulmonary artery, we should obtain information vastly more 
to the point. We should then be able to appreciate the degree of 
pulmonary obstruction by the fulness of the vessel, and to rate the 26 
SMITH—LOBAR PNEUMONIA. 
power of the right ventricle by the force of the arterial beat. And 
in the relation of these two factors one to the other is involved the 
issue of the case. Increasing obstruction with decreasing right-heart 
power means death; decreasing obstruction with sustained right-heart 
power gives promise of recovery. It is a question with which the 
left heart, and therefore the radial pulse, has almost nothing to do. 
For the peril is not from general exhaustion, as for example in fever, 
nor from failure of the heart as a whole, as in some cases of infec- 
tion, but specifically from tiring out of the right heart in its effort to 
unload the venous circulation through the obstructed vessels of the 
lungs. 
Now, while we cannot place our finger upon the pulmonary ar- 
tery, we can obtain nearly the same information by applying the 
stethoscope over the pulmonary valve. Owing to anatomical condi- 
tions which it is not necessary to describe here, it is entirely practi- 
cable to separate the pulmonary valve sounds from the aortic, and by 
means of auscultation to study the peculiarities of the former as indi- 
cating the condition of the pulmonary circulation. 
Unfortunately, however, in some cases the valve sound is masked 
by bronchial rales, so that it may be impossible to appreciate it 
accurately. But even in the most rapid breathing there are brief in- 
tervals during which the practised ear may nearly always gather the 
required information. 
Now, if we note carefully the sound of the pulmonary valve in, 
for example, a case of pneumonia, we shall find that at the outset, 
while the right ventricle is still in vigorous action, this sound is es- 
pecially clear and sharp, indicating a quick and strong recoil of the 
pulmonary artery following the ventricular systole. This sharp re- 
coil is due to unusual distention of the vessel, and this in turn is due 
to the resistance which the blood meets in passing through the lungs. 
If the case is to terminate favorably, this accentuation of the pul- 
monary sound will probably continue through the whole course of the 
disease, becoming less marked as the obstruction in the lung de- 
creases. But in cases of increasing severity and with an unfavor- 
able tendency, a time soon comes when not only this accentuation is 
lost, but the normal intensity of the valve sound is lessened, the sound 
becoming weaker and weaker until it ceases to be heard. This means, 
not that the obstruction has become less, but simply that tlio muscu- 
lar power of the right ventricle has become exhausted with the labor 
exacted of it. The blood is no longer driven through the artery with 
sufficient force to distend it, and there is not enough recoil to bring 
the valve cusps together with an audible sound. 
When this point is reached, the end is not far off. The wreaken- CLINICAL TYPES. 
27 
ing of tlie right heart favors still greater pulmonary obstruction, and 
this in tarn adds to the burden of the right ventricle, thus complet- 
ing the vicious circle. The struggles of the ventricle become feebler 
and feebler, while the tension within its cavity constantly increases, 
as the blood presses into it from behind. At last there comes a 
moment when the overtaxed muscle cannot summon the energy for 
another contraction, and its action ceases in diastole. 
The steps which lead up to this result are in a great degree trace- 
able by symptoms and physical signs. First of all, there are auscul- 
tatory and other signs of pulmonary obstruction; then come signs 
of general venous congestion. The distended right auricle may be 
traceable by percussion, or even may be seen pulsating at the right 
of the sternum. An increased area of cardiac dulness extending 
towards the xiphoid cartilage indicates the repletion of the right ven- 
tricle, and in spare subjects the labored beating of this may be felt 
by pressing the fingers under the costal cartilages. The superficial 
veins are seen to be unusually prominent, and the liver is enlarged. 
The spleen also is increased in size, and evidence of intestinal con- 
gestion may be afforded by copious diarrhoea. 
Proof of passive hypersemia of the kidneys is found in lessened 
excretion and in albuminuria. Thus all things combine to indicate 
a general preponderance of blood in the venous side of the circula- 
tion, the result which we should naturally expect from a retardation 
of the blood in the pulmonary vessels. 
Clinical Types. 
Bearing in mind that in a very large proportion of the community 
the potential cause of pneumonia is already present in the pneumo- 
cocci so often to be found in the air passages, it is easy to under- 
stand that a great variety of circumstances may act as exciting causes 
and determine an attack. Under normal conditions the vital forces 
are sufficient to protect the individual against the microbic action, 
but any influence which impairs this defence may open the way to 
effective invasion. These influences present a great variety, and it 
has been the custom with some writers to classify pneumonia accord- 
ing to the condition which seems to have given rise to it. Thus, we 
have bilious pneumonia, grippe pneumonia, malarial pneumonia, ty- 
phoid pneumonia, rheumatic pneumonia, traumatic pneumonia, etc., 
etc. With our present knowledge it is clear that these are not varie- 
ties of the disease, but merely designations of the agency by which 
in any particular case the defences of the system have been broken 
down and the specific germ afforded an opportunity to act. In some 28 
SMITH—LOBAR PNEUMONIA. 
instances there is a mingling of the phenomena of the exciting cause 
with those of the induced pneumonia, as when the fever under the 
influence of malarial infection takes on a remittent type, or the pres- 
ence of tubercle in the lung complicates the physical signs or changes 
the typical temperature curve. 
But while it does not seem that any useful purpose would be 
served by adopting such a classification and describing the various 
forms into which pneumonia may thus be divided, jet the prominent 
features of the disease vary in different cases, and the variations for 
the most part group themselves into three divisions, more or less 
marked, constituting three general types which shade into each other. 
In a clinical lecture by the writer, published in 1895, and in which 
these types are described the following passages occur.21 
“ To-day it is generally recognized that pneumonia is a disease of 
microbic origin, and that while the direct action of the microbe is 
limited in a greater or less degree to the lungs, the toxin derived 
from it pervades the entire system. 
“ The local lesion is not necessarily in proportion to the systemic 
infection; that is, we may have a very large implication of the lung 
with comparatively little evidence of general infection, and conversely 
we may have severe general infection with but little iralmonary im- 
plication. And again, without reference to the amount of lung in- 
volved, or even to the degree of fever present, we may have the vital 
forces but little impaired, or we may have the nervous and muscular 
systems completely overpowered by the intensity of the poison, con- 
stituting a condition that might almost be termed malignant. 
“ Giving to terms already in use a more definite meaning than they 
have had heretofore, we may call these two classes of cases sthenic 
and asthenic. We may also admit a third division, based upon me- 
chanical conditions by which the pulmonary circulation is rendered 
especially difficult, and to this division the term obstructive may be 
applied. Viewed then from our present standpoint we may rec- 
ognize three types of cases of pneumonia: sthenic, asthenic, and 
obstructive. 
“ It so happens that we have in the wards at this time patients 
illustrating these three divisions. 
“ The first case I will show you is that of a man twenty-eight years 
of age, of previously good health, and temperate in his habits; he is 
now in the fourth day of the disease. His initial chill, four days 
ago, was of moderate severity, the pain in the chest was considerable, 
the temperature rose on the second day to 103.5° F., and his pulse 
to 105, and on the following day the temperature reached 104.5° F., 
and his pulse 110. At this time the respirations were 32 per minute. CLINICAL TYPES. 
29 
There is in this case a remarkable absence of the prostration which 
we see in many cases of pneumonia. The patient, on arriving at the 
hospital, insisted upon walking from the carriage to the elevator, and 
from the elevator to his bed in the ward. You will perceive now that 
when he is asked to sit up for physical examination of the posterior 
portion of the chest, he rises without any evidence of feebleness; his 
hands are perfectly steady, and when his tongue is protruded there 
is no tremor. He is entirely capable, if allowed to do so, of walking 
about the ward. His mind is perfectly clear. When asked how he 
feels, the reply is ‘ first-rate. ’ On examination, we find that on the 
right side, with the exception of the space above the fifth rib in 
front, and above the middle of the scapula behind, there is evidence 
of consolidation over the whole lung, that is to say, we have dulness 
on i>ercussion and tubular respiration. Now, in this case, we have 
a large mass of lung implicated, while at the same time the constitu- 
tional symptoms are relatively slight. We are justified, therefore, in 
considering that in this case the force of the infection is compara- 
tively moderate, and that the local lesion is the more prominent 
factor. On examining the heart we find that the pulmonary second 
sound is decidedly accentuated, indicating that there is marked ob- 
struction to the pulmonary circulation on the one hand, and, on the 
other, a vigorous action of the right side of the heart. The blood is 
propelled into the pulmonary artery with force, but meeting resist- 
ance in the pulmonary circulation, there is corresponding recoil of 
the column of blood against the valve, causing a loud and sharp pul- 
monary sound. This patient’s urine has been examined, and has been 
found free from albumin. The test with nitrate of silver shows the 
usual absence of chlorides. 
“ The next case that I have to show you is one in which the condi- 
tions are materially different from those which we have just consid- 
ered. This patient is a man, thirty-five years of age, of fairly good 
previous health, a car driver by occupation. His initial chill oc- 
curred three days ago; it was very severe, lasting, as he stated, more 
than an hour; it was followed by very marked prostration. From 
the moment of its occurrence there was a feeling of intense weakness; 
he took to his bed immediately, and, when removed to the hospital, 
had to be carried from his bed to the carriage, and from the car- 
riage he was taken on a stretcher to the ward, and had to be lifted 
into bed. You find him now exhibiting the evidence of extreme 
muscular and nervous prostration. We place a glass of water in his 
hands, and in attempting to carry it to his lips he seizes the glass 
with both hands, nevertheless there is so much tremor that a portion 
of the water is spilled. The tongue is also tremulous. He is at 30 
SMITH—L0BAI1 PNEUMONIA. 
times delirious, with busy active delirum, a constant desire to get 
out of bed; but should he accomplish this, he would fall helplessly 
to the floor. His temperature on admission was 103.5° F., his pulse 
132, and his respiration 30. The relative slowness of respiration, as 
compared with the pulse, shows that it is not the amount of lung 
implicated which constitutes the gravity of the affection; the pulse 
being so much more frequent than the respiration indicates that the 
cardiac ganglia and probably the heart muscle are directly affected 
by poison. On examining the heart we find that the first sound is 
extremely feeble, and the pulmonary sound is almost inaudible. 
The pulse is very small as well as frequent. It is stated that at 
the onset, immediately after the chill, there was vomiting. These 
conditions together indicate a very grave implication of the nervous 
system, showing an intensity of infection in marked contrast with 
that of the previous case. The urine also is found to be albuminous. 
On physical examination, we find on the right side dulness and tu- 
bular breathing in the summit of the lung, extending as far down as 
the fifth rib in front, and nearly to the angle of the scapula behind; 
in other parts of the lung there are a few moist rales, and also occa- 
sionally throughout the left lung. Still, the evidence of the physical 
signs is that the action of the respiratory apparatus is but moder- 
ately impaired. The gravity of the case depends upon the virulence 
of the infection, the direct poisoning of the nervous and muscular 
systems. The muscular weakness, which is so marked elsewhere, 
extends to the heart, as is indicated by the small and very frequent 
pulse, and by the character of the first sound. It is in this that the 
danger to our patient lies; it is not that his respiratory function is 
so far impaired as to create peril in that direction, but the danger is 
primary heart failure, due to the poisoning of the nervous system and 
of the muscular fibre. The whole heart in this case, both the left as 
well as the right side, is markedly feeble, and in our treatment the 
effort must be to keep up the cardiac action until the force of the 
infection is spent. Cases of this type are more apt to prove fatal dur- 
ing the stage of pyrexia. If we can tide them over until defervescence 
takes place the prognosis becomes much more favorable. 
“ Our next patient is a man sixty years of age, whose habits have 
been irregular, and whose constitution has been broken down by 
alcohol. He is now in the sixth day of the disease; the chill was 
not well pronounced; there was but moderate pain in the chest, but 
early in the case the difficulty of respiration became a prominent fac- 
tor. We find him now with a temperature of 102° F., a pulse of 130, 
and with 48 respirations to the minute. The face is pale, the lips are 
blue, and the superficial veins- are distended. On physical examina- CLINICAL TYPES. 
31 
tion, we find that tlie lower lobe on tlie left side is for the most part 
consolidated; we find also that there are abundant mucous niles and 
perhaps a slight dulness throughout the remainder of the left lung, 
and also through the right lung. We have, therefore, a condition of 
pneumonic consolidation in the lower lobe of the left lung, with 
oedema more or less pronounced in the remainder of that lung and 
throughout the other. This condition necessarily implies a very 
grave impairment of the respiratory function. The amount of air 
which finds its way to the pulmonary vesicles is reduced to an extent 
which seriously threatens death by asphyxia. On examining the 
heart, we find by percussion that the right chambers are distended, 
the area of cardiac dulness being increased in the direction of the 
sternum. The pulmonary second sound is extremely feeble, being 
scarcely audible, obscured as it is by the mucous rales in that local- 
ity. The examination shows an increased area of hepatic and of 
splenic dulness, indicating that both the liver and spleen are dis- 
tended with blood. The urine is albuminous. In short, we have 
everywhere the evidence of venous repletion. There is more blood 
in the veins and less in the arteries than in the normal condition. 
The obstruction to the pulmonary circulation calling upon the right 
ventricle for increased action, that portion of the heart is especially 
exposed to exhaustion. 
“ The leading factor in this case, therefore, is the impairment of 
the respiratory function with consecutive exhaustion of the right 
side of the heart. The danger is that the right heart will fail. And 
yet the original area of pneumonic consolidation was not great, not 
nearly so great as in the first case we examined. The difference lies 
in the condition of the circulatory apparatus, due, in the first in- 
stance, to the age of the patient and, in the second, to the alcoholic 
habit which has impaired the whole mechanism of circulation. With 
a vigorous heart and sound blood-vessels, the amount of pulmonary 
consolidation present would have constituted but a trifling danger. 
We have not in this case, either, the evidences of virulent infection, 
and the nervous system is not markedly implicated. 
“ When death occurs in such conditions the post-mortem shows the 
right cavities and the pulmonary artery distended with blood. In a 
private note which I received a few days ago from Dr. Daland, of 
Philadelphia, he describes the post-mortem appearances in four cases 
of this kind which he had observed. The right auricle and ventricle 
and the pulmonary artery were crowded full with a substance resem- 
bling currant jelly. The tendency to an early unfavorable termination 
in these cases is not so great as in the preceding type. Defervescence 
is not so marked nor so complete, and its occurrence does not affect 32 
SMITH—LOBAR PNEUMONIA. 
the prognosis so favorably. The mechanical conditions are but little 
affected by the temperature, and death often occurs when the pyrexia 
is very slight.” 
In addition to the foregoing types there may be differences in the 
clinical features of the disease depending upon mixed infections. 
Other organisms may be present with the pneumococcus lanceolatus, 
such as the pneumococcus of Friedlander, Pfeiffer’s influenza bacillus, 
the Klebs-Loeffler bacillus, the typhoid bacillus, the staphylococcus 
pyogenes, and the streptococcus. One or more of these acting with 
the diplococcus proper to pneumonia may modify more or less the 
clinical picture. 
The one most likely to take part is the streptococcus. It may be 
present from the beginning of the attack, or it may become associated 
at a later stage. If present from the first, the onset is likely to be 
less violent than usual, and the invasion more tardy in its movement. 
The sputum is more purulent, less vitreous, less sticky, and contains 
both organisms. The face is less flushed and has the aspect of sepsis. 
The temperature is irregular, and there is no crisis. Lysis may be 
extended over three or four weeks. 
The upper lobe is more liable to be attacked, but the points of 
invasion change frequently, and the physical signs persist, perhaps for 
five or six weeks or longer. The cough is troublesome and there is 
great prostration. It is often months before the health is regained. 
And yet, with all this, the percentage of mortality is rather less than 
in pure pneumococcic infection. 
Weismayr reports 39 cases of pneumonia in which the pneumo- 
coccus lanceolatus was found alone in 34, and associated with the 
streptococcus in 2, while in 3 the streptoccocus was found alone. Of 
the 34 cases of pure pneumococcus infection 27 defervesced by crisis, 
4 by lysis, and 3 proved fatal on the seventh, tenth, and twelfth 
respectively, defervescence never being later than the eleventh day, ex- 
cepting in 1 case when it was completed on the fifteenth day. 
In contrast with this is the behavior of the five streptococcus 
cases. Of these one was fatal on the nineteenth day, and in the re- 
maining four there was kept up an irregular remittent fever, lasting 
in one case until the thirty-seventh day. The signs of consolidation 
continued from nineteen to forty days. 
The diagnosis of streptococcic pneumonia is based upon the 
atypical progress and long duration of the disease, but can be reached 
with certainty only by microscopical examination of the sputum.52 PATHOLOGY. 
33 
Pathology. 
Autopsical Findings. 
These correspond to a process extending from simple liypersemia 
of the affected part through extreme engorgement, fibrinous and cel- 
lular exudation into the air cells, complete consolidation, fatty degen- 
eration of the exudate, and removal of the latter by absorption and 
expectoration. All of these stages may be represented at the same 
time in different portions of the lung. As to how far these changes 
correspond with the clinical phenomena of the disease, and the results 
of auscultation and percussion, it will be interesting to quote from a 
work which is at present a leading authority on the subject of pneu- 
monia :2 
“We may pause here to consider whether in a disease clinically so 
well defined as pneumonia, it be not possible to assign correctly the 
special anatomical changes which accompany the various periods or 
stages of the disease, such as are denoted by the pyrexia and physical 
signs. It is undoubtedly true that this can be done to a certain ex- 
tent, but a little consideration will show a lack of absolute parallelism 
between the anatomical and clinical features. At the outset, the latter 
denote the existence of a more or less widespread area of congestion 
in the lung, as well as of incipient pleural inflammation, which are 
conditions of structural change possible to be detected in the dead 
body. Yet there must be a condition antecedent to these changes that 
constitutes the so-called ‘ first stage, ’ for which there is no anatomical 
indication. Indeed, as we have seen, the stage of pulmonary engorge- 
ment has seldom been clearly demonstrated anatomically; for the ob- 
vious reason that at this early period of the affection death rarely oc- 
curs, and also because in cases which run the most rapidly fatal course 
their very intensity carries them beyond this stage before death. And 
as has been pointed out, it is extremely difficult to infer from post- 
mortem appearances the existence of ante-mortem congestion in any 
organ, and especially in an organ like the lung, which is so readily 
influenced by the circulatory changes that arise in the last hours of 
life, or in the act of dying. It is wrell known how at this time the 
blood tends to accumulate in the venous system, and to be especially 
prone to collect in the dependent parts from the failure of the heart 
to propel it onwards; and this resulting condition of hypostasis is 
even more liable to occur when the heart is already weakened by the 
febrile process. The lung maj' become so filled with serosanguinolent 
exudation as to be quite solidified, and the term * hypostatic pneu- 
monia’ has been employed to denote this.” 
Vol. XVI.—3 34 
SMITH—LOBAR PNEUMONIA. 
The earliest lesion is simple hypersemia. When the chest is 
opened in a case in which death has occurred from pneumonia a por- 
tion of the lung may be found in this condition. It is seen not to be 
so fully collapsed as the surrounding normal lung, and to the touch 
it is slightly more resistant. The color is bright red, modified by 
the natural pigmentation of the lung. The pleural surface has lost 
some of its brilliancy, the epithelium being cloudy or perhaps exfoli- 
ated. On section, the surfaces fire bright red, and exude a bloody 
frothy serum. The physical sign corresponding to this condition is 
scarcely more than a slight localized feebleness of respiration, with 
more or less abundant moist rales. A few hours later, the hyper- 
aemia has passed into an extreme degree of vascular engorgement. 
The diseased part shrinks but little when the chest is opened. The 
pleural surface is of a deep red color, veiled by more or less of fibrin- 
ous exudate, which peels off readily in flakes. A similar condition 
is often observed on the corresponding costal surface. The resistance 
to the touch is markedly increased, and on section the tissue is more 
readily divided than in healthy lung. The cut surfaces are dark red 
in color, and dark blood mingled with air follows the knife. The 
appearance resembles closely that of an incised spleen, and the term 
splenization is applied to this stage of the local disease. At points 
minute extravasations of blood may be observed in the substance of 
the engorged tissue. Microscopically, the pulmonary capillaries will 
be found distended with blood, more or less fluid occupying the air 
cells. 
But the lung still crepitates between the thumb and finger, and 
can be squeezed dry without breaking down. A piece of it thrown 
into water floats. 
The physical signs belonging to this condition of the lung are 
diminished resonance on percussion, bronchovesicular respiration, 
crepitant rales, and slightly increased vocal resonance. In addition 
a pleural friction sound is often present. 
The distinguishing feature of the next stage is the filling up of 
the air cells with a fibrinous exudate by which the parenchyma is 
completely solidified. If a considerable area is involved the lung is 
increased in bulk and pushes out into the intercostal spaces, so that 
furrows are imprinted on its surface by the ribs. The lung is usually 
covered by a dense white, or grayish, or yellowish layer of fibrin, 
which if removed shows a deep mottled red or purple color beneath. 
This layer is adherent to the costal pleura also, and the separation 
leaves both the pulmonary and the costal surfaces rough and irregu- 
lar. Osier23 states that the pleural exudate may form a creamy layer 
an inch in thickness. When cut into, the solidified mass is found to rATHOLOGY. 
35 
have much the consistence of liver, and to be dark red or brownisli- 
red in color; and for this reason the condition is known as red hepa- 
tization. In asthenic cases the proportion of fibrin in the exudate 
seems to be less, and the liepatized portion is flabby as compared 
with what is seen in cases belonging to the sthenic type. The cut 
surface has a granular appearance due to the projection of the little 
Fig. 2.—Air-cell Filled with Pneumonic Exudate. (Drawn bv Dr. Louise Cordes from a specimen 
in the laboratory of the Presbyterian Hospital, New York.) 
plugs of fibrin with which the alveoli and the bronchioles are filled. 
These can readily be scraped from the surface of the section, and are 
found to be casts of the air cells intermixed with cylindrical moulds 
of the ultimate divisions of the air tubes. The infiltrated tissue does 
not crepitate on pressure, is friable, and can be torn much more 
readily than normal lung structure. Where a bronchial tube is cut 
across a sticky mucus of variable color flows out. A piece of liepa- 
tized lung sinks in water. 36 
SMITH—LOBAR PNEUMONIA. 
During this stage the weight of the lung may reach 2,500 or 3,000 
gm., instead of 600 gm. which is the normal average. 
Microscopically the moulds of the alveoli already alluded to are 
found to consist chiefly of fibrin in the form of a delicate mesh, to 
which are added red blood corpuscles, leucocytes, epithelial cells, 
and numerous diplococci pneumonite. Other organisms, such as 
streptococci, staphylococci, etc., are often found associated with the 
specific microbe. 
As this stage approaches completion the capillaries derived from 
the pulmonary artery become occluded, and the resulting thrombosis 
extends backwards into the larger vessels, even as far as to the giving 
off of the branch supplying the lobe. Indeed, there are cases on 
record in which the thrombus has reached the bifurcation of the pul- 
monary artery itself, and a portion of the clot has broken off and 
been swept into the sound lung, causing immediate death. 
This stoppage of the functional capillary circulation is perhaps 
due in part to vital changes growing out of the microbic invasion, but 
the chief agency is the pressure exerted by the exudate. The tension 
in the pulmonary circulation being scarcely half that in the systemic, 
a comparatively slight mechanical cause is sufficient to arrest the 
movement of the blood. 
The septa between the air cells are but little changed beyond the 
above-mentioned engorgement of the vessels and perhaps some loss 
of epithelium. In their migration from the capillaries some of the 
leucocytes remain entangled in the stroma. The nutritive vessels 
remain pervious. 
The pleura at this stage is usually covered by a dense layer of 
false membrane, which dips also into the interlobar fissures, and 
bridges them over. This layer of fibrin very generally extends be- 
yond the area of hepatization, becoming thinner towards the edges 
of the patch. It may cause an adhesion of the two pleural surfaces, 
which latter, however, are easily torn apart. 
The physical signs indicating the existence of hepatization are 
dulness, approaching to flatness, and increased resistance on percus- 
sion, with tubular breathing, or perhaps entire absence of resyuratorv 
sound if the exudate extends far into the tubes. To this is added in- 
crease of vocal resonance and of vocal fremitus. 
Succeeding the stage of red is that of gray hepatization. The 
change results from the absorption and removal of much of the color- 
ing-matter of the red cells in the exudate, the addition of white cor- 
puscles in great number, and a disintegration of the formed elements 
comprised in the contents of the air cells into a fatty, granular ma- 
terial. As the term indicates, the color of the cut surface is changed PATHOLOGY. 
37 
from red to gray, but as the change takes place irregularly the color 
is more or less mottled. In consistence the tissue is softer than in 
the previous stages, so that the finger may be thrust into it, and the 
pit thus formed fills with a dirty puriform fluid. This becomes more 
marked as the change progresses, and the cell contents become more 
liquid. The term purulent infiltration is applied to this condition 
incorrectly, as the fluid is not pus but a fatty and granular detritus. 
Some confusion, however, has arisen in regard to the condition to 
which the term 'purulent infiltration properly belongs. By some’this 
is considered as merely an advanced stage of gray hepatization, the 
fibrin and the red cells in the exudate having broken down and the 
leucocytes undergoing fatty degeneration. These authorities regard 
the condition as a step in the progress toward resolution, a prepara- 
tion of the exudate for being absorbed. 
Other authorities describe purulent infiltration 'as one of the is- 
sues of pneumonia, and almost necessarily fatal. To them it means 
a diffuse suppuration of the affected portion of the lung, an event so 
grave as practically to preclude recovery. 
It is not difficult to see how this confusion has arisen. Necessarily 
our knowledge of the local conditions has been obtained from the post- 
mortem findings, and these may admit of either interpretation. But 
it seems to me that there are two distinct processes, the results of 
which may be differentiated both by the clinical history and by the 
changes found in the lung. 
We may find a subject whose expectoration had gone through the 
usual changes and become mucopurulent, and who had passed the 
crisis, but has not been able to rally afterwards. Death has taken 
place from mere exhaustion. The autopsy shows the cell walls in- 
tact, and the cells filled with the grayish material, which gives the 
name to this stage of hepatization. 
In another case the creamy sputa will have made their appearance 
in due sequence, and soon afterwards there will have been a more or 
less complete defervescence, but the temperature has not remained 
down. There have been fluctuations resembling those of hectic, 
with chilliness and perspirations. After a course of several days 
death has taken place under these septic manifestations. The au- 
topsy shows the affected area filled with a creamy fluid identical with 
pus, and the septa infiltrated, softened, and more or less broken 
down. 
Now in the first case death has overtaken the patient in the midst 
of a process tending to restoration to a normal condition. In the 
second, the restorative action had been interrupted by a new process 
with its seat in the cell wall. The nutritive vessels have been at- 38 
SMITH—LOBAR PNEUMONIA. 
tacked, and tliero lias supervened a veritable “ inflammation of the 
lungs,” going on to suppuration and breaking down of tissue. To 
this condition the term purulent infiltration is very applicable, and 
it will be readily apparent that such extensive suppurative action in- 
volving corresponding loss of lung substance and coming upon the 
heels of an exhausting j)yrexia could scarcely be recovered from. 
There is no physical sign by which the transition from red to 
gray hepatization is indicated. If resolution begins in this stage it 
may be marked by a return of the crepitant rale. But resolution 
may take place before this stage is reached, and in that case the re- 
turn of crepitation would be during red hepatization. 
As to the time at which these several stages develop the greatest 
diversity obtains, and in this connection the interest of the following 
note is such that no apology is necessary for its insertion: 
“ As illustrating the variability of the anatomical characters of the 
inflamed lung at the time of death, and the lack of any definite re- 
lation of these to the time at which death has occurred, the following 
cases may be quoted, in which death took place at periods varying 
from six to seventeen days from the onset. 
“1. Male, aged 40, death on sixth day. Gray hepatization of 
greater part of left lower lobe. 
“2. Male, aged 75, death on seventh day. Gray hepatization of 
anterior part of upper lobe (congested posteriorly) and of upper one- 
fourth of lower lobe of right lung. In left lower lobe a £ recent ’ pneu- 
monic nodule. 
“ 3. Male, middle-aged, death on seventh day. Whole of lower and 
part of upper lobe of left lung hepatized; gray at base, elsewhere red. 
“4. Male, aged 4, death on seventh day. Gray hepatization and 
‘ purulent infiltration ’ of right upper lobe. 
“ 5. Male, aged 62, death on eighth day. ‘ Bed passing into gray ’ 
hepatization of right lower lobe. 
“6. Male, aged 50, death on eighth day. Gray hepatization of 
right lung (except apex). 
“ 7. Male, aged 24, death on ninth day. Gray hepatization of left 
upper and low’er lobes. Patches of ‘ reddish-gray ’ hepatization in 
right upper and lower lobes. (Fibrinous coagula in bronchi.) 
“8. Female, middle-aged, death on ninth da}r. ‘Grayish-pink’ 
(early gray) consolidation of right upper and lower lobes. 
“ 9. Male, aged 48, death on tenth day. Bight lung, except extreme 
apex and anterior margin, entirely in state of gray hepatization. 
“ 10. Female, aged 4, death on the tenth day. Lower and part of 
upper lobe of right lung in state of ‘ reddish-gray ’ hepatization. 
“11. Male, aged 18, death on thirteenth day. Both lower lobes 
‘ dark colored and granular. ’ (This case was rheumatic, and was 
accompanied by peri- and endocarditis.) 
“ 12. Male, aged 50, death on sixteenth day. Gray hepatization, 
studded with yellowish points, of whole of right lung, except anterior 
and lower margins. [Probably consecutive “pneumonitis” A. H. S.] PATHOLOGY. 
39 
“13. Male, aged 4, death on seventeenth day. Gray hepatization 
of left lower lobe.” (Sturgis and Coupland.2) 
According to Delafield and Prudden,24 the lung is found passing 
from red to gray hepatization at any time between the second and 
the eighteenth days of the disease. It is found completely gray at any 
time from the fourth to the twenty-fifth day. In about one-lialf of 
the fatal cases death takes place in the condition of red and gray he- 
patization ; in about one-fourtli in the condition of gray hepatization. 
As resolution progresses the infiltrated material is gradually re- 
moved, and little by little the air regains access to the alveoli. The 
lung tissue becomes less friable, shrinks in volume, is more elastic, 
crepitates again on pressure, and resumes a more natural color. 
Corresponding with these changes the physical signs which marked 
the invasion reappear in reversed order. Percussion dulness be- 
comes less absolute, and bronchial breathing, if previously all respi- 
ratory sounds were absent, returns for a time, and then gradually 
gives place to vesicular respiration accompanied at first by crepitation. 
Vocal resonance and vocal fremitus are less marked. It is a long 
time, however, before the physical signs get to be entirely normal, 
especially if the fibrinous layer covering and uniting the pleural sur- 
faces is of considerable thickness, thus dampening the joercussion 
note and obscuring the auscultatory sounds. 
In most cases besides the specific pneumonic lesion, which is 
limited to a certain area, there will be found evidence of congestion 
in other parts of the same lung, and perhaps in its fellow. This con- 
gestion may be so intense, and the resulting secretion so abundant, 
as to leave insufficient breathing surface, and to be the immediate 
cause of death. The congestion may be hypostatic, when it will be 
limited to the dependent portion of the lung, or it may be due to car- 
diac weakness, and affect all parts. Very frequently more or less 
pulmonary oedema is present. 
In rare instances the affected portion of the lung undergoes a sup- 
jmrative process. The surface has then a yellowish color, and on 
section a purulent fluid exudes. The cells, resembling pus cells in 
all respects, not only fill the alveoli, but infiltrate the interalveolar 
walls.” The pressure thus induced interferes with the nutrition of 
the septa, and may lead to their softening and breaking down. This 
may result in the formation of abscesses, but the condition if at all 
extreme usually proves fatal before this point is attained. 
Abscess of the lung as an event of pneumonia occurs in between 
one and two per cent, of all cases. The abscess may have firm walls, 
or may be only an irregular cavity in broken-down tissue. Abscesses 
vary in size from that of a pea to the dimensions of the entire lobe. 40 
SMITH—LOBAR PNEUMONIA. 
They sometimes discharge through a bronchus, at other times, when 
small, they become encapsulated and undergo caseation. 
After death from pneumonia a characteristic condition of the heart 
is usually found, in which the left cavities are nearly or quite empty 
while the right cavities are distended by firm coagula that often ex- 
tend into the branches of the pulmonary artery. 
The spleen is often enlarged, especially in asthenic cases in which 
the infection has been intense. Under like conditions the liver is 
congested, particularly when the respiration has been greatly embar- 
rassed and the right heart overtaxed. 
In the kidneys the cells lining the tubes are often in the condition 
of cloudy swelling, and in a small proportion of cases there is fully 
developed nephritis. 
There is a form of pneumonia28 in which the air cells, instead of 
becoming entirely free as the result of resolution, are found to contain 
more or less of connective tissue springing from the cell wall and in 
intimate connection with it. This is not uniformly disseminated 
through the air vesicles, some of these containing only fibrin and 
various cells. The connective tissue may become organized, the new 
vessels communicating with the vessels of the septa. 
The clinical history is somewhat different from that of ordinary 
pneumonia, being more protracted, and the phenomena of crisis are 
not well marked. The process realizes the idea of a true pneumo- 
nitis. If life continues for several months, the air spaces become com- 
pletely filled and their walls much thickened; and smooth connective 
tissue takes the place of the natural structure of the lung. 
Pathology. 
It is now very generally conceded that tlie essential phenomena of 
pneumonia are due to the action of one or more forms of bacilli. In 
nearly every case the diplococcus pneumoniae of Friinkel is found in 
the exudate, and it may also in rare cases be disseminated through 
the system more or less generally. With this are sometimes associated 
other microorganisms in such number as to suggest the probability 
that they play an important though subsidiary part both in the local 
process and the general infection. 
As to the relation of the specific organism to the disease as a 
whole, we may note: 
First, that no amount of traumatism inflicted upon the lung, be 
the methods ever so varied, produces pneumonia. We majr cut, 
pierce, bruise, burn, or s *ald the lung; we may introduce mechanical 
or chemical irritants into the air passages, and while we get inflam- 
mation as the result we do not get pneumonia. PATHOLOGY. 
41 
Second, we may have pneumococcic infection in several serous 
and synovial cavities at the same time, resulting in suppuration in 
each, and not have pneumonia. 
Third, we may introduce the pneumococcus into any portion of 
the body save the lungs, and even into the blood itself, and we do not 
get pneumonia. 
Fourth, but if we introduce active pneumococci into the paren- 
chyma of the lung we always get pneumonia as the result. 
Fifth, in probably every case of pneumonia coming to autopsy 
during the active stage, if the search is properly conducted, the pres- 
ence of pneumococci in the lungs can be demonstrated. 
The inference from these facts is that the one thing necessary for 
the development of pneumonia is the presence in the alveoli of pneu- 
mococci in a condition of active multiplication. 
In regard to the nature of the local lesion, while it is commonly 
designated as an inflammation, the term is scarcely correct in the 
sense in which it is understood when applied to that process as it oc- 
curs in other structures. We consider inflammation as affecting the 
tissue itself, and causing an anatomical change in its elements. But 
in pneumonia the interalveolar septa seem to be but little affected by 
the enormously active process taking place within the cells. After a 
few days these cells are emptied of the mass of exudate with which 
they were filled, and the cell walls are found practically in their nor- 
mal condition, having suffered at the most only a little loss of epi- 
thelium. Had this been an ordinary inflammation, as of the liver or 
the kidneys, accompanied by a corresponding amount of local change, 
we should expect to find such damage to the part as would require a 
long process of repair, if, indeed, complete recovery could ever take 
place. Vessels would be obliterated, new connective tissue would be 
formed, permanent indurations would remain, etc. Indeed, such 
changes are the usual accompaniments of chronic pulmonary inflam- 
mations, and sometimes remain after pneumonia of an aberrant type. 
That they do not occur in typical croupous pneumonia seems sufficient 
evidence that the process in the latter case is essentially different from 
inflammation in general. 
But if other evidence were needed it is supplied in the fact that at 
the crisis the fever, which if the process were an inflammation we 
should have to regard as an inflammatory fever, ceases abruptly, 
while the so-called inflammation goes on. In typical cases there 
comes a time, usually from the fifth to the eighth day, when the tem- 
perature falls suddenly nearly or quite to the normal line, while the 
physical signs denote that the local conditions remain unchanged. 
In what inflammation occurring elsewhere, and of sufficient intensity 42 
SMITH—LOBAR PNEUMONIA. 
to occasion a temperature of 103° to 106°, do we find such a defer- 
vescence with all the local signs of the inflammation persisting after- 
wards? 
But if this is not an inflammation of the lung tissue, what is it? 
This question has received various answers. It has been suggested 
that the fever is the juimary affection and that the changes in the 
lung bear some such relation to it as the rash of scarlatina, for ex- 
ample, bears to the fever that accompanies it. The term lung fever 
is a survival of this view. 
It has even been suggested by Trousseau that the process is es- 
sentially a form of erysipelas, modified by the peculiar structure in 
which it has its seat. And again it has been thought to be a herpes 
zoster of the lung, having a nervous origin. But even these fantastic 
suggestions, designed to meet the difficulties in the way of regarding 
pneumonia as a simple inflammation, still leave the phenomena of 
the crisis above referred to unexplained. 
The discovery of the pneumococcus has carried us along so far as 
to enable us to say that pneumonia is an infectious disease depend- 
ing upon the action of this organism. This is a great advance, but 
it still leaves the question open, How does the micrococcus bring 
about the local and general conditions? How does it find its way to 
the lung, and when it gets there, how does it act? 
It seems to the writer that there is an answer to this that is at 
once consistent with the facts and affords a satisfactory explanation 
of the phenomena observed. It is that instead of an inflammation 
of the lung tissue we have essentially a process of germ culture going 
on in the air cells. To make this intelligible, we must recall the fact 
that in the lung we have two separate and distinct circulations, the 
one derived from the bronchial vessels, and designed for the nutrition 
of the structure; and the other derived from the pulmonary vessels, 
and devoted to the function of the organ. It being chiefly with the 
latter that the pathological process has to do, while the former is left 
to maintain the integrity of the tissues, we can see that a diseased and 
a relatively healthy action may go on side by side, dependent upon 
the condition of the respective systems of vessels. 
Let now a diplococcus find its way into an air cell, and there ex- 
cite an irritation in the delicate structure that separates the interior 
of the cell from the functional blood supply. An exudation from 
the latter follows, and the coccus at once finds itself surrounded by 
a medium suitable for its multiplication. The conditions as to 
temperature, etc., are similar to those in artificial cultures in the 
laboratory. The microbes increase rapidly, more exudate is poured 
into the cell, which becomes filled and overflows into an adjoining PATHOLOGY. 
43 
cell, where the process is repeated, cell after cell and lobule after 
lobule being invaded. All this time the cell wall is nourished by its 
nutrient blood supply, and is almost as indifferent to what is going 
on in the space which it encloses as is the glass of the culture tube to 
the process within it. 
If asked what, after all, is the evidence that the process does not 
affect both circulations alike, the answer is, that if it did so, the re- 
sulting condition would be incompatible with the maintenance of 
vitality in the affected part. We have, for example, a portion of 
hepatized lung, perhaps as large as a child’s head, in which the 
branches of the pulmonary artery are thrombosed, and into which 
no blood from the right side of the heart can penetrate. Suppose 
for an instant that a like condition existed in the nutrient circulation, 
that its vessels also were occluded, and that no blood could reach the 
parenchyma of the lung from the left side of the heart. So large a 
mass could not be nourished by imbibition from surrounding parts, 
and there would be nothing left for it but speedy loss of vitality. 
What actually does happen, however, is, as we have seen, that the 
cell wall escapes without injury, and not only so, but the absorptive 
apparatus remains in full activity as is proved by the quickness and 
completeness with which the removal of such a bulk of material is ef- 
fected. 
From the moment that the culture process begins, the specific 
toxin also begins to be formed, and is at once absorbed into the cir- 
culation. From this we have the chill, the high temperature, the 
prostration, and all the other evidences of a virulent infection. The 
rapidity with which the toxic product finds its way into the system is 
explained by the favorable conditions presented by the great vascu- 
larity of the lung and the enormous surface from which absorption 
takes place. Indeed, it would almost seem as if the lung. structure 
were arranged with a view to such a result. 
So long as fresh supplies of toxin are being formed, or, iu other 
words, so long as the consolidation is spreading, so long the toxaemia 
will be maintained. But here again, as in artificial cultures, there is 
a limit beyond which the process cannot extend. A given quantity 
of a culture medium can maintain the life of a given number of germs 
only for a certain time. Beyond that time the changes produced in 
the medium render it unfit as a soil for the further growth of the or- 
ganisms, and the death of the latter puts an end to the process. 
With the supply of toxin cut off the temperature falls. If the inva- 
sion has been regular and rapid, coming to an abrupt termination 
with the complete consolidation of the lobe, the suppty of the toxin 
will cease abruptly, and we shall have defervescence by crisis. If, 44 
SMITH—LOBAR PNEUMONIA. 
on tlie other hand, the effusion into the air cells has been gradual, 
and the process of consolidation slowly carried forward, the supply 
of toxin will continue in one part while it fails in another; the proc- 
ess will be prolonged, and the defervescence will be by lysis. 
This does not exclude the theory of the production of an anti- 
toxin. Indeed numerous observations, and especially those of the 
Klemperer Brothers (see page 124) go to show that a transient im- 
munity is created by an attack of pneumonia, and that this immunity 
may be transferred to another subject by serum inoculation. This 
could scarcely be explained except on the theory of an antitoxin, and 
I can see no obstacle to accepting both theories in explanation of the 
clinical phenomenon in question. 
As beariug upon the formation of an antitoxin the following ob- 
servation by Pinna-6 is of interest: He found that the pus obtained 
by injecting turpentine into the cellular tissue of a man, and which 
pus was absolutely sterile, had the power when injected into rabbits 
of rendering the animals immune to inoculations of pus containing 
pneumococci. The rabbits recovered and remained healthy, while 
others not so protected succumbed to pneumococcus septicaunia 
within thirty-six hours after receiving a like amount of pneumonic 
pus. It would seem from this that the pus itself, apart from any 
microbic action, possesses antitoxic properties. 
This suggests the probability that the exudate during the process 
of retrogression assumes the character of simple sterile pus in its 
relation to the pneumotoxin. The theory of an antitoxin will be 
further discussed in treating of serum therapy. 
But the matter is still further complicated by a chemical factor 
that enters into the case the moment the current in the functional 
capillaries is arrested. Normally there is carried in these vessels a 
varying amount of sodium bicarbonate held in solution in the blood. 
It is requisite that the carbon dioxide contained in the bicarbonate 
should be set free in the lungs, in order that it may escape with the 
expired air. Nature provides for this by the production of a special 
organic acid in the parenchyma of the lung, known as pneumic acid. 
This combines with the sodium, and the carbon dioxide thus liberated 
passes iuto the alveoli. 
But when the functional circulation ceases, the sodium bicarbonate 
is no longer at hand to neutralize the pneumic acid, which continues 
to be produced as a part of the nutritive process. The parenchyma 
of the lung, therefore, becomes saturated with a free acid, and the 
slightest trace of acid in the medium is, as has been proved from labo- 
ratory experiments, fatal to the propagation of the pneumococcus.* 
* The acid reaction of hepatized lung has been demonstrated in the cadaver. PATHOLOGY. 
45 
Thus there are three things that tend to bring about the crisis : 
failure of the supply of toxin, the formation of an antitoxin, and the 
presence of a free acid in the affected part inhibiting the action of the 
diplococcus. 
Probably the phagocytosis of Metclinikoff also plays a part, the 
phagocytes destroying the pneumococci. This, however, is only con- 
jectural. 
With regard to the mode of access of the germ to the air cell there 
are only three channels by which it might reach the seat of its activity 
in the lung. These are the blood-vessels, the lymphatics, and the air 
passages. As to the first of these it has been amply demonstrated 
that the pneumococcus may find its way into the blood-vessels, and 
may set up a peculiar action in localities that are shut out from all 
communication with the exterior of the body. Thus it is sometimes 
found in the fluid of pericarditis, and in the pus of meningitis, the 
lung not being at all implicated. We must therefore concede the 
possibility of its reaching the lung in this way; but is this the usual 
route? Against this supposition is the fact that in the vast majority 
of cases of pneumonia the local infection is strictly limited to the 
lungs, although, as we have seen above, the organism is capable of 
attacking other structures. Moreover, if we were to admit a selective 
action on the part of the lungs whereby the coccus is attracted, as it 
were, to the pulmonary structure (as the gonococcus is, for example, 
to certain tissues), we still have to account for the fact that as a rule 
the morbid process begins in a single focus in the lung and spreads 
from that as a centre, instead of attacking different places in the 
lungs, as it would be likely to do if the organisms were floating in 
the blood. When we add to this what the researches of Kantliack a7 
and others prove, that if in a case of pneumonia the pneumococci are 
found in the blood, and can be cultivated from it, the prognosis is 
bad, while, as we know, under usual conditions a large proportion of 
cases of pneumonia terminate favorably, we have a strong probabil- 
ity, to say the least, that the blood-vessels are not the usual channel 
by which the infection reaches the lung. 
As to the lymphatics, the same reasoning holds good, and in 
addition we have the extreme improbability that the organisms could 
pass the barrier of the lymphatic glands. 
This brings us back to the air passages as the most likely avenue 
of infection. * But this is by no means an open one. The anatomical 
* As corroborative of this view of the mode of access of the infecting germ it is 
interesting to observe that as in two-thirds of the cases foreign bodies passing down 
the trachea find their way into the right bronchus, owing to its greater width, so 
wTe find in practice a very considerable preponderance of right-side pneumonia, 46 
SMITH—LOBAR PNEUMONIA. 
configuration of the bronchial tree is such that it is impossible that 
a solid particle, however minute, should be carried with the inspired 
air beyond the second or third divisions without coming into contact 
with the bronchial wall. Even gaseous material cannot pass from the 
glottis to the alveoli at a single inhalation. It is only by a series of 
inspiratory impulses, aided at last by molecular interchange between 
the inspired and the residual air, that it can reach the air cells. 
Once deposited upon the mucous surface of the tubes all the con- 
ditions favor the expulsion of a solid particle rather than its further 
progress inward. In respiration the outward current is much more 
rapid than the inward, and expiration tends therefore to drive back- 
ward with a greater force than inspiration exerts in drawing forward. 
To this constant outward impulse is added the action of the ciliated 
epithelium, by which a movement in the direction toward the glottis 
is imparted to the fluid which bathes the bronchial mucous mem- 
brane. These influences combined render it extremely difficult for 
any solid substance, however minutely divided, to be carried into the 
alveoli by simple inhalation. 
This provision of nature for preventing access of foreign material 
to the air cells is so complete that they are very seldom invaded by 
even the finest particles that are carried in the atmosphere. 
Doubtless this provision is operative to a very great extent in pro- 
tecting the lungs from the ingress of pathogenic germs. These may 
appear in the mouth and pharynx, where the epithelium is of the 
pavement variety, but when they reach the point where the ciliated 
epithelium begins, the action of the cilia opposes their further pro- 
gress. But for this we should find all manner of germs disseminated 
over the whole extent of the respiratory tract, instead of being con- 
fined, as a rule, to the regions above the glottis and to the larger 
bronchial tubes. 
But this protection is not absolute at the best, and is liable to be 
impaired by any cause that affects the bronchial mucous membrane. 
Thus, for example, the efficiency of the ciliary movement is lessened 
during the early dry stage of a common cold, and in bronchial catarrh. 
Even if the protection remained intact it would not prevent the 
spread of microorganisms over the bronchial mucous surface by the 
process of multiplication, which process acts with inconceivable ra- 
pidity under favorable conditions. A single microbe lodged in one 
of the smaller tubes, and there finding a suitable culture medium in 
the secreted mucus, would in a few hours produce millions of its 
probably the result of the same anatomical condition by which germs on reaching 
the bifurcation in their passage downwards are influenced to pass into the right 
bronchus rather than the left. PATHOLOGY. 
47 
kind. Tlie colony spreading in this manner would not be long in 
reaching the vesicles. Here the epithelium is of a different charac- 
ter, resembling closely the type of serous membranes, which are 
prone, under irritation, to yield a fibrinous exudate. In the alveolus, 
however, this form of exudate appears from present indications to be 
the product of only one form of irritation, viz., that resulting from 
the presence of microorganisms. It seems to be afforded principally, 
if not wholly, by the pulmonary, as distinguished from the bronchial, 
capillaries. When there is infiltration into the septum from its nu- 
trient vessels the infiltration is corpuscular and not fibrinous. 
As has already been seen, the pneumococcus lanceolatus is present 
in the mouth and nasopharynx in perhaps the majority of healthy 
persons. Dr. Neumann’s studies made at my instance show that in 
three out of sixteen autopsies in persons dying of other disease than 
pneumonia this organism was found in the smaller bronchi, say, of 
the fourth or fifth division. Why in such subjects tliej' do not 
always penetrate into the air vesicles and excite pneumonia is a ques- 
tion of great interest, the answer to which is not at hand. That they 
do so penetrate under certain conditions we already know, but wrliat 
the conditions are, and how they act, we cannot tell. In general 
terms, their presence in the air cells seems to be associated with de- 
pression of vitality, as if the protection against their entrance was 
sufficient so long as the vigor of the subject remained unimpaired, 
but failed when it was diminished. Starr28 suggests that the pneumo- 
coccus becomes more virulent after exposure to cold. 
It w ill be urged against this view of what takes place in the pneu- 
monic lung that there is no necessary relation between the amount of 
lung involved and the degree of toxaemia. This is true as a simple 
proposition; but in this as in all other forms of toxic infection, dif- 
ferent persons show remarkable differences in susceptibility to the 
poison, and at the same time the poison itself varies extremely in 
virulence. 
Furthermore, accepting the theory of an antitoxin, the period at 
which the formation of this substance begins in a given case and the 
rate at wdiicli it progresses, become at once factors in determining 
the general condition of the patient at a given time. 
But perhaps the most important consideration in this connection 
is that the area in which the toxin is being formed may greatly exceed 
that in which physical signs can be detected. The thinnest film 
of exudate will be a sufficient medium for the growth of microbes, 
and that under conditions most favorable for a rapid absorption 
of the poison they afford. So that while there may not be material 
enough in the bronchioles and alveoli to change the percussion note, 48 
SMITH—LOBAR PNEUMONIA. 
or to give rise to crepitus, it may still be the source of very active 
infection. 
Keeping these points in view we may safely say that, other things 
being equal, the systemic impression will be closely proportioned to 
the extent of the local invasion. 
Occasionally in the progress of a pneumonia, gangrene of a por- 
tion of the lung takes place. We may assume that in these cases a 
branch of the bronchial artery becomes involved in the process, thus 
shutting off the nutrient circulation from the corresponding portion 
of lung tissue. That this does not occur more frequently shows how 
passive is the role played by the pulmonary parenchyma. 
A process of less intensity involving the nutrient vessels would 
account for the permanent change found in chronic pneumonia. 
Suppuration with the formation of abscesses in the lung tissue is 
now and again observed. This is probably due to a mixed infection, 
in which pyogenic germs take part with the diplococcus and produce 
a more intense degree of local irritation involving the lung structure 
itself. 
The evolution of new germs having ceased, and the system having 
recovered in a measure from the depression of the toxamiia, the proc- 
ess of the removal of the exudate from the air cells begins. This is 
accomplished chiefly by absorption, and is facilitated by the lique- 
faction of the fibrin and the granular disintegration of the corpuscular 
elements which characterize the stage of resolution. 
In the course of a few days, if all goes well, the cell is entirely 
relieved of its contents. Its walls remain intact and ready for an 
immediate resumption of function. 
The sum of the argument, finally, is that from its peculiar con- 
struction the lung is enabled to afford a field for bacterial culture and 
to supply a culture medium, and this without calling upon its own 
nutritive resources, or directly compromising its own tissues. It is 
the fact that in the lung there are empty spaces accessible to bacteria, 
and separated from an unlimited blood supply by only the thinnest 
and most permeable wall, that makes the phenomena of pneumonia 
possible. It is the further fact that the framework between these 
spaces has its own separate blood supply, apart from the vessels in- 
volved iu the pneumonic process, that prevents a sweeping destruc- 
tion of the lung tissue. 
In no other organ in the body is such a mingling of structural 
health and diseased action conceivable, for in no other organ is the 
blood supply for nutrition and function separately provided for.* 
* A somewhat analogous condition is met with in the heart, inasmuch as blood 
llows through its cavities for functional purposes, while its nutrition is supplied PATHOLOGY, 
49 
The sequence of events taking place in an attack of pneumonia 
would seem to be as follows: 
1. The occurrence of some cause of depression, either local or 
general, which favors the germination of pneumococci, already pres- 
ent in some one of the smaller tubes. 
2. The formation of a colony that spreads until it reaches the 
group of air vesicles that are terminal to the tube in question. 
3. The setting up of an irritation in these vesicles, causing a 
fibrinous exudation, an emigration of leucocytes, and a diapedesis of 
red cells from the functional capillaries. 
4. The formation of a colony of pneumococci in the medium 
afforded by this exudate. 
5. Arrest of the blood stream in the functional capillaries, fol- 
lowed by accumulation of free pneumic acid in the parenchyma of 
the affected area. 
fi. Overflow of exudate into neighboring lobules, starting the proc- 
ess in them also. 
7. Arrest of germ growth by exhaustion of the medium and the 
accumulation of free acid in the tissue of the lung. Up to this time 
there has been a constant formation and absorption of toxin. 
8. Retrogressive changes in the exudate preparatory to its removal 
bv absorption. 
9. Probably, in this latter process, formation of an antitoxic 
principle. 
10. Entire removal of the exudate and restoration of the vesicle to 
its normal condition. 
11. Resumption of the functional capillary circulation. 
The physical signs of pneumonia being in a typical case so dis- 
tinctive, we are liable to fall into the error of considering that the 
disease is not present until some one or more of these signs can be 
made out. But, regarding as the first step in the process the invasion 
of the air cells by the germ, pneumonia is present the moment the first 
lodgment is effected. Investigation has shown that the pneumococ- 
cus is most active in creating toxin at the earliest period of its life, 
and also that the toxin it produces is then most virulent. Hence, we 
can understand that an amount of exudate not yet sufficient to be 
detected by the physical signs would still be sufficient to afford a 
medium for the growth of cocci in adequate numbers to poison the 
system with their toxin. Until such poisoning reaches a point at 
which general symptoms are manifested, fever, chill, etc., there may 
through the coronary vessels. It would be a legitimate, if gross caricature of the 
old idea of pneumonitis if one should find a heart with its cavities filled with fibrin- 
ous clots and should label the specimen carditis. 
Von. XVI.— 4 50 
SMITH—LOBAR PNEUMONIA. 
be nothing to indicate what is going on in the lung except perhaps 
prodromes, which may or may not arrest the attention of the pa- 
tient. In other words, an important stage of progress may be 
reached before the disease is openly declared. This explains those 
cases of very sudden invasion, as, for example, one cited by Sturgis, 
in which a person started to cross London bridge from the Surrey 
side without pneumonia, but had pneumonia when he reached the 
City. 
The conditions for rapid absorption of the poison are best when 
the air cell is but partly filled; later, when the cell is crowded with 
exudate,, and the affected portion of lung is distended beyond its 
natural bulk, the pressure renders absorption less active. At the 
same time, as the germs grow older, the toxin becomes less virulent, 
and a time arrives when the fully liepatized portion ceases to be an 
unfavorable factor in the case except for the breathing surface it with- 
draws from use. On the contrary, it may be that the older germs 
now reverse their role and begin the production of an antitoxin. 
Were it not for the fresh growth constantly spreading about the cir- 
cumference of the liepatized portion and extending in a wider circle 
than that indicated by the physical signs, the infection would soon 
come to a standstill and crisis would result. As it is, the crisis is 
deferred until the infecting are balanced by the disinfecting forces, 
the latter including the various emunctories by which the poison is 
discharged from the body. 
Bacteriology. 
The history of the pneumococcus is interesting in that the organ- 
ism was known for some time before its connection with pneumonia 
was suspected. During this interval it received various designations, 
such as micrococcus Pasteuri, micrococcus of sputum septicaemia, 
bacillus septicus sputigenus, etc. Later, when its pathogenic rela- 
tions had been established, it received more specific names— 
diplococcus pneumoniae, pneumococcus capsulatus, pneumococcus 
lanceolatus, pneumococcus of Fraenkel, micrococcus pneumoniae 
crouposae. 
In 1880 Sternberg discovered to his surprise that his saliva, he 
being in perfect health at the time, was fatal to rabbits if injected 
into the cellular tissue, death taking place within forty-eight hours. 
Cultures made from the bodies of these animals resulted in the pro- 
duction of bacilli of a kind not before recognized, and inoculation with 
which was uniformly fatal. Waiving his right to give his own name 
to the new organism, he called it the micrococcus Pasteuri. These BACTEIilOLOGY. 
51 
observations were followed by others made by different bacteriolo- 
gists and with results confirming the discovery of Sternberg. Netter 
found by inoculation experiments in rabbits that the saliva of one 
hundred and sixty-five healthy individuals showed the presence of 
this micrococcus in fifteen per cent, of the number. 
In 1888 Talamon demonstrated the presence of this organism in the 
sputum of pneumonia, and produced pneumonia in rabbits by inject- 
ing material containing the germs 
directly into the lungs through the 
chest wall. 
In 1886 Weichselbaum pub- 
lished the results of investiga- 
tions showing the presence of the 
diplocoecus in the fibrinous exu- 
date of croupous pneumonia in 
the ninety-four eases 
in one hundred and twenty-nine. 
Since then it has been generally 
accepted that croupous pneumonia 
is an infectious disease caused 
by the pneumococcus lanceolatus, 
though other organisms may be 
associated with the latter. 
For the following description 
and the accompanying drawing I 
am indebted to Dr. George A. 
Tuttle, assistant pathologist of the Presbyterian Hospital, New York. 
“ The micrococcus lanceolatus, called also Fraenkel’s diplocoecus 
or pneumococcus, and diplocoecus lanceolatus pneumoniae, was first 
described by Sternberg in 1880 as the micrococcus Pasteuri. He 
noted its very frequent presence in normal saliva and demonstrated 
its virulence by animal inoculations. A. Fraenkel confirmed the 
observations of Sternberg, and noted the presence of this diplocoecus 
in the rust-colored sputa of pneumonia, while it was absent in other 
acute inflammations of the lungs. He also obtained this organism, 
called by him the diplocoecus of sputum septicaemia, in many cases 
of empyema following pneumonia and in the exudation of meningitis 
complicating pneumonia. In 1885-86 he was able to prove conclu- 
sively the causal relationship of this micrococcus to acute lobar pneu- 
monia. 
“ The micrococcus lanceolatus in the blood of inoculated animals 
and in pneumonic sputum is generally seen in pairs of oval or lancet- 
shaped elements surrounded by a capsule of a substance resembling 
Fig. 3,—The Micrococcus Lanceolatus in 
Pneumonia Sputum. AA, Leucocytes; BB, 
red blood cells; C, epithelial cell; D, cili- 
ated epithelium; EE, pneumococci. X 1000. 52 
SMITH—LOBAR PNEUMONIA. 
mtiein. In cultures short chains of three to four members are com- 
mon, anti at times longer chains of ten to twelve are seen, while the 
capsule is absent. There is a marked variation in the size and shape 
of the individual elements in cultivated specimens, and this peculiar 
characteristic is of considerable importance in distinguishing this 
organism from the streptococcus pyogenes which it so closely resem- 
bles in other respects. Like the other micrococci it is non-motile. 
“ It growTs in all of the common faintly alkaline culture media, with 
or without the presence of free oxygen, at a temperaure of 35°-38° C. 
It will not grow at the ordinary room temperature, or on potato. On 
the surface of agar or of blood serum it forms minute, grayish, trans- 
lucent colonies, at first resembling minute drops of water. In gela- 
tin it grows rather slowly along the entire puncture and at the 
surface, the growth beneath the surface consisting of minute white 
colonies. It does not liquefy gelatin. It grows rapidly in milk, 
producing coagulation; also in bouillon, causing a slight cloudiness 
of the fluid and a little whitish sediment at the bottom of the tube. 
It loses its vitalit\r in cultures on solid media in five to ten days; in 
bouillon its life is somewhat longer. By transplanting every fourth 
or fifth day the growth may be continued indefinitely in favorable 
conditions. The virulence of artificial cultures is rapidly lost, but 
can be restored by passing them through susceptible animals. 
“It is readily stained with all of the aniline colors and by Gram’s 
method. The capsule can be demonstrated in blood or sputum prep- 
arations by staining with carbol-fuchsin solution, and lightly wash- 
ing with alcohol. The deeply stained diplococci will be seen sur- 
rounded by an oval colorless area representing the capsule. ” 
This organism is found in the expectorated material in all but a 
very small percentage of the cases examined for it.* When appar- 
* R. M. Pearce, in the Journal of the Boston Society of the Medical Sciences, 
for June, 1897, records that in 121 cases of acute lobar pneumonia the pneumococcus 
was found in the solidified lung in 110 cases, in 84 of which it was the only micro- 
organism present. In the remaining cases it was associated with varying fre- 
quency with the staphylococcus pyogenes aureus and albus, streptococcus pyo- 
genes, Klebs-Loeffler bacillus, and the bacillus capsulatus (Wright). In some 
cases the association was with two of the above. Of the remaining 11 cases, in 8 
the lung culture was not taken in 4, lost in 2, and sterile in 2, but in each of these 
there was general infection with the pneumococcus, and in 8 it was present in either 
pericardial or pleural feVudate. This Would justify the conclusion that the process 
in the lung was due to the same organism and was the source of the genetal infec- 
tion. If, therefore, these cases are added to the others they make a total of 118 out 
of 121, or 97.5 percent, due to the pneumococcus. In the exudate of acute pleuritis 
and acute pericarditis with pneumonia, the pneumococcus was found iii every case 
in which examinations were made, 49 times in pleural exudates and 15 times in 
pericardial exudates. In various infections due to the pneumococcus, numbering BACTERIOLOGY, 
53 
ently absent it is probable that faulty methods of search have been 
employed, or that some special circumstance has masked its develop- 
ment. When a pure culture is injected into the substance of the lung 
it invariably results in a typical croupous pneumonia. Injected into 
the cellular tissue or into the peritoneum it causes 'septicaemia. 
The coccus growing rapidly is commonly inert at the end of a 
week. Probably this contributes, at least, to determine the crisis. 
It may also explain the benign course of pneumococcic infection in 
other tissues. Such infection of the pleura, for example, results 
commonly in a mild and tractable empyema as contrasted with infec- 
tion from other pathogenic organisms of slower growths and more 
enduring vitality. 
The pneumococcus exhibits great differences in virulence, sug- 
gesting that there may be several varieties. Inoculation experiments 
appear to show that one of these, the cedematogenic, causes local 
oedema with toxaemia. This is the variety most commonly found in 
pneumonia. Another produces abscess at the point of inoculation, 
and “is an exquisitely pyogenic microorganism.” 29 
Eyre and Waslibourn30 in a very elaborate paper demonstrate that 
“there are a large number of types of the pneumococcus which differ 
from one another in virulence and in biological characters.” The 
parasitic type, the typical pneumococcus, is the most virulent and 
also the least hardy and has the shortest life. Tlie saprophytic type, 
such as is found in the mouths of normal individuals, is almost desti- 
tute of virulence, but is very hardy and long lived. By repeated 
passages through animals the several types may be made identical 
as to virulence, but in the case of the saprophytic type this virulence 
is reached and maintained with difficulty. The maximum of viru - 
lence, obtained by eight passages of the parasitic type and fifty-three 
passages of the saprophytic type, was such that .0000005 mgm. in- 
jected into the peritoneal cavity of a rabbit was fatal within twenty- 
four hours. 
55 cases, there were 26 acute infectious processes which were neither preceded nor 
accompanied by a lobar pneumonia. The cases comprised acute ulcerative endocar- 
ditis, acute purulent meningitis, acute fibrinous pericarditis, acute fibrinous peri- 
tonitis, and acute general infection with pneumococcus. 
James J. Curry, of Boston, in the Journal of the Boston Society of the Medi- 
cal Sciences, for March, 1898, mentions two cases of acute lobar pneumonia in 
which the capsule bacillus (bacillus pneumonia; of Friedlander) was found in cul- 
tures of the lung together with the diplococcus lanceolatus, the growth of the cap- 
sule bacillus being so powerful that it obscured entirely the development of the 
diplococcus. The results of bacteriological investigation of acute lobar pneumonia 
at the Boston City Hospital have shown it to be due invariably to the micrococcus 
lanceolatus. , 54 
SMITH —LOBAR PNEUMONIA. 
When in a dry state the pneumococcus retains its virulence for 
long periods. This is especially the case when it is protected by 
being mixed with mucus in desiccated sputum. Cases are on record 
in which the disease was communicated to newcomers in houses that 
had been closed for many months. Scliroeder refers to a house from 
which thirty-two cases came to the clinic at Kiel in the course of 
fifteen years, one year furnishing six.31 
According to Simon,32 recent researches show that in fatal cases 
of pneumonia the specific diplococcus is quite commonly present in 
the blood, while in cases ending in recovery it is only exceptionally 
encountered. Wirtz found positive results in eighty-nine per cent, 
of fatal cases. 
In investigations conducted at the Presbyterian Hospital, New 
York, the blood was examined in twelve cases of pneumonia. Two 
of these ended fatally, the remaining ten in recovery. In none of 
them wras a growth of the pneumococcus obtained in the tubes in- 
oculated with the blood.33 The invasion of the blood usually occurs 
from twenty-four to forty-eight hours before death, but may be earlier 
or later. For prognosis this may be important. Some cases end in 
recovery. 
With a view to ascertaining whether there wTas any relation between 
the occurrence of pneumonia after operations under an anaesthetic and 
the presence of pneumococci in the upper air passages before the anaes- 
thetic was given, the writer caused a culture to be made from the fauces 
of each patient anaesthetized for operation at the Presbyterian Hos- 
pital during a period of several weeks. The result was that it was 
found to be the rule rather than the exception that the coccus was 
present, and this being the case no conclusion could be arrived at on 
the point proposed for investigation. Indeed, it was only in a verjr 
small proportion of the cases that the cultures failed to develop the 
pneumococcus, not enough to determine whether its occasional ab- 
sence offered even the slightest immunity from operation-pneumonia, 
itself an infrequent occurrence. 
It was next sought to ascertain whether the organism existed in 
the deeper air passages with anything like the same frequency as 
above the glottis. At my request Dr. Neumann, in the laboratory 
of the Presbyterian Hospital, examined the smaller bronchi in six- 
teen cadavers of persons dead from other diseases than pneumonia. 
The examinations were conducted with great care, a number of 
cultures being made in each case from different localities in the 
lungs. The result showed the presence of Fraenkel’s pneumococcus 
in four cases and the presence of an organism resembling Fraenkel’s 
in one case, while in eleven cases no bacilli pneumonise were found, DIAGNOSIS. 
55 
The cultures were taken from the smallest branches into which the 
needle could be carried. 
It would seem, therefore, that while the pneumococcus of Fraen- 
kel is very generally present above the glottis, it occurs in only from 
one-fourtli to one-tliird of the cases in the deeper portions of the res- 
piratory tract. It is an interesting question what proportion of all 
the cases of pneumonia is to be found in subjects whose deeper air 
passages are already the habitat of the specific organism. 
Diagnosis. 
A typical case of croupous pneumonia seen from the beginning 
can hardly be mistaken for any other disease. The abrupt onset, the 
chill, the pain, the fever, the respiration accelerated out of proportion 
to the pulse and temperature, and, finally, the peculiar expectoration, 
will suffice to establish the diagnosis even without the aid of the 
physical signs. But when the latter are added, and we have fine 
crepitation with inspiration and a little later a blowing sound with 
expiration, while the vocal resonance and the vocal fremitus are ex- 
aggerated, and the percussion note becomes constantly duller until it 
approaches flatness, there is presented a clinical picture which for 
vividness and individuality can hardly be surpassed. 
But cases are not always seen at the outset, or accompanied by 
reliable histories, and we may be called upon to make a diagnosis at 
any stage, and with little or no knowledge of what has gone before. 
This is often the case in hospitals, especially in those having an am- 
bulance service, patients being brought in in a condition of delirium, 
or unable from natural stupidity or from ignorance of the language to 
give any account of their illness. Under such circumstances we must 
depend largely upon the physical signs, interpreting them by such 
objective symptoms as may be present at the moment. 
If the signs are such as have been already indicated and the tem- 
perature is high and the breathing hurried, we may be sure that we 
have a pneumonia which has not yet defervesced. 
If with the physical signs of consolidation we have a low tempera- 
ture, and the breathing is but little accelerated, and there is more 
or less creamy expectoration, we may assume that the case is one of 
pneumonia which has passed the crisis. If under like conditions we 
detect crepitation in the consolidated portion, we have a commencing 
resolution signalized by the rale redux. Finally, if we have a tem- 
perature varying but little from the normal, slight percussion dulness, 
vesiculotubular breathing interspersed with coarse mucous rales, and 
accompanied by a mucopurulent and partly frothy expectoration, the 56 
SMITH—LOBAR PNEUMONIA. 
inference is that the case is one of pneumonia pretty well advanced in 
the process of resolution. 
We must remember, also, that not all cases of pneumonia run a 
typical course. There is scarcely one of the classical symptoms or 
signs that may not sometimes be wanting. In about twenty per cent, 
of all cases the chill is absent. Pain is not a marked feature unless 
the pleura is involved, and in central pneumonia it is often not severe 
enough to excite complaint. In feeble or elderly persons the fever 
may be slight; indeed, even apart from these conditions, some of the 
worst cases we meet with show but a moderate temperature through* 
out. The pulse is likely to correspond with the temperature; and 
the respiration, usually the most characteristic of the symptoms, is 
sometimes not strikingly frequent. Cough and expectoration may 
be entirely absent through the whole course of the disease, or the 
cough may bring up only a little frothy mucus from the bronchial 
tubes. 
As to the physical signs, all of them may be in abeyance for a 
considerable time when the consolidation is confined to the central 
portion of the lung. A greatly thickened pleura remaining from a 
former pleuritis may obscure the results of both auscultation and 
percussion, and lead to mistaken inferences. 
Apart from the above considerations the diagnosis of pneumonia 
involves differentiation from quite a range of affections, such as 
bronchopneumonia, pulmonary oedema, pleurisy with effusion, ab- 
scess of the liver, pulmonary apoplexy, pulmonary phthisis, cancer 
of the lung, atelectasis, engorgement in fever, typhoid fever. 
Bronchopneumonia is distinguished from acute lobar pneumonia 
by the less frequent occurrence of chill in the former, the less degree 
of pain, the pain being at the same time less fixed, a generally lower 
temperature, less increase in the rate of respiration as compared with 
temperature; while the cough is more severe, and the expectoration 
is more abundant, more frothy, less stained, and less adhesive. The 
disease is more frequently bilateral in the bronchial form than in the 
lobar. The dulness is much less circumscribed, and is more likely 
to appear in several places at once, and to shift its locality from day 
to day. The breathing over the affected part lias not the tubular 
blowing type of lobar pneumonia, and is relatively feebler. Fine 
crepitation is absent, and in its place are subcrepitant rales heard 
with expiration as well as inspiration. The vocal rasonance and vo- 
cal fremitus are less exaggerated. In short, the physical signs indi- 
cate that the consolidation is far less perfect than in the lobar form. 
As the case progresses we miss the distinctive crisis, and there are 
not the characteristic traits of a self-limited disease. In favorable DIAGNOSIS 
57 
cases amendment may begin at any time, or it may be indefinitely 
deferred. 
According to Delafield and Pruddeu,"4 “ there is a form of broncho- 
pneumonia in adults which resembles lobar pneumonia. There is a 
general catarrhal bronchitis, with bronchopneumonia and consolida- 
tion of one or more lobes. The symptoms and physical signs are 
those of lobar pneumonia, but with some difference. The invasion 
of the disease is not as sudden, the pulse is more rapid, the cerebral 
symptoms are more constant, the expectoration is like that of bron- 
chitis, the physical signs are more slowly developed, the duration of 
the disease is rather longer and resolution is slower.” 
In pulmonary oedema we have cough, expectoration, embarrassed 
respiration, and some dulness on percussion. But there is no chill, 
no pain, no rise in temperature; the expectoration is profuse and 
watery, instead of small in amount and viscid. Pulmonary oedema 
is bilateral and begins usually in the most dependent portion of the 
lung, instead of being unilateral and occurring indifferently in one 
portion or another. In pneumonia we have the dry crepitant rale, 
while in oedema the rales are coarse and liquid. Bronchial breathing 
and bronchophony, heard in pneumonia, are absent in pulmonary 
oedema. Percussion dulness is less in oedema, and vocal fremitus is 
not exaggerated. The absence of chlorides from the urine so general 
in pneumonia is not observed in oedema of the lungs. 
But it must be remembered that very many cases of pneumonia 
are complicated at some period in their course with pulmonary 
oedema, and we must always be alive to the possibility of the coexist- 
ence of the two affections. 
Pleurisy ivitli effusion has many points in common with lobar 
pneumonia. There is pain; there may be chill; there is fever; the 
respiration is hurried; there is a cough; and there is an area of per- 
cussion flatness. In some cases there is also bronchial breathing. 
When this is present the differential diagnosis may be far from 
easy. 
But the fever is comparatively mild, the temperature rarely reach- 
ing 103° F., and the respiration does not fluctuate so widely with each 
change of temperature as is the case in pneumonia. There are not the 
nervous shock, the loss of muscular strength, the evidences of profound 
intoxication, seen in pronounced toxic cases of pneumonia. The cough 
is dry, there is but little exf>ectoration, and what there is is frothy, 
not stained, not adhesive. If the effusion is considerable, the heart 
will be displaced towards the unaffected side. 
Coming to the physical signs, we note the absence of crepitation, 
and generally, though not always, of bronchial breathing. On the 58 
SMITH—LOBAR PNEUMONIA. 
other hand, we have the presence in the early stage of a pleural fric- 
tion sound, which is often enough found in pneumonia. 
Percussion reveals an area of flatness (not dulness as in pneu- 
monia) occupying what has been the most dependent portion of the 
pleural cavity on the affected side, with often increased resonance 
above. Sometimes the level of this area will change with change of 
the patient’s position, but generally the fluid whose presence gives 
rise to the flatness is kept in place by interpleural adhesions. Over 
this area there is in most cases absence of respiratory murmur and 
of voice sounds, in place of bronchial breathing and bronchophony, 
though both of these are present in exceptional cases. Even in these 
cases there is absence of vocal fremitus, instead of the exaggeration 
observed in pneumonia. 
There is one sign which if present and well marked goes far towards 
establishing the diagnosis, and that is segopliony above the line of flat- 
ness. There is nothing in pneumonia that fully answers to this, but 
it is not always present in pleurisy with effusion. The latter is true 
also in regard to bulging of the intercostal spaces and displacement of 
the heart or of the liver. Yet while there is no one sign or symptom 
which is always to be relied upon, unless it may be the absence of 
vocal fremitus, it is seldom that we need remain long in doubt, and 
in any case the matter may be cleared up by the harmless expedient 
of an exploratory puncture. We must bear in mind, however, that 
there are instances in which both conditions are present, and also 
that adhesions resulting from former inflammation may bring about 
some very perplexing distributions of fluid in subsequent attacks. 
In simple liydrothorax there is an area of flatness with a some- 
what bronchial character of the breathing and voice above it, but the 
upper line of the flatness, which is higher behind than in front, 
changes when the posture of the patient is changed. JEgophony is 
usually well marked. There is little or no fever, and the dyspnoea is 
comparatively slight, even when a large amount of fluid is present. 
In pyotliorax the physical conditions are much the same, and 
there are the symptoms of pysemic infection, including wide excur- 
sions of temperature, sweating, etc. 
In abscess of the liver and in subplirenic abscess, the pain and 
the rigor, together with an area of dulness, may suggest pneumonia of 
the right base. But the rigor is likely to recur again and again, there 
is absence of the auscultatory signs of pneumonia, and though cough 
may be present, we do not have the characteristic expectoration. If 
any doubt remains it is soon cleared up by the clinical phenomena, 
which, as the case proceeds, diverge widely from those observed in 
pneumonia. DIAGNOSIS. 
59 
In pulmonary apoplexy or hemorrhagic infarct we have pain often 
of a very severe character, frequent respiration, cough, an area of 
dulness, and, perhaps, bronchial breathing. These symptoms and 
signs suggest pneumonia, but the onset is too sudden, we miss the 
chill; the temperature is less elevated; the expectoration is abun- 
dant, and consists largely of pure blood. There are coarse rales 
within the lungs from the first. Moreover there is usually a history 
of antecedent cardiac disease, or of some infection by which the 
formation of pulmonary emboli or pulmonary thrombi is provoked. 
Attention to these points will suffice to establish the differential diag- 
nosis. 
Tuberculosis.—The consolidation attendant upon tuberculous de- 
posit, especially if pleuritic pain be present, and if at the same time 
the temperature be considerable and the breathing frequent, might 
reasonably raise the question of the existence of pneumonia, if a his- 
tory of the case should not be attainable. It might even be difficult 
if not impracticable at once to exclude this possibility. But the differ- 
ence in the character of the sputa, the different temperature curve, 
and the afternoon hectic in phthisis would soon lead to a correct diag- 
nosis. Besides, if in sufficient extent to raise the question of diagno- 
sis, there would be likely to be auscultatory evidence of the breaking 
down of lung tissue. It is to be borne in mind, however, that an 
area of tuberculous deposit may be included in one of pneumonic 
exudation. If doubt remain, it may be removed by microscopical 
examination of the sputum. 
Cancer of the lung has some features in common with pneumonia. 
There are pain, respiratory embarrassment, and cough, with expec- 
toration which may be more or less stained with blood or otherwise 
colored. The physical signs of consolidation are also present in the 
affected region. But the onset is gradual and the disease protracted; 
there is little or no fever, no chill, the pain is continuous, there is a 
cancerous aspect after a time, and cancerous growth is apt to exist or 
to be developed in other organs. Indeed, there could be but little 
chance of confounding the two affections unless an inflammatory proc- 
ess should have been set up in a cancerous lung, and the previous 
history should not be obtainable, conditions which I met with once 
in consultation, and which had given rise to a diagnosis of unresolved 
pneumonia. 
Atelectasis gives rise to circumscribed percussion dulness, and 
rapid respiration, but lacks the other features of pneumonia. Be- 
sides, it is a condition found almost exclusively in infancy. 
Hypostatic Congestion.—During the course of a low fever, in which 
the vital powers are considerably depressed, there is likely to occur 60 
SMITH—LOBAR PNEUMONIA. 
a, congestion of the lungs affecting especially the posterior portion. 
This gives rise to some shortness of breath, cough, frothy expectora- 
tion sometimes a little bloody, mucous rales, and some degree of dul- 
ness on percussion, and might be taken for the early stage of pneu- 
monia. But its presence in both lungs, the absence of the crepitant 
rale, the comparatively slight effect upon the respiration, and the 
history of a preceding fever which still continues, render the distinc- 
tion easy. 
On the other hand, it often happens that in a protracted case of 
pneumonia symptoms arise that very closely resemble those of 
typhoid fever; and if the progress of the case has not been followed, 
it is quite easy to overlook the lung condition and see only the ap- 
pearances that indicate a low form of fever. Indeed, not one of these 
may be wanting, and it may be only because we have more than is 
needed to constitute a case of typhoid that our suspicion of the true 
nature of the affection is aroused. 
Of course, mistake would be possible only in the febrile stage of 
the pneumonia, and then the excessive frequency of the respiration 
should at once attract attention. In most cases the cough and expec- 
toration would be significant; but granting these to be absent as they 
might be, there would still be enough in the respiration, including 
the unequal movement of the two sides of the chest, to show that the 
lung was implicated, and to lead to a physical examination which 
would be conclusive. How often this examination is neglected, how- 
ever, may be inferred from the annual report of the Metropolitan 
Asylum Board for 1897, which states that among the cases of mistaken 
diagnosis are found sixty-one of pneumonia erroneously included in 
two hundred and ninety-three cases reported as typhoid fever."4 
The routine application of the Widal test would reduce the chances 
of such error to a minimum. 
The following is quoted from Osier36: 
“Nervous symptoms are more frequent in pneumonia than in 
typhoid, and from the onset may so dominate that the local lesion is 
entirely overlooked. For instance, in the case of cerebral pneumonia 
of children, in which the disease sets in with a convulsion, there are 
high fever, delirium, great irritability, muscular tremor, and perhaps 
retraction of the head and neck, and consequently meningitis is usu- 
ally diagnosed. Cases occur in which the malady sets in with acute 
mania. For example, a young man behaved so strangely on the train 
that he was handed over to the police as a lunatic, and as he had no 
cough and little fever (though he complained of a pain in the side) 
pneumonia was not recognized for several days. Again, pulmonary 
features are frequently marked where the patient has delirium tre- COMPLICATIONS. 
61 
mens, and error is certain to occur unless it is made an invariable 
rule to examine the chest in these cases. Then there are cases with 
toxic features resembling uraemia; without chill, cough, or pain in 
the side the patient may develop fever and a little shortness of breath 
and then gradually grow dull and heavy, and within three days there 
may be a condition of profound toxaemmia with low-muttering deli- 
rium. In many of these cases the most characteristic symptoms of 
the disease may be absent, particularly the cough and the rusty 
sputum; but the physical signs, if they are elicitable, are well marked. 
Even in the gravest of these cerebral cases the crisis and the onset of 
convalescence may occur in the ordinary way, and the patient may 
pass from a condition of extreme danger to one of perfect safety.” 
Complications. 
Strictly speaking, the complications of pneumonia are only those 
morbid conditions which are so associated with the primary disease 
as to indicate that they are dependent upon it and would not have 
taken place in its absence. Conditions previously existing, or that 
are simply coincident, cannot rightly be considered as complicating 
the pneumonia, though they may be complicated by it. Thus an old 
cardiac or renal lesion can scarcely be said to complicate a pneu- 
monia, though its presence may very materially affect the gravity of 
the case. On the other hand, an acute pericarditis or nephritis occur- 
ring in the course of a pneumonia, and evidently involved with it in 
some sort of causal relation, Would be an illustration of what strictly 
constitutes a complication. There are several affections which so 
often appear with pneumonia as to make it reasonably certain that 
there is a common influence at work, and this influence can often be 
found in the presence of the pneumococcus in the locality in question. 
The following tables, compiled by Dr. Howland, show the complica- 
tions observed at the Presbyterian Hospital, New York. 
Complications op Pneumonia. 
Out of 488 Cases. 
Number 
of cases. 
Recovered. 
Died. 
Pleurisy with effusion 
20 
17 
3 
Pericarditis (acute) 
6 
1 
5 
Otitis media * 
6 
6 
Thrombosis of femoral vein 
3 
3 
Bronchitis f 
13 
9 
4 
Jauhdice 
2 
1 
1 
* Otitis of catarrhal form in every case. 
t These were cases complicated with well-marked bronchitis from the outset 
and not those merely developing signs of oedema or of the softening of resolution. 62 
SMITH—LOBAR TNEUMONIA. 
Number 
of cases. 
Recovered. 
Died. 
Gangrene of leg * 
1 
1 
Delayed resolution 
7 
7 
Relapse 
2 
2 
Delirium tremens 
11 
5 
6 
Pyaemia 
2 
, . 
2 
Abscess of lung f 
1 
1 
Laryngitis 
1 
1 
Erysipelas 
2 
2 
Persistent bronchopneumonia 
1 
1 
Acute nephritis % 
3 
2 
1 
(Edema of lungs 
Empyema || 
6 
10 
1 
5 
Out of 304 Cases. 
Pneumonia Complicated by Coexisting Diseases or Conditions. 
Out of 488 Cases. 
Number 
of cases. 
Recovered. 
Died. 
Chronic endocarditis 
11 
3 
8 
Cirrhosis of liver 
5 
5 
Fatty liver 
4 
3 
1 
Out of 304 Cases. 
Number 
of cases. 
Recovered. 
Died. 
Chronic nephritis 
7 
1 
• 6 
Typhoid fever 
1 
1 
Phthisis 
4 
4 
Pregnancy 
1 
1 
Sacculated aneurysm of aorta 
1 
1 
Paralysis agitans 
1 
1 
Chronic bronchitis 
1 
1 
Influenza 
6 
6 
Cystitis 
2 
' 2 
Emphysema 
2 
1 • 
1 
Endarteritis 
1 
1 
* Caused by thrombosis of anterior tibial artery. 
f Recovered after prolonged convalescence. 
X These were well-marked cases without previous nephritis and with symptoms 
of acute nephritis much worse than transient albuminuria. 
§ These are cases of oedema developing during the course of the disease. 
|| Satisfactory data could not be obtained as to the final outcome of these 
patients, but it might be interesting to notice the conclusion arrived at by Dr. 
Hartwell in a report covering ten years. Out of 52 cases of empyema treated in 
this hospital 26 gave good history of previous pneumonia and 6 more gave a pos- 
sible history. Out of these 26 pneumonia cases 19 recovered and 7 died. He found 
that children with empyema, as a rule, did very badly unless treated early by oper- 
ation ; with such treatment then they did well. COMPLICATIONS. 
63 
Pleuritis.—The complication most frequently met with in pneu- 
monia is pleuritis. Indeed the sharp pain, which is included in the 
familiar picture of the stage of invasion in pneumonia, is due, not to 
the disease of the lung itself, but to the involvement of the pleura. 
When the pneumonic process begins centrally, pain at first is either 
entirely absent or is manifested only as a dull ache, and it does not 
assume its characteristic severity until the disease has worked its 
wray to the surface and taken hold upon the serous investment of the 
lung. In the great majority of cases, however, the pleura is very early 
involved, the stitch often being the first thing observed by the patient. 
Usually the pleurisy is dry, that is it gives rise only to a fibrinous 
exudate, which appears as well upon the parietal as upon the visceral 
layer, and ultimately glues the two surfaces together. In a minority 
of the cases there is a moderate amount of serous effusion which is 
later absorbed. Not very infrequently the pleura becomes the seat 
of pyogenic infection, and empyema results. This occurs in from 
one to three per cent, of all cases.* The infecting organism in these 
cases is the pneumococcus, which has worked its way from the lung 
into the pleura, and which in a serous or synovial membrane is prone 
to excite suppuration. 
Usually the empyema occurs on the same side as the affected 
lung, and is then of moderate severity and runs a favorable course. 
But it has been observed that when this complication occurs on the 
side opposite the pneumonia, the prognosis is much more grave. 
This doubtless arises from the fact that in the first case the affection 
of the pleura is due to simple continuity of tissue, while in the sec- 
ond it is excited by cocci circulating in the blood. As already shown, 
cases in which the blood is infested with the organisms generally do 
badly, and it is to this circumstance, and not to any peculiarity 
of the pleuritis, that the gravity of the prognosis is to be referred. 
In such cases other organs than the pleura are extremely likely 
to be involved, either simultaneously or in succession, and under 
the pressure of multiplied foci of infection the patient speedily 
succumbs. 
The friction sound of the pleuritis is quite likely to be mistaken 
for crepitus within the lung. Indeed the similarity of sound, espe- 
cially to the subcrepitant rale, is very striking. But it cannot be 
gotten rid of, nor its character changed, by coughing; and this is a 
very important test. . Of course, if the rubbing can be felt as well as 
heard this puts an end to all question. 
Bronchitis.—Next to pleuritis bronchitis is the most frequent com- 
*It occurred ten times in three hundred and four cases at the Presbyterian 
Hospital. 64 
SMITH—LOBAR PNEUMONIA. 
plication of pneumonia. In a considerable number of cases a bron- 
chial catarrh precedes the pneumonic attack, and a common cold is 
said to have “run into pneumonia.” The frequency with which per- 
sons are declared to have been “threatened with pneumonia” bears 
witness to the apprehension of such sequence which is rooted in the 
popular, not to say the professional, mind. 
In a certain sense there is always a degree of bronchial catarrh in 
the affected portion of the lung. Invariably the mucous membrane 
of the tubes leading to a consolidated area is reddened by hyperaunia, 
and covered by a viscid mucus. Whether this is due to irritation 
by the sputum, or is a primary condition, in fact a part of the proc- 
ess deeper down in the lung, is a question to be considered. The 
view of the writer is that this hypersemia marks the track down which 
the microbes marched to their proper field of activity in the paren- 
chyma of the lung. Be this as it may, there is always evidence of 
such liypersemia, and its products are mingled in greater or less pro- 
portion with the characteristic pneumonic sputum. 
A general association of bronchitis with a form of pneumonia con- 
stitutes a disease by itself, bronchopneumonia, which has been al- 
ready treated of by another writer in an earlier volume of this 
work. 
Somewhat allied to bronchitis is the condition known as col- 
lateral hypenemia, wdiicli is frequently developed in the course of 
pneumonia. It appears in the previously unaffected lung and con- 
sists of a more or less intense congestion. It is largely mechanical, 
and is the product of two factors. The first is the forcing into the 
sound lung of a portion of the blood which normally should have 
passed through the vessels of the obstructed lung. In this the right 
heart is the active agent. The second factor is the aspiration of an 
excess of blood into the sound lung by the action of the muscles of 
respiration. The inspiratory effort, not resulting in adequate expan- 
sion of the crippled lung, produces a condition of negative pressure 
in the sound one, and blood into the latter in consequence. 
This condition, however, is seldom serious except in advanced cases, 
when weakness and exhaustion of the right heart are a further cause 
for its supervention. 
Bronchitis can be considered in the light of a complication of 
pneumonia only when in addition to the signs of consolidation over 
a given area there are bronchial rales scattered abundantly over both 
lungs.2 
Gangrene of the Lung.— In rare instances a portion of the liepa- 
tized lung perishes, and a condition of gangrene is established. This 
is due to an involvement of the nutrient vessels in the process that COMPLICATIONS. 
65 
ordinarily interests only tlie functional blood supply. The precise 
mechanism by which the germ obtains access to a bronchial twig cannot 
be traced and probably is not the same in all cases. According to 
Osier,23 “the gangrene is associated with the growth of the sapro- 
phytic bacteria on a soil made favorable by the presence of the pneu- 
mococcus or the streptococcus.” 
The extent of the gangrene will depend upon the size of the vessel 
at the point where infection takes place or to which the resulting 
thrombus extends in a backward direction. 
The occurrence of this accident is marked by an intolerable fetor 
of the breath and in some cases by the appearance of the physical 
signs of a cavity. Occasionally the destruction of tissue opens a way 
into the pleura, and pneumothorax results. 
Though a very grave complication gangrene is not by any means 
necessarily fatal. If the amount of lung involved be not too great, 
and the vitality of the patient not already too greatly depressed, a fair 
chance for recovery may remain. 
Pericarditis.—This complication occurs in from two to eight per 
cent, of the cases of pneumonia, according to different authorities. It 
is often overlooked during life, the area of the pneumonic dulness in- 
cluding that of the pericardial effusion, and auscultation not being 
practised at the time when the pericardial friction sound might have 
been heard. At the Presbyterian Hospital it was made out during life 
in six out of four hundred and eighty-five cases of pneumonia. It is 
supposed to occur more frequently when the left lung is involved, and 
the inference is that the disease extends from the lung and pleura by 
continuity df tissue. More recent investigations, however, seem to 
show that there is no material difference in this respect. Doubtless 
it is more likely to be recognized during life when the pneumonia is 
on the opposite side, as the area of pericardial dulness in this case is 
not obscured by the dulness of consolidation. 
It should be the rule in every case of pneumonia to examine the 
cardiac area at least daily. This is especially imperative when the 
respiratory and circulatory conditions appear out of proportion to 
the temperature and the nervous symptoms. Ortliopnoea, in partic- 
ular, suggests something more than the dyspnoea of pneumonia, and 
will often be found to be associated with effusion into the pericar- 
dium or the pleura. 
The extreme flatness on percussion and the absence of vocal and 
respiratory sounds and of vocal fremitus over the effusion will gener- 
ally suffice for the diagnosis. Auscultatory percussion may be of 
great value in fixing the limiting line between solid and fluid, a 
change in the character of the note occurring at once in passing from 
Vol. XVI.— 5 66 
SMITH—LOBAR PNEUMONIA. 
one to the other, though to ordinary percussion there might be no ap- 
preciable difference. 
When pericarditis occurs during the progress of pneumonia the 
pneumococcus lanceolatus very generally be found in the effused 
fluid. It is frequently associated with other organisms, but under 
such conditions as leave little doubt that it is the determining 
factor. 
A pericarditis occurring as a complication of pneumonia is much 
more likely to be purulent than when it is primary or associated with 
rheumatism. In such cases pneumococci may be found in the blood, 
and collections of pus may form in other serous or synovial cavities. 
Such conditions offer little hope of recovery. 
Acute Endocarditis.—This affection appears in pneumonia both as 
an acute condition engrafted upon an old lesion, and as a fresh inva- 
sion apart from previous anatomical change. In some cases both the 
pneumonia and the heart affection seem to be the outcome of rheu- 
matic poison. 
It may assume the simple form with warty vegetations, or the 
malignant or ulcerative type with the pneumococcus as the active 
agent. In either case the effect of the disease is so intensified by 
the associated pulmonary affection that opportunity for a complete 
development of the clinical history is seldom afforded. This would 
be still more the case, were it not that the valvular trouble involves 
the left side of the heart, while it is the right side that has to bear 
the brunt of the struggle with the unfavorable pulmonary condi- 
tions. 
The following case, seen in consultation with Dr. Jauvrin, of this 
city, illustrates an acute pneumococcic infection engrafted upon an 
old valvular lesion: 
Mr. T , age 67, had had for years a valvular lesion, which, how- 
ever, caused him no very serious inconvenience. On December 18th, 
1898, after some two weeks’ confinement to the house with influenza, 
which did not extend below the larynx, he had a severe chill, and 
signs of pneumonia soon developed in the right base. There was 
little cough and no expectoration. Chills recurred at irregular inter- 
vals thereafter, and not yielding to quinine and arsenic, the suspi- 
cion gained ground that they were of mycotic origin, which sus- 
picion was soon confirmed by the occurrence of murmurs indicating 
a fresh endocarditis. Meanwhile the pneumonia cleared up very 
kindly, perhaps assisted by the massive doses of quinine. But the 
chills, perspiration, and extreme prostration persisted with increas- 
ing severity, and death took place on the seventeenth day of the 
attack. 
Although an autopsy could not be obtained, there can be no doubt COMPLICATIONS. 
67 
that the organism which excited the endocarditis in this case was the 
pneumococcus. Drs. Janeway and Armstrong, who also saw the 
case, concurred in the diagnosis. 
Chronic Endocarditis.—This is not properly a complication of pneu- 
monia, but rather a preexisting condition. At the Presbyterian Hos- 
pital, New York, of four hundred and eiglity-eiglit cases of pneumonia 
eleven occurred in persons already having chronic valvular lesions. It 
is a very serious combination in view of the embarrassment of the cir- 
culation which it involves. Indeed, if the leakage is considerable, or 
the compensation defective, the chance of recovery is very small. Of 
the eleven cases above referred to eight proved fatal. A chronic 
valvular lesion is also important as affording a possible seat for an 
acute infective process, as in the case just cited. 
Myocarditis as an actual complication of pneumonia can very sel- 
dom be substantiated. The high temperature to which cardiac de- 
generation is so often attributed is not often of sufficient duration in 
pneumonia to bring about this result. But pneumonia may attack a 
person who already has a softening of the cardiac walls, and in such 
a case the crippling of the heart adds greatly to the danger of heart 
failure or, at least, of hypenemia and fatal engorgement of the 
lung. 
In the absence of a previous history of recognized cardiac weak- 
ness it may not be easy to say whether a softening of the myocar- 
dium, found post mortem, existed before the pneumonia or was in- 
duced by it. But we may be aided in our judgment by the character 
of the heart beats in the early stage of the attack, as well as by the 
degree and duration of the temperature. 
Parotitis occurs in a small proportion of cases of pneumonia either 
during the course of the disease or as a sequel to it. It is rarely seen 
in young or vigorous persons, but belongs to the later period of life, 
or to conditions of depressed vitality. In all probability it is the 
result of microbic invasion by way of the parotid duct. It nearly 
always eventuates in suppuration, and it resembles the parotid ab- 
scess which occurs in typhoid fever. 
It is a very serious complication both because of its occurrence in 
enfeebled persons, and because of the somewhat formidable character 
of the affection itself. It more frequently affects only one of the 
glands, which fact points rather to a local than a general source of 
infection as above indicated. 
Diarrhoea is occasionally met with in the course of pneumonia. 
In some cases it seems to be one of the results of the first shock of 
the infection. In others it occurs at a later period, and may be due 
to the resorption of the exudate, inasmuch as it continues after the 68 
SMITH—LOBAR PNEUMONIA. 
crisis. Doubtless tlie cause lies iu many iustauces in excessive feed- 
ing under conditions very unfavorable to proper digestion. It is 
seldom a serious complication. 
Jaundice is an infrequent complication. It was noted in two 
cases out of four hundred and eiglity-eiglit at the Presbyterian Hos- 
pital, though other observers have met with it in a larger proportion 
of cases. The precise conditions upon which it depends have not 
yet been decided. It is not attended by the evidence of obstruction, 
and is probably the direct effect of the specific poison acting upon 
the liver. It is usually slight and of no practical significance. Oc- 
curring, however, in a patient already having a fatty or cirrhotic 
liver it is of more serious import. It is sometimes associated with 
gastroduodenitis. 
Otitis Media.—This occurred six times in four hundred and eighty- 
eight cases at the Presbyterian Hospital. In all these cases it Avas of 
the catarrhal variety and ended in recovery. Purulent otitis media, 
however, is occasionally met with, and in these cases the pneumo- 
coccus may usually be demonstrated in the pus. It is fair to presume 
that the coccus finds its way into the middle ear through the Eusta- 
chian tube. The purulent form adds a considerable element of danger 
to the existing pneumonia. 
Neuroses.—Among the neuroses complicating pneumonia Isager3" 
observed aphasia in a boy nine years old. The aphasia was complete, 
the boy being unable to speak though understanding what was said. 
After a fortnight the aphasia gradually disappeared. 
Leszynsky37 presented a man before the New York Neurological 
Society suffering from neuritis of the brachial plexus which had come 
on in the course of pneumonia. 
Voute, of Amsterdam,38 observed external oculomotor paralysis 
arising in a case of apical pneumonia, the paralytic symptoms sub- 
siding as resolution took place. He considered the paralysis to be 
of toxic origin rather than meningeal, as there was complete absence 
of cerebral symptoms. 
Pregnancy. — The existence of advanced pregnancy adds greatly to 
the seriousness of an attack of pneumonia. The interference with res- 
piration occasioned by the upward pressure is a matter of grave mo- 
ment. In addition to this, premature labor is very likeW to occur, 
imposing a heavy tax upon the already overburdened system. In 
the early months the danger is much less. Should the life of the 
foetus be destroyed at this stage of the infection the abortion may be 
delayed sufficiently to give time for recovery from the pneumonia. 
An interesting case is reported by Yerlet39 in which a pregnant woman 
was attacked Avitli pneumonia followed by a relapse. Premature de- COMPLICATIONS. 
69 
livery resulted, the child born at seven months was cared for in an 
incubator, and both mother and child did well. 
Venous Thrombosis.—Thrombosis of the femoral vein is met with 
not very infrequently. Three cases are recorded in the four hundred 
and eighty-eight mentioned above. Increased fibrinosis seems to be 
a characteristic of the pneumonic state, and jjrobably this condition 
lies at the bottom of the coagulation in the vessels. As in thrombosis 
from other causes, the left leg is more frequently affected than the 
right. 
Da Costa40 in a clinical lecture refers to three cases of this kind 
which have occurred in his practice. I saw a similar case in-private 
practice some years ago. The vein remained occluded years after- 
ward, and the limb became swollen after much standing or walking. 
In the treatment of recent cases of thrombosis local frictions 
should be carefully avoided lest the clot be dislodged and carried 
into the circulation. Clots may be formed in the vessels of the in- 
terior, and doubtless many of the cases of sudden death observed in 
pneumonia are due to their translation into the pulmonary veins.- 
Meningitis.—Diplococci have been reported as found in the pus of 
meningitis by many bacteriologists, and these organisms have been 
frequently and fully identified as “ diplococcus pneumoniae.” Netter, 
in 1889, in a report of 25 cases of purulent meningitis, states that 13 
of these were examined microscopically, by cultures, and by inocula- 
tions into animals, 6 microscopically and by experiments on animals, 
and the rest microscopically only. Six of the cases were complicated 
with pneumonia, 4 with purulent otitis, and 3 with ulcerative endocar- 
ditis. In 16 of the 25 cases the pneumococcus was found; in 4 the 
streptococcus pyogenes, in 2 the diplococcus intracellularis menin- 
gitidis of Weichselbaum, in 1 Friedlander’s bacillus, in 1 Newman 
and Schaffer’s motile bacillus, and in 1 a small curved bacillus. 
Out of 45 cases gathered by Netter, this micrococcus was found in 
27; streptococcus pyogenes in 6; and the diplococcus intracellularis 
meningitidis of Weichselbaum in 10. 
In 4 cases of cerebrospinal meningitis, reported in 1889, Monti 
demonstrated the presence of this micrococcus in 3 of which pneumo- 
nia was a complication. In 2 cases the staphylococcus pyogenes 
aureus was present with the diplococcus pneumoniae. Weichselbaum, 
in 29 cases of ulcerative endocarditis examined in 1888, found the 
diplococcus pneumoniae in 7. 
Testi in 1889, in a case of parotitis complicating lobar pneumo- 
nia, obtained the micrococcus pneumoniae croujjosae from the pus in 
pure cultures, and in another case of pneumonia complicated with a 
purulent pleuritis, bilateral parotid abscess, and multiple subcuta- 70 
SMITH—LOBAR PNEUMONIA. 
neous abscesses, the pus from these varied sources all contained the 
diplococcus in large numbers. This was shown by microscopical 
examination and by inoculation iuto rabbits. Gabbi (1880) obtained 
the same coccus in pure cultures in a case of tonsillitis resulting in 
abscess. 
In a considerable number of cases of otitis media this micrococ- 
cus has been found, and in pus secured by paracentesis of the tym- 
panum, and frequently in pure cultures; by Zaufal (1889) in 6 cases, 
Levy and Scliraeder (1889) in 3 out of 10 cases in which paracentesis 
was performed; by Netter (1889) in 5 out of 18 cases occurring in 
children. In 1889 Monti and Belfanti both reported cases of arthritis 
of the wrist-joint complicating pneumonia, in which this micrococcus 
was found in pure cultures. Ortmann and Samter in the same year 
obtained the diplococcus pneumoniae in pure cultures in a case of 
purulent inflammation at the slioulder-joint following pneumonia and 
pleurisy.12 
Prognosis. 
The prognosis in pneumonia is modified by a number of pre- 
existing conditions, the principal of which are sex, age, season of the 
year, habit as to the use of alcohol, and the presence or absence of 
certain chronic diseases. 
It is conceded that while pneumonia occurs more frequently in 
men, it is more fatal in women. Of 223 patients with pneumonia 
admitted into the Presbyterian Hospital, 170 were males, with a 
mortality of 28.8 per cent., and 53 females, with a mortality of 31.2 
per cent. 
Pneumonia—434 Cases 
Relation to Age. 
Died. 
Percentage 
dying. 
Recovered. 
Percentage 
recovered. 
Below 5 years 
0 
0 
13 
100 ' 
Between 5 and 10 years 
0 
0 
18 
100 
“ 10 “ 15 “ 
1 
9 
11 
91 
“ 15 “ 20 “ 
7 
23 -| 
- 
23 
76 + 
“ 20 “ 30 “ 
28 
22- 
- 
95 
77 + 
“ 30 “ 40 “ ... . 
37 
37 i 
b 
62 
62 + 
“ 40 “ 50 “ 
31 
42- 
42 
57 + 
“ 50 “ 60 “ 
16 
47 -1 
18 
52 + 
“ 60 “ 70 “ 
16 
66- 
8 
33 + 
Over 70* years 
5 
62 H 
3 
37 + 
141 
32 + 
293 
67 + 
*It is not to be inferred, however, that the increased mortality as 
age advances 
is due entirely to senility. The greater frequency of preexisting morbid conditions 
comes into the reckoning. The man of sixty has had two chances to contract bad PROGNOSIS. 
71 
Before the age of two years lobar pneumonia is a rather rare dis- 
ease. After that age the mortality is greater in proportion as the 
patient is older. The preceding table, based uj)on four hundred and 
thirty-four cases treated at the Presbyterian Hospital, New York, 
shows not only the frecxuency of occurrence, but also the mortality at 
the different ages. 
Statistics accumulated by Frankel and Reiche (Maragliano41) cov- 
ering 1,130 cases give the mortality by ages as follows: 
From 1 to 
5 
years 
30.0 
per cent. 
“ 6 “ 
10 
44 
3.84 
44 
“ 11 “ 
20 
44 
10.05 
“ 
“ 21 “ 
30 
u 
8.70 
u 
“ 31 “ 
40 
a 
24.70 
u 
“ 41 “ 
50 
“ 
39.30 
u 
“ 51 “ 
60 
u 
43.10 
44 
“ 61 “ 
70 
“ 
63.60 
44 
“ 71 “ 
80 
(4 
86.70 
44 
The relative mortality of pneumonia in the different seasons of 
the year is variously stated by different writers. In the above two 
hundred and twenty-three cases, the spring months gave the lowest 
mortality, the summer showed a slight increase, while in the autumn 
and winter the death rate attained its highest percentage. 
The habitual abuse of alcohol unfits the system to bear up against 
pneumonia. Of 11 such cases, referred to by Ewing as occurring at 
Roosevelt Hospital, only 3 recovered. The records of the Presby- 
terian Hospital covering 428 cases give the following results as to mor- 
tality among those markedly alcoholic, those moderately alcoholic, 
and those non-alcoholic. 
Relation to Alcoholism. 
Died. 
Percentage 
dying. 
Recovered. 
Percentage 
recovered. 
Markedly alcoholic* 
36 
70 
15 
29 
Moderately alcoholic 
52 
32 
109 
67 
Non-alcoholic 
45 
20 
171 
79 
Pneumonia—428 Cases. 
A preexisting rheumatic habit has generally been observed to 
add to the gravity of the prognosis. It was present in 20 of the 223 
Presbyterian Hospital cases and was attended by a mortality of 40 
per cent. As the rheumatic habit, however, is more pronounced as 
kidneys for one chance that has come to the man of thirty ; and so through all the 
list of chronic diseases whose presence renders an attack of pneumonia more peril- 
ous. 
* A noticeable fact was that of the fifteen recoveries, most of them were in 
young men between twenty and thirty years. 72 
SMITH—LOBAR PNEUMONIA. 
life advances, tlie influence of age in these cases must not be over- 
looked. 
The prognosis is extremely unfavorable in diabetic patients. The 
combustion of the sugar, already imperfect, is diminished in propor- 
tion to the impairment of the respiration. Death in such cases is 
preceded by delirium and coma. 
The preexistence of chronic nephritis makes the prognosis of 
pneumonia more grave in proportion to the renal insufficiency and 
the accompanying cardiovascular changes. 
Pneumonia occurring in a subject of advanced cardiac disease is 
likely to prove fatal. The prognosis is less grave before secondary 
changes have taken place in the right side of the heart. 
Coming now to the conditions arising in the course of the dis- 
ease, and which seem to influence the mortality, the first is the ini- 
tial chill. This occurred in 144 out of the 223 cases, with a mortal- 
ity of 34 per cent., while the remaining 79 cases in which the chill 
was absent gave a death rate of only 19 per cent. From this it is 
evident that the chill is an expression of a severer grade of infection, 
and I have observed that usually a prolonged rigor with tardy reac- 
tion presages an unusual degree of muscular and nervous prostration. 
The prognosis depends largely upon the extent of the pneumonia. 
When both lungs are involved not half of the patients recover. 
Pneumonia occupying the whole of a lung is more dangerous than 
when only a part of the lung is involved. 
As to the location of the lesion, the right lung is more frequently 
affected than the left, and also gives a higher mortality. Of 94 
cases implicating the right lung alone, 28 ended fatally, giving a 
mortality of 29.8 per cent., while only 62 cases involved the left lung 
alone, of which 16, or 24.5 per cent., were fatal. In 39 cases both 
lungs Avere involved, with a mortality of 19, or 48.7 per cent. Pre- 
vious attacks do not affect the prognosis. 
A feeble pulse that is frequent in relation to the respiration and 
temperature has much the same prognostic significance as a heavy 
and prolonged chill. In my experience it indicates a profound spe- 
cific infection, that is likely to carry off the patient at or before 
the crisis. 
The respiration is always frequent in pneumonia, but when ex- 
treme frequency is associated Avitli a high temperature, it lias less 
'significance than Avlien it occurs Avitliout this association. In the 
former case it is due in part to the fever; in the later it denotes ex- 
tensive lung implication, and probably oedema, always a perilous 
condition. 
Up to 105° the danger does not seem to increase materially with PROGNOSIS. 
73 
the rise of temperature. Tlius in 45 cases with the maximum tem- 
perature ranging between 100° and 108° the mortality was 26.G per 
cent., while in 99 cases with temperature between 103° and 105° the 
mortality was 26.3 per cent. The conditions that raise the tempera- 
ture above 105°, however, immediately tell upon the death rate. In 
49 cases with a temperature between 105° and 106° the mortality was 
32.1 per cent., and 13 cases at 106" and upwards gave 61.5 per cent, 
of deaths, liecovery, however, may take place though the tempera- 
ture attain an extraordinary height. Wagner has reported such a 
case in a boy five years old, the temperature having reached 109.2° F. 
Indeed, it is an error to attach too much importance to the tempera- 
ture alone, so long as the condition otherwise remains favorable. 
Measures intended merely to control the pyrexia are indicated only 
in extreme cases. It cannot be too often repeated that to give coal- 
tar preparations according to indications furnished by the thermome- 
ter is to expose the patient to a real danger in an effort to rescue 
him from a fancied one. 
There is a physical sign to which I called attention some years 
ago that I regard as important in the prognosis of pneumonia, and 
to which I have already referred in another connection. This is the 
character of the valve sound heard in the pulmonary area. The re- 
sistance in the pulmonary circulation which always exists in these 
cases must necessarily increase the tension in the pulmonary artery, 
provided the force of the ventricular systole is not impaired. With 
this increased tension come a sharper recoil of the blood against the 
valve cusps and a greater intensity of the valve sound. It follows, 
other things being equal, that in this intensity we have practically 
a measure of the degree of obstruction to the blood current in the 
lungs. 
It is generally very easy to note as consolidation progresses 
the constantly increasing sharpness of the pulmonary second sound, 
and in favorable cases this accentuation, after reaching a certain 
point, is maintained with little change until commencing resolution 
renders the circulation easier, when the valve sound loses in inten- 
sity in proportion as the pulmonary condition improves. 
But, unhappily, loss of accentuation of the pulmonary second 
sound does not always depend upon relief of tlio pulmonary circula- 
tion. It may signify instead a weakening of the right ventricle and 
a lessened power to force the blood into the artery. This comes when 
the right heart begins to flag either from exhaustion from excessive 
labor, or because of the depression arising from the specific infection. 
In either case, when we find the pulmonary second sound becoming 
weaker without any evidence of a favorable change in the condition 74 
SMITH - LOBAR PNEUMONIA. 
of tlio lung, we may draw the conclusion that the right heart is fail- 
ing, and that the tendency of the case is towards a fatal termination. 
The information furnished by the pulmonary valve sound is much 
more reliable than that supplied by the radial pulse, for in most cases 
the chief peril is of failure of the right heart from exhaustion, and of 
this the condition of the radial pulse will give only indirect and in- 
conclusive evidence. The right ventricle may be on the verge of ex- 
haustion, while the left retains almost undiminished vigor, and the 
radial pulse then will simply indicate that less blood than usual is 
flowing beneath the finger, as the result of paucity of blood in the left 
ventricle. 
Unfortunately it will sometimes happen that the region of the 
pulmonary area is occupied by noisy rales, so that it may be difficult 
or perhaps impossible to appreciate the action of the valve. But 
unless the dyspnoea is extreme the breath can be held for an instant, 
and for the practised ear the briefest moment is sufficient. An em- 
physematous condition of the left apex may also obscure the sound 
of the valve or render it inaudible. 
As to the prognostic value of the data furnished in this way, I 
can only say that I have never seen disaster come in a case of pneu- 
monia unless it was preceded by a period in which the pulmonary 
valve sound was progressively losing in intensity. Or, to put it in 
other words, I have never seen a case with sharp and distinct pulmo- 
nary valve sound in which a favorable prognosis as to the immediate 
future was not justified by the event. The weakness of the right 
heart that is indicated when the valve sound becomes less intense 
takes jdace chiefly in two classes of cases. The first is that in which 
the system is overwhelmed by the virulence of the infection. These 
cases are marked by a severe and protracted initial chill, great mus- 
cular prostration, a small and relatively frequent pulse, and marked 
involvement of the nervous system. We may well believe that in 
such cases the heart muscle is poisoned, and that consequently the 
right ventricle with the increased labor thrown upon it early becomes 
exhausted. Such cases are apt to prove fatal before defervescence 
takes place. If they can be carried beyond this period the prognosis 
is greatly bettered. 
The second class of cases is made up of those in which from age, 
intemperance, previous illness, or other cause, the integrity of the 
circulatory apparatus is compromised in advance. Here we have a 
constant tendency to the invasion of fresh areas of lung, and to the 
supervention of oedema. This tendency, while it increases the labor 
required of the ventricle, is itself increased in proportion as the ven- 
tricle weakens under its burden. PROGNOSIS. 
75 
The exact relation between the temperature and leucocytosis in 
pneumonia is not yet fully determined; but in general terms it 
may be stated that a high temperature in a vigorous subject carries 
with it a large number of leucocytes. From a prognostic point 
of view this is of great importance. Whether we consider the leu- 
cocytes as scavengers, and assume that they destroy the cocci which 
are the medium of infection, or whether we assign to the white 
cells a share in the production of antitoxin, certain it is that severe 
cases in which there is marked leucocytosis do better, as a rule, 
than similar cases in which the increase of white cells is relatively 
slight. 
When the leucocytosis is inconsiderable it will generally be found 
that the system is not reacting energetically against the infection, a 
condition which suggests an unfavorable prognosis. 
On the other hand, there may be a high degree of leucocytosis 
which is not due to the pneumonia pure and simple, but to some 
complication as pleuritis or pericarditis, and if this is not taken into 
account a faulty prognosis may result. 
Ewing, in an excellent article on this subject,41 a gives the count 
of the white cells in 101 cases, of which 37 were fatal. He says: 
“ An examination of the deaths will show that in severe forms of lobar 
pneumonia a slight leucocytosis is a very unfavorable sign. In 6 
fatal cases the number of leucocytes was subnormal. In 11 cases 
the average number was 9,000. Not one case recovered, in which 
the disease was even of moderate severity, when the number of leu- 
cocytes fell below 14,000. In several instances, again, a slight leu- 
cocytosis seemed at the time the only unfavorable prognostic sign in 
cases ending fatally.” 
M. Laehr,41b in an article on “Leucocytosis in Pneumonia,” pub- 
lished in 1893, maintains that in pneumonia there is an unmistakable 
connection between the temperature and the leucocytosis. When the 
disease is at its acme the count of the white cells is at the highest, 
while at the crisis there is a falling-off. In pseudo-crisis and deferred 
resolution the leucocytosis continues though the temperature falls. 
In the generally constant agreement of the course of the fever, the 
amount of the lung infiltration, and the leucocytosis, the author sees 
a dependence upon a fourth factor, viz., the intensity of the infection, 
that is, the quantity and quality of the bacillus poison and the power 
of reaction of the individual. He goes on to say: “ Still more im- 
portant is the prognostic significance. If the number of leucocytes 
does not fall with the decline of the fever we may conclude that the 
process has not yet arrived at a standstill. If it falls with the fall of 
the temperature, but rises again the following day, we must be pre- 76 
SMITH—LOBAR PNEUMONIA. 
pared for a renewed attack of tlie fever or the occurrence of some 
form of complication.” 
11. 0. Cabot42 gives the count of the white cells in 49 cases of pneu- 
monia. Leucocytosis was present in 41 cases with 10 deaths; absent 
in 5 cases with 5 deaths; doubtful in 3 cases with 2 deaths. He says: 
“ So far as these figures go, therefore, it would seem that while the 
presence of leucocytosis is not a very hopeful sign, its absence makes 
the outlook bad. Moreover, in two of these five cases the other rea- 
sons for giving a bad or guarded prognosis were not present. The 
individuals were both under fifty, were not at all alcoholic or weakly, 
and there was nothing in the condition of the pulse, temperature, or 
physical signs in the chest to lead one to expect a fatal result. Yet 
both went down with surprising rapidity, and without any reaction 
to vigorous stimulation and supportive treatment.” 
In a subsequent paper43 he adds twenty-four new cases, without 
materially changing the conclusions to which his figures would point. 
Regarding this subject Dyce Duckworth44 concludes that both 
clinical inquiry and laboratory experiments have shown that leucocy- 
tosis is usually a favorable sign in pneumonia. This is well estab- 
lished by the observations of von Limbeck, Hillings, and others who 
find that an active inflammatory leucocytosis during fever usually indi- 
cates a good reaction and while not invariably so, is often a good prog- 
nostic sign. The cells increased in number are the multinuclear or 
neutrophile, or finely granular eosinopliile cells. Conversely, ab- 
sence of leucocytosis is, in.any case, usually a bad omen. Kanthack 
and Lloyd declare diminished leucocytosis with falling temperature 
to be a favorable sign, while a continuous high temperature with a 
small number of leucocytes is unfavorable. They also noticed that 
a persisting or increasing leucocytosis with fever is favorable. A 
satisfactory prognosis is not established by the presence of leucocj - 
tosis, but it is a most valuable indication when taken with associated 
temperature, the curves of which are often roughly parallel. Kan- 
thack and Romer confirm these views through experiments upon 
animals, since they found that on injecting pneumonic bacterial 
toxin, if recovery took place, there was at first a sudden decrease in 
the number of leucocytes, followed 1)3' a rapid increase together with 
fever, and again persisting leucocytosis, with a gradual disappear- 
ance of the excess of leucocytes as the temperature fell. When a 
fatal dose was injected, the leucocytes diminished in number, and 
continued so, while the temperature became subnormal. 
A remarkably high leucocytosis, especiall3r if associated with a 
low temperature, suggests a suppurative complication. Thus in a 
case of pneumonia at the Presbyterian Hospital the temperature of PROGNOSIS. 
77 
the seventh day was 103°, and the count 54,500. The crisis occurred 
the next day, but with a temperature of only 99° F. there was still 
a leucocytosis of 42,000. Examination showed that an empyema was 
developing. In another case with a similar complication the count 
was 44,000, while the temperature was 101.3°. In eight uncompli- 
cated cases the highest in eiglity-one daily counts was 41,000. 
At the Presbyterian Hospital, in cases in which we wish to follow 
the leucocytosis from day to day, we have adopted the plan of record- 
ing it on the temperature chart, allowing for each additional 3,000 
leucocytes a space on the chart equal to one degree of temperature. 
Regarding 9,000 as the normal, this figure would correspond with the 
normal temperature line; 13,000 would be recorded on the 100° line; 
10,000 on the 101° line; 19,000 on the next line above; and so on, the 
tracing being done in red ink (in the accompanying chart [No. 3, page 
28J in dotted line.) In this way the relation of the count to the tem- 
perature is apparent at a glance. 
Much has been said regarding the prognostic significance of 
herpes labialis, an affection that occurs very frequently in the course 
of pneumonia. The general opinion is that it is of good augury, 
though wrhy it should be so is not easily explained. Tallman,45 how- 
ever, concludes that it is due to individual peculiarity, many person's 
having outbreaks at other times and, therefore, being liable to an 
attack during pneumonia. It is not critical and may appear early 
or late indifferently. It is not coincident with a fall of tempera- 
ture or a change in the general or local conditions. Its prognostic 
significance is generally, though not always, good. Germain See 
observed a mortality of 9 per cent, in cases with herpes as against a 
mortality of 25 to 30 per cent, in general. 
Dyce Duckworth44 considers that it is a good sign and usually ac- 
companies cases in which a well-defined crisis occurs on the sixth 
day. Cases that are grave and those that are prolonged with deferred 
crisis, usually do not present it. He says further that a good sign, 
even in a lean and elderly patient, is an abundant rusty sputum 
with a fresh bright color. But when the sputa are of a “ green-gage” 
color or bistre tint the augury is not good, and sputa of a dirty 
orange color are of distinctly unfavorable prognosis. The prognosis 
in Bright’s disease is grave and indications of dextrocardiac disten- 
tion and general cardiac failure are invariably serious. Favorable 
symptoms at the crisis are sweating and some diarrhoea. 
According to Loomis,1 the appearance of prune-juice expectora- 
tion is an unfavorable symptom, as it indicates a depraved condition 
of the blood. If there is an absence of expectoration in the second 
and third stages or if the expectoration becomes scanty and difficiilt 78 
SMITH—LOBAR PNEUMONIA. 
1 - 7 I * I f | I I 
/O A3 / k* 933 / & */S. 4s&*/Z 4 * S3//f Al f 32 * * 23 // S /J /, * 2* 4 J>/t & <T AZ & f/A 
Chart No. 3.—Tim patient entered hospital on the sixth day of the disease with a temperature of 105.5°; highest leucocytosis on the seventh day, 29,000; 
normal temperature by crisis on the eighth day ; normal leucocytosis on the tenth day, 
9t 2+ 
/2Z 3# 
/of Jf 
;<?// 32 
/2a 32 
/7//. 7// 
//// 3 s- 
/o// 2P- 
//f 2/ 
/of 2f 
/Of 3f 
//2 if 
7/ 
//'/ 22 
/AO 2f 
//>/> 2<? 
ft 23 
S3 Sf 
f/ 2a 
~Pc~77: 
fa 3// 
P// 33 
if 7? 
Pf 3c> 
%t 3* 
~w & 
pa 2a 
0 3.3 
J// 2a 
//> /<*= 
Jb 3a 
~jr~7r 
fb 2a> 
Jo 3a 
ft/ 2a 
fP 3a 
7/f 3a 
~77~ 
Pa 2a 
fa 2s>. 
HOUR. 
Temp... 
C. F. 
41.1° 106° 
40.5° 105° 
40° 104° 
39.4° 103° 
38.8° 103° 
38.3° 101° 
37.7° 100° 
37.2'- 99° 
36.6° 98° 
30.1° 97° 
R 
P PROGNOSIS, 
79 
the outlook is grave. Any sudden cessation of expectoration at any 
stage of the disease, if accompanied by tracheal rales, indicates the 
near approach of death. Delirium is an unfavorable sign except when 
it occurs early in the disease. 
In the aged a sudden rise or fall of temperature, apathy, somno- 
lence, and a sallow complexion, are all indicative of great danger. 
The mortality in pneumonia varies enormously under different 
conditions. It is much greater in hospitals than in private practice, 
and in civil than in military hospitals. In civil hospitals the patients 
are usually taken from a class of persons imperfectly nourished, under 
bad hygienic conditions, and often wdtli impaired constitutions as the 
result of these conditions. Then, too, only the very wrorst cases are 
sent to hospitals, the milder ones being treated at home. Add to 
this that the hospital patients as a rule do not present themselves 
until the disease is far advanced, and that they are subjected to the 
exhaustion due to removal, and it is not remarkable that the death 
rate in such institutions is very high. Of the last 458 cases treated 
at the Presbyterian Hospital 154 terminated fatally, being about 33.2 
per cent. 
Osier48 gives the mortality in eight large hospitals as follows: 
Montreal General Hospital, 20.4 per cent.; Massachusetts General 
Hospital, 25 per cent.; Charite New Orleans Hospital, 38 per cent.; 
Boston City Hospital, 29.1 per cent.; Pennsylvania Hospital, 29.1 
I>er cent.; St. Thomas’, London, 20 per cent.; St. Bartholomew’s, 
London, 18.6 per cent.; Edinburgh Boyal Infirmary, 28.8 per cent. 
This gives an average of 26.1 per cent., which pretty fairly repre- 
sents the result of hospital practice. The greater mortality at the 
Presbyterian Hospital is due to the ambulance service, which brings 
in many patients who are practically moribund on admission. 
In military hospitals, where the patients are young, vigorous 
males, and are admitted at the first moment of the attack, the mor- 
tality ranges from 31 to 7.V per cent. 
In private practice the conditions are for the most part the re- 
verse of those obtaining in civil hospitals, and the mortality is pro- 
portionately less. For obvious reasons it is not practicable to ac- 
cumulate accurate statistics, but the general fact is patent to every 
practitioner. 
There has been for the last few years a very general impression 
in the minds of the profession that the death rate in pneumonia 
in this country had rather increased than diminished during the last 
two or three decades. Statistics gathered by Dr. Coolidge, of Bos- 
ton, seem, however, to refute this idea. 
Epidemics of pneumonia differ greatly in the death rate which 80 
SMITH—L013AII PNEUMONIA. 
attends them. The same is true of different years and different lo- 
calities, even when no epidemic influence appears to be prevailing. 
There are epidemics in which a large number of persons are affected, 
but the mortality is small. In other epidemics “ almost every person 
is doomed” (Wells'"). In certain years nearly all the cases in a given 
locality terminate favorably, while in other years in the same locality 
the mortality is very great. 
These facts can scarcely be explained except on the assumption 
that there is a difference in the microbe at different times and in 
different places, similar to the differences existing in the cultures 
obtained in the laboratory. 
These variations in the type of the disease probably afford the 
explanation of the phenomenal success of given forms of treatment 
in the hands of certain practitioners, and their utter failure when em- 
ployed at other times, and in other places, and by other practi- 
tioners. They should warn us not to accept too readily the enthusias- 
tic praises of particular methods (backed up it may be by an array of 
favorable statistics) which are passing in constant procession through 
the medical periodicals. It has happened to most of us, no doubt, to 
have had a succession of favorable cases under a particular manage- 
ment, until we came to believe that at last we had learned how to 
treat pneumonia. But just as we were beginning to rest in this 
assurance, we have been chagrined by encountering an equal array of 
failures with our trusted method, and have been ready to conclude 
that all treatment was of doubtful value. The lesson to be learned 
is, that an intelligent application of principles is to be aimed at, 
rather than a search for some particular method or formula. 
Etiology. 
While the essential cause of pneumonia is the development of a 
specific germ in the pulmonary alveoli, it is evident that as a rule 
there must be a contributing cause that in some way lays the system 
open to attack. We know that the pneumococcus is present in the 
upper respiratory tract in very many persons in perfect health, nay 
more, that it may be found in the blood, and even may be the pyo- 
genic agent in a meningitis, a pleuritis, or a synovitis, and yet the 
lung escape. We must therefore assume that in any given case 
there is a condition present that favors either the migration of the 
germ into the lung or its development when there, or both. 
Some of the causes that bring about this condition we are able to 
recognize, though we may not be able to trace their mode of action. 
Hex seems to be a predisposing cause, since males are more fre- ETIOLOGY. 
81 
quentlj attacked than females. That this is not due wholly to differ- 
ence of occupation and habits, but partly to difference of structure or 
of constitution, is shown by the fact that in infancy boys are more 
frequently attached than girls. Men are moro exposed than women 
to cold and dampness and to excessive and exhausting labor, all of 
which increase the liability to pneumonia. Intemperance, too, is 
more common among men and adds greatly to the risk. 
Tlio relative frequency in the two sexes is variously stated; Wells,18 
from an analysis of 33,(506 cases, gives 23,853 as occurring in males, 
and 9,753 in females. In 223 cases at the Presbyterian Hospital, in 
New York, the figures were 170 and 53 respectively. 
Age.—Considering the total number of persons living at any given 
age, it is probable that the ratio of cases in successive decades is 
fairly uniform, except during the most active period of life, when ex- 
posure is greatest. Senility can scarcely be said to increase the lia- 
bility to attack, though it adds immensely to the danger if an attack 
occurs. 
Race.—In America, the negro race seems to be decidedly more 
liable to pneumonia than the white. This is clearly shown by the 
statistics of the Southern States, and also by the reports of army 
medical officers in the charge of colored troops. In the latter case 
it cannot be due to difference in mode of life, as the conditions are 
absolutely the same for all soldiers irrespective of color. It is doubt- 
less only a manifestation of the peculiar delicacy of the respiratory 
organs characteristic of the negro when removed from the original 
habitat of his race. 
Former Attacks.—Unquestionably a person who has passed through 
one attack is more liable to incur another. Instances are cited in 
which as many as eight or ten or even more attacks have been recov- 
ered from. In such cases it is probable that a bacterial residuum 
remains from one seizure to the next. 
Unsanitary Living. — Pneumonia occurs more frequently in 
crowded, dark, and ill-ventilated dwellings than where the supply cf 
light and air is ample. The life of the tenement house is peculiarly 
favorable to its development, and the crowded, stuffy, overheated 
workshop is responsible for an undue proportion of cases. Fortu- 
nately the germ is short-lived, or the disease would become endemic 
in such locations. As it is, the conditions render the lungs especially 
vulnerable to the action of the specific organism and increase the 
chances of infection. 
Such being the principal predisposing causes of pneumonia, we 
have now to consider those which appear directly to determine the 
attack. 
Vol. XVL -6 82 
SMITH—LOBAR PNEUMONIA. 
The first, and by far the most frequent, is exposure to cold. The 
connection between such exposure and the subsequent attack is often 
too direct to leave any doubt of the causal relation. For example, 
of persons rescued after falling into very cold water a considerable 
proportion will have pneumonia, and that without having been sub- 
merged or having taken water into the air passages. But even com- 
paratively slight chilling of the surface, especially if continued for 
a considerable time, is very frequently followed by an attack which 
may, or may not, be preceded by the usual symptoms of a cold. A 
period of unusually low temperature very generally leads to an in- 
creased prevalence of pneumonia, especially among young children 
and aged people. The former for the most part get well, but after 
a long cold snap there is pretty certain to be a notable increase in 
the obituary notices of old people, most of whom will have died of 
the disease in question. How it is that this impression of cold brings 
about the specific disease in the lung wo do not really know. It may 
be that the temporary arrest of the function of the skin causes a 
retention of excrementitious matter in the blood, which, seeking elimi- 
nation through the lungs, determines there a local irritation favorable 
to the development of the germ. Or the constringing effect of cold 
upon the cutaneous vessels, by forcing the blood back upon the inter- 
nal viscera, may induce such a congestion of the pulmonary capil- 
laries as to favor the initiation of a pathological process. A chilling 
of the surface is very generally attended by a sense of discomfort in 
the lungs which -warns us that we are in danger of “taking cold.” 
To this may be added a dryness of the bronchial mucous mem- 
brane, which, by impairing the action of the cilia, deprives the deeper 
portion of the lung of the protection that the ciliary movement af- 
fords against the invasion of harmful particles, the pneumococcus 
included. And, lastly, it may be that cold occasions a general lower- 
ing of the system, making it an easier prey to morbific influences. 
This last is the explanation usually given, but it is difficult to under- 
stand how such a degree of depression should be so quickly induced, 
and why it should not manifest itself in other ways as well, and also 
why much greater depression produced by other causes does not have 
pneumonia as a result. 
While in a large proportion of hospital cases the disease is found 
to have followed upon a debauch, we are not warranted in assum- 
ing that intemperance as such is a cause of pneumonia. But it so 
often leads to exposure, and so generally interferes with regular and 
proper living, that its victims are always the subjects of impaired 
vitality, and therefore especially liable to this disease. 
While it is popularly believed that a common acute bronliialc ETIOLOGY. 
83 
catarrh may “ run into pneumonia,” there is no clinical evidence of 
such a tendency. When pneumonia occurs it is very rarely pre- 
ceded by bronchitis or other pulmonary affection, and the presence 
of such a condition does not expose to greater risk of pneumonia. 
Even tuberculous subjects are not for that reason more likely to con- 
tract the affection, and it is just as likely to seize upon another por- 
tion of the lung as upon the seat of tuberculous deposit. On the other 
hand, pulmonary emphysema and asthma seem to confer some degree 
of immunity against pneumonic attacks. Flint thinks that this is 
true also of valvular disease of the heart.06 
Other infectious diseases seem often to open the way to infection 
by the pneumococcus. The sx>ecific fevers, typhus and typhoid, 
measles, erysipelas, dysentery, each is a frequent forerunner of pneu- 
monia, and holds a causal relation to it. In these cases the pneu- 
monia is modified by the preexisting disease, and seldom follows 
the regular clinical course. It is apt to assume a wandering form, 
appearing in patches in different parts of the lungs, presenting ir- 
regular and fluctuating temperatures, lacking a definite crisis, etc. 
The morbidity varies considerably with the different seasons of 
the year. According to Flint,47 the period of greatest frequency is 
during the spring months, the winter months come next, while the 
period from June 1st to December 1st affords the smallest number. 
This corresponds with observations at the Presbyterian Hospital in 
New York. 
In reference to climate, pneumonia occurs more frequently in the 
southern portion of this country than in the Northern States, where 
the air is colder, and the conditions are apparently more favorable for 
its development. Thus it is evident that it is not a question of tem- 
perature, but of some other influence, the nature of which is not yet 
understood, but which probably has a relation to the life history of 
the specific microbe. 
The frequency of the disease at the same season of the year and 
in the same locality varies greatly in different years. 
Pneiimonia sems to be more prevalent in high altitudes than at 
places nearer the sea-level. The epidemics of pneumonia occurring 
in Switzerland are mostly confined to the high valleys, while the 
reverse is true with regard to epidemic catarrh.48 
Arthur Trower49 mentions a case of septic pneumonia in a patient 
who had suffered from spinal paralysis for three years and was in 
feeble health. The sepsis apparently resulted from the pressure of, 
and inattention to, a dental plate that had not been removed for sev- 
eral weeks. Upon its removal a gangrenous condition of the mucous 
membrane of the hard palate was discovered, and the continuous 84 
SMITH—LOBAR PNEUMONIA. 
inhalation, swallowing, and absorption of the poison was the un- 
doubted cause of the pneumonia. 
Kronig1*0 insists that it is dangerous to place a patient with pneu- 
monia near one suffering from tuberculosis, as the latter infection is 
peculiarly liable to engraft itself upon the former. 
Post-Operative Pneumonia.—The use of anaesthetics by inhalation 
in surgical operations seems to be occasionally the cause of pneu- 
monia. Silk quotes Clieevers as giving pneumonia a prominent place 
among the causes of death after operations. This was in 1843, be- 
fore the days of anaesthesia. In Cheevers’ paper are given some 
observations of Ericlisen, showing that of forty-one deaths after sur- 
gical injury no less than twenty-three subjects presented signs of 
pneumonia. In contrast to this, modern surgery, as shown by Silk 
presents only one case in 5,000 operations.61 Prescott, on the other 
hand, estimates that in 40,000 cases of etherization there were only 
3 cases of acute lobar pneumonia.62 
At the Presbyterian Hospital, New York, in the ten years from 
1887 to 1897, there were 4,914 administrations of ether followed by 
17 pneumonias, 9 of which were fatal; 689 administrations of chloro- 
form with 8 pneumonias, 7 fatal; 116 administrations of ether and 
chloroform with 2 pneumonias, both fatal. 
It will be seen from these figures that pneumonia after anaesthesia 
is much oftener fatal than under other conditions, and that the ad- 
ministration of chloroform is much more likely to be followed by a 
fatal attack than when ether is employed. Scliultze, however, from 
whose report the above statistics are taken,63 does not believe that 
this large mortality following chloroform inhalation is due to the 
anaesthetic chosen so much as to the fact of the great number of cases 
of malignant disease of the mouth or respiratory tract among those 
to whom chloroform was given. 
Of the cases at the Presbyterian Hospital 18 occurred in males 
and 9 in females. The right lung was involved in 14 cases, the left 
in 6 cases, both in 3 cases; no record in 4 cases. Pain was one of 
the earliest symptoms, and was felt often a day or two before the 
temperature rose noticeably or physical signs could be made out. 
Only 5 of the 27 cases were ushered in by a chill, and of these 
5, 3 were fatal. The rarity of the initial chill in these cases is 
worthy of note, also the fact that the absence of chill did not indi- 
cate, as it usually does, a milder course of the disease. 
Pneumonia after operations seems to be much more frequent in 
England and Germany than in this country. In the clinic at Erlan- 
gen during the period 1887 to 1894 there were 38 ether narcoses with 
6 pneumonias, of which 4 were fatal. During the same period there ETIOLOGY. 
85 
were 300 narcoses with chloroform with 15 pneumonias, 4 fatal. In 
abdominal operations the use of ether seems to be followed by pneu- 
monia with especial frequency. 
Whitney64 suggests that the mouth should be disinfected before 
taking the anaesthetic, to destroy the specific germ and prevent its 
descending into the lung. Lucas has raised the question wdietlier the 
frequent occurrence of pneumonia after operations may not some- 
times be due to infection from the inhaler and suggests measures for 
avoiding the danger. '6 Bad ether may contribute to the result in 
some cases. 
When we consider, however, the great frequency of pneumonia 
after operations before the days of anaesthetics, it is evident that 
their use prevents vastly more cases than it causes, if indeed it is 
ever the active agent in the production of the disease. It seems 
much more fair to say of ether and chloroform that they sometimes 
fail to protect the patient from post-operative pneumonia, than that 
they ever bring about an attack. This protection comes probably 
through lessening of shock and of nervous depression. It is pos- 
sible also that the anaesthetic may exert a direct antagonistic influ- 
ence upon the coccus. 
Communicability of Pneumonia. 
While pneumonia is unquestionably a communicable disease, it is 
not readily transmitted from person to person. From what has been 
already stated in regard to the very frequent presence of the specific 
germ in the air passages of healthy persons, it will be inferred that 
something more is required than simply the transfer of microbes 
from one individual to another in order to communicate the disease. 
Nevertheless, there is much in literature to show the occurrence of 
limited local epidemics of pneumonia, as well as the appearance of a 
number of cases in single households, either simultaneously or in 
rapid succession. In addition to this, certain houses have been 
observed to firrnish year after year an undue proportion of cases, 
apparently indicating that the infecting principle lurked in the 
apartments. 
During the building of the new Croton aqueduct in New York a 
large number of Italian laborers were employed. They congregated 
together in wretched huts along the line of the aqueduct, sleeping in 
a confined and contaminated atmosphere, and living in ignorance of 
every principle of health. Pneumonia was of very frequent occur- 
rence among them. In 1886 Darlington60 treated one hundred and 
fifty cases. The conditions were such as to invite pneumonia apart 86 
SMITH—LOBAR PNEUMONIA. 
from transmission from one person to another, yet doubtless this 
contributed to the result. 
In Middleborough, England, there occurred in one year (1888) 
367 cases of pneumonia in a population of 40,000. Hal well reports 
the occurrence of 50 cases in 13 days in a village of 400 inhabitants.57 
Emmerich 1,8 reports an epidemic of pneumonia occurring in a 
prison at Arnberg in 1880, and lasting for six months, in which 161 
cases occurred and 46 proved fatal. In dust found beneath the 
flooring of the dormitory in which the cases were treated, Emmerich 
demonstrated the presence of the pneumococcus, and obtained results 
similar to Friedlander’s by inoculating animals with it. Dust from 
the floor of other dormitories in which there had been no cases of 
pneumonia was examined without detecting pneumococci. After 
thorough cleaning and disinfection no further cases of the disease 
appeared. 
Tyson60 says: “ Out of a ship’s crew of 815, 410 have been attacked 
in rapid succession, and of 720 attacked 298 fell victims.” 
In hospitals, and under ordinary conditions in private families, 
there is, however, very little danger of communication. The appar- 
ent instances of such transmission are probably quite as often due 
to depressing causes incident to grave illness in the household, or to 
prolonged and exhausting attendance at the bedside. In my experi- 
ence I have seen but a single instance in which I thought the disease 
was directly communicated, and this was in the person of a hospital 
nurse, who while in attendance upon a patient with pneumonia was 
himself fatally attacked. 
As, however, it has been shown by Fliigge and others that in the 
act of coughing a fine spray may be formed from the expectoration, 
which spray is capable of floating in the air for an hour or more 
before it subsides, it is quite possible that the inhalation of this may 
convey the specific germs directly into the deeper air passages and 
thus excite an attack. An instance of communication apparently in 
this way was narrated by Girdner in a discussion before the New 
York Academy of Medicine, December 17tli, 1896. In this case the 
nurse, who was very constant and faithful in her duties, lifted the 
patient’s head at each attack of coughing, and held the towel into 
which he expectorated. She developed fatal pneumonia during the 
progress of the case. 
The many similar instances in literature leave little room to doubt 
that the disease is communicable under very favorable conditions, 
and it id therefore incumbent upon the medical attendant in each 
case to adopt precautions against such infection. 
As to the etiology of pneumonia in general, we are obliged to TREATMENT. 
87 
admit that in a large proportion of cases the attack seems to come on 
spontaneously, that is to say, there is no appreciable antecedent con- 
dition which appears to hold a causal relation to it. 
Treatment. 
Tlie first step in the treatment of pneumonia is to place the pa- 
tient in a single bed, so situated as to be accessible from either side. 
Space also should be left for passing between the head of the bed 
and the wall. The room should be large and well ventilated and if 
practicable should be lighted by a window on each side of the head 
of the bed, and not by one at the foot. The temperature should be 
kept at about 65° F., the attendants wearing a little extra clothing 
if necessary, especially for the feet. The air of the room should be 
completely changed every two or three hours according to the size of 
the apartment, and in the intervals a window should be kept slightly 
open, the bed being protected by a screen if required. 
The modern high bedstead now generally adopted in hospitals 
adds greatly to the comfort of the physician and attendants. In view 
of the probable use of water more or less freely for sponging, etc., 
the mattress should be protected by rubber cloth. 
The patient should be clothed in a soft flannel gown which should 
be made to open in front to facilitate examinations, local applications, 
etc. The bed clothes should be light and not so abundant as to bundle 
up the patient too much or to retain the exhalations from the body. 
Clean cloths should be provided for receiving the expectoration, 
and these should be burned before they have an opportunity to dry. 
The sheets should be changed frequently and “antiseptic precau- 
tions” observed in every particular. 
Alimentation.—Undoubtedly the usual tendency is to give too 
much food to pneumonic patients. The extreme adynamia some- 
times seen in the course of the disease, together with the oft-repeated 
injunction of lecturers and writers “to keep up the strength,” fre- 
quently results in as much nourishment being crowded upon the 
patient asxhe can be induced to swallow. But the febrile condition 
is unfavorable to digestion, and fermentation with consequent flatu- 
lence often results. The abdominal distention in turn interferes with 
the descent of the diaphragm and adds to the difficultyof respiration. 
All this is the residt of a mistaken zeal in the matter of feeding. 
The fact is overlooked that the loss of strength is due to the inten- 
sity of the infection which poisons nerve and muscle, and not to lack 
of nutriment. Furthermore, even if the food were digested and ab- 
sorbed into the circulation, there would remain the equally impor- 88 
SMITH—LOBAR PNEUMONIA. 
taut function of assimilation to be accomplished before the system 
could profit by the nutritive material added to the blood. Assimila- 
tion depends largely upon oxidation, and when the respiration is 
seriously embarassed hsematosis is correspondingly imperfect. Un- 
der these conditions an excess of pabulum, even if taken into the 
blood current, can only add to the burden of the system. 
The condition of the alimentary canal, therefore, should be con- 
stantly watched, and only so much food and of such a quality should 
be given as will be completely digested and assimilated. The appear- 
ance of stomach or intestinal flatulence, or of a thick and muddy 
urine, should lead to a readjustment of the diet. This may consist 
at first chiefly of milk, of which forty ounces per diem will usually 
give a better result than a larger quantity. If not readily digested 
the milk may be peptonized, and if it acquires a bitter taste by the 
process being continued too long, this may be covered by the addi- 
ton of a little coffee. Kumyss or matzoon may be substituted wholly 
or in part, if more agreeable to the patient. 
Beef tea, or expressed beef juice, may be used alternately with 
the milk to relieve the monotony of the diet. 
There are several food preparations on the market that supply 
both nitrogenous and starchy elements already acted upon by their 
appropriate digestive ferments. These preparations contain some 
alcohol, added to preserve them, and they therefore serve both as food 
and stimulant. Such products, coming from reputable laboratories, 
may be relied upon as to their composition, and can be made to fill 
an important place in supplementing other articles of diet. They are 
not likely to cause flatuence, and are generally acceptable to the patient. 
During the pyrexia, whatever food is given should be in liquid 
form and in small quantities at short intervals. After the crisis, if 
the digestion be fairly good, the diet may be more generous; eggs, 
fish, and finally meat being added as the appetite returns. 
Throughout the disease the patient should have as much water 
as he desires. An active diuresis tends to carry off the toxins in the 
blood, and the best diuretic is pure water in abundance. 
Treatment of the Local Condition. 
When we have pneumonia we have an area of lung in which every 
air cell represents a tiny culture tube filled with a culture medium, 
and harboring a colony of diplococci; the lung tissue meantime being 
nourished by a separate set of nutrient vessels which are not ma- 
terially involved in the process. This is the essential condition; 
incidentally more or less breathing surface is withdrawn from use, TREATMENT. 
89 
and the system is flooded with a toxin more or less virulent. Un- 
happily what is incidental in the situation is of much more serious 
import than what is essential. 
Now it is clear that this state of things is absolutely unique. We 
have not, and for anatomical reasons we cannot have, anything resem- 
bling it in any other locality. Analogy, therefore, can aid but little 
if at all in the matter of treatment. Nor can therapeutical methods 
based upon former pathological conceptions be utilized otherwise 
than as they may furnish authenticated facts having a value apart 
from their theoretical setting. Hence, there would be little prac- 
tical utility in entering upon the history of the treatment of pneu- 
monia. Until very recently, except so far as it was wholly empiri- 
cal, this has merely reflected the current views as to the proper 
management of inflammation in general. The local process having 
been regarded as inflammatory, the disease has shared in turn the 
onslaught of the lancet, of mercury, of tartar emetic, and of all the 
long list of autiphlogistics. Even up to the present moment we 
hear of the use of certain drugs or methods to “ reduce the inflam- 
mation” at the same time that the infectious nature of the disease is 
recognized. With this recognition, however, many, if not most au- 
thorities show a disposition toward therapeutic nihilism. “The dis- 
ease is infectious and self-limited, there is nothing for us to do but 
to guide it if possible to a favorable termination.” But the gener- 
alization that would classify pneumonia with scarlet fever and 
smallpox simply because it is technically infectious, is almost as un- 
fortunate as that which would label it an inflammation and give it 
nosological fellowship with everything that ends in ills. 
Keeping before us the nature of the disease, it is evident that a 
rational treatment must have both a local and a general bearing. 
The local bearing will require in the first place measures tending to 
lessen the production of toxic material in the lung, and in the second 
place measures that obviate so far as may be the mechanical obstacles 
to respiration. The general bearing will be in the direction of mini- 
mizing the toxic effects upon the system at large, or enabling the 
system to bear up under these effects. 
Over and above the indications thus afforded, special conditions 
which may arise will require to be met by special measures. 
Moving upon these lines the first object is so to act upon the blood 
as to make the fibrin which is exuded from it into the air cells as 
unfit a medium as possible for the growth of the specific germ. 
In considering the possibility of thus restraining the activity of 
the local process we come at once upon two facts important for our 
encouragement. The first is that the life of the diplococcus is very 90 
SMITH—LOBAR PNEUMONIA. 
short, not exceeding ten or twelve days at the most in artificial cul- 
tures. The second is that of all known germs this is perhaps the 
most sensitive to its environment, laboratory experience showing 
that it can be cultivated successfully only by the most careful atten- 
tion to its habits and peculiarities. The slightest deviation from the 
conditions these impose puts an end to its growth. Furthermore, 
the probability of successfully inhibiting the action of a germ through 
the influence of an agent diffused in the blood is greatly enhanced if 
the germ is located in the lung. This is due to the fact that the 
whole mass of the blood passes through the comparatively small pul- 
monary circulation every time that it traverses the vastly greater sys- 
temic circuit. Hence any substance in the blood comes into much 
more intimate contact with a germ in the lung than it would with a 
germ placed elsewhere, and the assault is proportionately concen- 
trated and energetic. 
It is true that to be fully effective a germicide designed to act 
within the air cell must be employed before the circulation in the 
functional capillaries is arrested. After such arrest it can reach its 
destination only by the very narrow channel of the nutritive blood 
supply. But as the pressure of the exudate is the ultimate factor in 
closing the functional vessels (whatever coagulating influence the 
morbid process may have exerted) it is not until consolidation is 
comjdete that access through these vessels is entirely cut off. It is 
also encouraging to note, in looking back, that various methods have 
been found useful in a marked degree, and have even been credited 
with the power of cutting short the disease in a certain proportion 
of cases. These measures were employed either before germs were 
known, or certainly without any germicidal intent, but we now feel 
that they owed their value chiefly to their antimicrobic influence. 
Mercury. —Foremost among these is the use of mercury. Half a 
century ago this was universal, and it is hard to believe that intelli- 
gent and acute clinicians, men, for example, who could draw such 
an admirable picture of pneumonia as that furnished by Sir Thomas 
Watson, could have been wholly deceived in their estimate of the 
value of this agent. Watson80 says (the italics are mine): “ Many 
persons I am persuaded are saved by treatment of this kind, pushed 
to slight ptvalism: the effusion of lymph, tending to spoil the tex- 
ture of the lung, is arrested, and the lymph already effused begins to 
be absorbed: and the ease and comfort of the patient, as well as the 
alteration for the better of the physical signs, attest the healing qualities 
of the remedy.” 
Twenty-five years later, Dr. James II. Learning01 writes: “ I well 
remember my astonishment when thirty years ago the late Dr. E. P. TREATMENT. 
91 
Cammann ordered a large dose of calomel in an attack of intercurrent 
pneumonia in a case of clironie phthisis, and my gratification at see- 
ing the disease successfully controlled thereby. It was perhaps the 
most practical of all the valuable lessons I received from him. . . . 
The admirable sedative effect of calomel when needed is best seen 
when it is placed dry upon the tongue of the patient. . . . The tem- 
perature at once begins to fall (italics mine), the heart to gain strength," 
etc. . . . 
Personally I have witnessed too often both in Dr. Learning’s prac- 
tice and my own the beneficial effect in pneumonia of a single dose of 
thirty to fifty grains of calomel, given early, not to share to some 
extent in the enthusiasm of the writer. 
The New York Medical Journal for June and July, 1879, contains 
a very interesting report on the “ sedative” dose of calomel, made to 
the Therapeutical Society of New York by Dr. Putnam Jacobi, Secre- 
tary of the Committee on Antipyretics. It is a summary of the re- 
sults of a collective investigation covering fifty cases in which large 
doses (twenty to sixty grains) of calomel were given. In most cases 
the object was to reduce an inflammatory process. In nearly all 
there was a marked decline of temperature within twelve to twenty-four 
hours after the dose. Fourteen cases were of croupous pneumonia, 
all of them severe. Of these patients thirteen recovered and one 
died. This is a remarkable showing, and it is impossible to read 
the report and not yield to the conviction that in sOme of these cases 
the calomel turned the scale toward recovery. In no case was there 
excessive purging from so large a dose. Stomatitis occurred only 
twice in the fifty cases, and produced no serious inconvenience. 
At the present time we can scarcely accord to mercury the “ anti- 
phlogistic” property with which it was formerly credited, and Learn- 
ing does not ascribe the benefit derived from it to such a quality but 
to its sedative action when given in the (large) sedative dose. We can 
understand, however, that when an agent so inimical to germ growth 
is taken into the blood and effused into the air cells along with the 
fibrin that is to act as a culture medium it must have an effect to 
retard at legist the activity of germ formation in that medium. Lab- 
oratory exiieriments show that the pneumococcus is peculiarly sen- 
sitive to mercury; and with so large a quantity of calomel diffused 
through the alimentary canal it is easy to conceive that enough mer- 
cury, probably in the form of the bichloride, should be absorbed and 
exuded with the fibrin to sensibly affect the pabulum upon which the 
microbe feeds. A forticnd would this be the result when the blood is 
so charged with mercury as to produce the phenomena of ptyalism. 
More recently, Pieragnoli'" strongly recommended the employment 92 
SMITH—LOBAR PNEUMONIA. 
of calomel in croupous pneumonia. His method consisted in the 
daily administration of calomel combined with opium and in the 
avoidance of expectorants in the first few days of the attack. His 
results were very satisfactory. Of five patients to whom the calomel 
was not given all died, of fifteen who were treated with calomel all 
but one recovered. Equally good was the result in children. The 
course of the disease was milder, the infiltration was less firm, and 
the wandering of the disease in the lung less marked. The appear- 
ance of diarrhoea, also, seemed to have a favorable influence. 
Smarkovskv,63 of Moscow, claims that calomel given in doses of 
5 or G cgm. (gr. f-1) every hour until a purgative effect is produced, 
is capable of jugulating croupous pneumonia and causing its abor- 
tion. This does not result, he observes, from any direct influence of 
the calomel upon the pulmonary lesion, but from a general antiseptic 
action upon the toxic material circulating in the blood, thus augment- 
ing the resistance of the organism to the morbid local process. 
Granting the major proposition, it would be more reasonable to 
infer that the drug acted toward limiting the production of the poi- 
son, rather than its destruction after it has reached the current of the 
blood. 
For almost fifty years Clemens, of Frankfort, has been employing 
iulialations of chloroform in pneumonia with a view to its sedative 
action upon the nervous system and its anticoagulating (?) effect upon 
the blood. His success, as will be seen later, has been remarkable, 
and others following his example have obtained like results. Here 
again we have a powerful germicide which in this case is not only 
introduced into the blood, but is at the same time brought into direct 
contact with the culture medium itself, up to the time when complete 
consolidation excludes it from the air cells. 
Later we have the introduction of quinine in large doses, given 
with a view to its antipyretic effect. Many authorities, including 
Flint,47 believe that it is possible in this way to abort a pneumonia 
in its initial stage. Flint says: “As long ago as 1861, I was led by 
the results of the analysis of a considerable number of cases in which 
sulphate of quinine was given to the extent of only fifteen grains 
daily, to the conclusion that this remedy exerted a marked curative 
influence upon the disease. I can now (1881) bear testimony to the 
fact that, given in larger doses, namely twenty to thirty grains daily, 
this remedy, in a certain proportion of cases, renders the disease 
abortive, and that when this does not follow, the disease is often 
modified to a greater degree than by smaller doses. Now whatever 
efficacy belongs to these remedies proceeds evidently not from any 
direct effect upon the pulmonary affection, but from a controlling TREATMENT. 
93 
influence over tlie pyrexia, thus sustaining the doctrine that the dis- 
ease is an essential fever.” 
How this abortion is to be effected simply by acting upon the 
heat centre there is no attempt to explain. 
Hare84 expresses the belief that quinine with aconite or veratrum 
viride, employed before consolidation has taken place, has the power 
of so modifying the liypersemia in the affected area as practically to 
abort tiie local process and prevent exudation. 
He warns, however, against the assumption that every case if left 
untreated would necessarily go through all its stages. He says: 
“ Personally I believe that it does not always run a full course and 
that those cases, such as Bristow mentions, which get well after the 
second day are instances where, from one reason or another, the in- 
fecting micoorganism is incapable of carrying out its ordinary proc- 
esses.* Believing this, which is based upon the best of bacterio- 
logical investigation, we should be able so to modify the process by 
treatment as to partly abort the illness, provided we see the patient 
before the microorganism has accomplished its purpose and produced 
such pathological changes in the pulmonary tissues that resolution 
and absorption processes must take place.” 
A. H. Kerr65 advocates warmly the use of creosote in large doses in 
the treatment of pneumonia. He says: “ I do not say that creosote is 
a specific in pneumonia, but I do say, and with emphasis, that it is 
the nearest approach to one that has j et been reached.” He dwells 
upon its being eliminated largely by the lurgs, and thus being 
brought into direct contact with the lesion. It permeates the tissues 
rapidly, and the air at each expiration is loaded with it, as is evi- 
denced by the odor of the room within twenty-four hours from the 
beginning of its use. He gives the details of a case seen within 
twenty-four hours after the chill. The pulse was 120, temperature 
104.2° F., respiration 40. Dulness and fine crepitaut rales over 
*As regards this matter, we frequently hear it said of a person who has had a 
brief illness, that he was “threatened with pneumonia.” Formerly I had little 
patience with this expression, believing that it necessarily meant mure to the friends 
than it meant to the physician who employed it. But I have come to thinking that 
it describes vex*y well an abortive invasion of germs, which after a brief struggle 
have been overcome by the resisting-power of the system. For myself, I believe 
that scattering germs stray into the air vesicles oftener than we suppose, but not 
finding a suitable nidus fail to effect a permanent lodgment. How frequently we 
meet with a stitch in the side accompanied by some fever, and on examination are 
not a little relieved by the absence of physical signs. At the next visit there is 
scarcely a trace of the attack remaining. For one such case coming under the no- 
tice of the physician there are probably many more for which advice is not sought. 
A proportion of such cases are, I believe, to be accounted for in the way I have 
suggested. 94 
SMITH—LOBAR PNEUMONIA. 
the base of the left lung. Ten minims of creosote were given every two 
hours, and for the first day a grain of opium every three hours. The 
following day (the third of the disease) the pulse remained at 120, tem- 
perature 104°, respiration 3(5. Twenty-four hours later (fourth day) 
pulse 96, temperature 102°, respiration 26. At the next visit (fifth day) 
pulse 80, temperature 99°, respiration normal, patient convalescent. 
Under the head of “Note di Terapia” the Clinica Moderna®* 
states that it has been demonstrated that clysters of creosote, each 
containing from twenty-five to forty drops, are of great value in pneu- 
monia, and cause a subsidence of all the alarming phenomena of the 
disease. (References not given.) 
Robinson67 insists strongly upon the value of creosote inhalations 
from the very beginning of an attack of pneumonia, not only for their 
beneficial effect upon the patient, but as having a tendency to lessen 
the danger of infection to the attendants. He provides for the va- 
porization of pure beech-wood creosote in considerable amount along 
with the production of steam. The apparatus is placed near the 
patient’s bed, but the atmosphere of the whole room is thoroughly 
impregnated with the combined vapors, so that they are inhaled by 
the attendants as well. He is firmly convinced of the utility of this 
practice, which has an evident foundation in reason. 
The pneumococcus, as we have already seen, is extremely vulner- 
able, and while it may not be actually killed by any vapor that could 
be safely taken into the lung, yet there is no reason why its growth 
should not be inhibited to a considerable extent, and the amount and 
virulence of the toxin materially lessened. It is no sutficent objec- 
tion to this proposition that the inhaled material could not reach the 
interior of the air cells in the liepatized area, since all goes to show 
that the most active conditions for general infection are supplied by 
the partly filled alveoli surrounding the consolidated focus. To these 
cells a gaseous germicide can easily penetrate. 
As to the possibility of aborting pneumonia and the value of anti- 
septic inhalations, Robinson says: 
“ One of the points in regard to the course of acute croupous pneu- 
monia which is most important is this: to determine, if possible defi- 
nitely, whether or not pneumonia has a certain well-defined course 
terminating in crisis on a given day, which is, so to speak, unchange- 
able. In other words, is pneumonia capable of jugulation? Can we 
abort it by any one of our known medicinal means? This question 
has been answered differently by different authors. Osier, for ex- 
ample, denies that it can. Bristow seems to be of a somewhat differ- 
ent opinion, since he believes that ‘ in very mild cases all the symp- 
toms may subside in three days, or even two days. ’ TREATMENT. 
95 
“ One tiling is true, however, if we may attach faith to the experi- 
mental researches of Welch, and it is that the micrococcus lanceo- 
latus, the admitted cause of croupous pneumonia, is a pathogenic 
organism, one of those least tenacious of life, and that its loss of viru- 
lence is frequent and apt to occur rapidly. Is there not in this im- 
portant fact a very substantial reason why we should endeavor to 
employ antiseptic inhalations early in the treatment of pneumonia, 
before lung consolidation has taken place, and while we may yet legit- 
imately hope that the antiseptic vapor may reach every portion of 
the affected pulmonary area?” 
Salicylates.—Robert Liegel68 contributes a remarkable paper in 
which he describes a treatment which has been successful in his 
hands in seventy-two consecutive cases of croupous pneumonia oc- 
curring in the miners at Leoben-Seegraben. The patients ranged 
from sixteen years of age to seventy-four and included many subjects 
of anthracosis. Eight had pulmonary emphysema, six cardiac dis- 
ease. A large proportion were alcoholics. The drug relied upon 
was sodium salicylate in “large doses,” not less than 8 gm. daily. 
This was given in solution, with aqua mentlim piperitis to cover the 
taste. No other medicine was employed except perhaps an expecto- 
rant containing ipecac, if the cough was tight and racking, and small 
doses of morphine when the pain was excessive. Ice was applied to 
the head when the temperature was above 39.5° C. (103° F.). 
Under this treatment not only did recovery take place in every 
case, but the duration of the attack was diminished one-lialf. In no 
case did crisis occur. The temperature declined from the end of the 
first day, until at the end of three or four days it reached the nor- 
mal, and convalescence was established. The expectoration lost its 
distinctive character and became catarrhal, the physical signs did not 
fully develop, or if present, speedily retrogressed. The microscopi- 
cal examination of the sputa showed a constantly diminishing num- 
ber of diplococci, tuTil, at the end of the third or fourth day, they 
were found to have entirely disappeared. 
In the earlier cases the medicine was suspended as soon as the 
temperature became normal, but this was found in a number of in- 
stances to be followed by relapse; observing this, the doses thereafter 
were continued for some two or three days longer, and no further 
relapse occurred. 
Previous to the adoption of this treatment the management of the 
disease by the usual methods had been very unsatisfactory and the 
mortality excessive. 
Liegel considers that the salicylate exerts a specific effect, such 
as it exhibits in rheumatic fever. He, however, assumes that it acts 96 
SMITH—LOBAR TNEUMONIA. 
upon tlie mucous membrane, increasing its secretion and thereby 
throwing off the exudate, as croupous membrane is thrown off from 
/O/ J < 
xoz Jo 
/oi J* c 
/00 2S ( 
/<?£. Jo 
<?f V 
AO Jf 
f/ U 
A . jp. 
fr 3o 
7f 3* 
.fr. U. 
/oo 3o 
M. 27 
ft 
A(/ 37 
A 7 A 
fz 21 
U. lA 
A 22 
fV. zf 
U x7 
to i7 
77. 27 
V 2 i. 
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77 i7 
J( V 
7777 
7* » 
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10 Xi 
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70 & 
71 ip 
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/f 7o 
•Chart No. 4.—A Caso Treated with Ammonium Salicylate. Patient was admitted immediately upon the occurrence of the chill, and 20 grains of the drug 
were administered every four hours. Temperature reached the normal on the fourth day. 
HOBR. 
Temp 
C. F. 
41.1° 106° 
40.6° 105° 
4t.0° 104° 
39.5° 103° 
38.9° 102’ 
38.3° 101° 
37.7° 100° 
37.2° 99° 
36.6° 98° 
36.1° 97° 
K 
P TREATMENT. 
97 
the larynx. In no instance did it give rise to any symptoms more 
unpleasant than a buzzing in the ears. Indeed, the dosage was 
fairly moderate, less than we habitually employ in the early stages of 
acute rheumatism, and anything like poisonous effects could scarcely 
be apprehended. 
Liegel believes that this treatment will save nearly all cases, and 
he cites some instances to show that the most unfavorable conditions 
may be recovered from under its use. In one of these a man sixty- 
seven years of age was taken with pneumonia while living in a damp 
cellar, in which six persons were huddled together. He had been in- 
sufficiently nourished before the attack, and when first visited was 
found delirious and too much prostrated to be removed to the hos- 
pital. He recovered, however, in the same time as the others, not- 
withstanding his miserable surroundings. 
This is the latest and most important illustration of the possibil- 
ity of so acting upon the blood as to hinder the growth of the bac- 
teria, and to diminish, if not prevent, the formation of toxin. 
The following is from a private letter to the writer, from Dr. A. 
Boss Matheson, of Brooklyn. The substitution of the ammonium 
salicylate for the sodium salt has much to recommend it, but the 
latter has seemed to me to be better borne by the stomach: 
“ For several years I have used the salicylate of ammonium in pneu- 
monia, more especially in those cases occurring during the grippe sea- 
son and in which there was a grippe element more or less pronounced. 
I am now treating a case of lobar pneumonia in the third stage in 
which the only remedies administered have been salicylate of ammo- 
nia, codeia sulphate, and strychnia sulphate. The symptoms in this 
case in the beginning were formidable in the extreme, but modified 
early as a result, I believe, of the effects of the ammonium salicylate. 
I administer it in ten to fifteen grain doses, and endeavor to have the 
patient take from one and a half to two drachms in twenty-four hours. 
“ I find that ammonium salicylate has some advantages over the 
soda salt. It is stimulating, while the latter is more or less depress- 
ing, and it does not produce to the same extent the throat and ear 
disturbances. J am satisfied that it has decided value in the treat- 
ment of pneumonia.” 
Dr. J. H. Ferguson, of Mine La Motte, Mo., informs the writer 
that he has records of one hundred and six cases of pneumonia 
treated by him with sodium salicylate, showing one hundred recov- 
eries and six deaths. He was led to this method by the belief that 
inflammation in general was intensified by uricacidsemia. He gives 
five grains every two hours, together with potassium citrate, to stim- 
ulate the kidneys. 
Vol. XVI.—'7 98 
SMITH—LOBAR PNEUMONIA 
Chart No. 5.—Patient having Double Pneumonia who was Treated with Sodium Salicylate. Patient entered hospital on the third day 
of the disease with pneumonia of the lower right lobe. On the sixth day the left lower lobe become involved. Cold packs applied 
to chest for temperature above 103.6°, and 20 grains of sodium salicylate administered every four hours. Defervescence by 
lysis. Normal temperature on tenth day. 
Hour. 
Temp.... 
C. F. 
41.1° 106° 
40.5° 105° 
40.0° 104° 
39.4° 103° 
38.8° 102° 
38.3® 101° 
37.7® 100° 
37.2® 99° 
36.6® 98° 
36.1® 97° 
~R~ 
P” 
Salicylic acid lias been employed as an antipyretic in pneumonia 
by different clinicians, but lias not been found to possess special ad- 
vantages over other remedies of that class. It has not, I believe, been 
used in this disease with a view to its antimicrobic effect.* 
* According to Buchliolz 0.15 percent, of salicylic acid will prevent the develop- 
ment of bacteria in ordinary organic mixtures, and the influence of 0.005 per cent. 
(1 -.20,000) is plainly visible. Sodium salicylate has about the same power.—Wood’s 
“Therapeutics, its Principles and Practice, ” 10th ed., Philadelphia, 1898, p. 705. TREATMENT. 
99 
From the foregoing facts and opinions, as well as from the theo- 
retical considerations already brought forward, it seems clear that 
there is ample justification for a treatment of pneumonia based largely 
upon the causal indication. In other words, we may reasonably ex- 
pect benefit in a considerable proportion of cases from the use of 
means addressed directly to the germ present in the lungs. The 
practical question to be solved is what agent will act most powerfully 
upon the specific organism with least inconvenience or danger to the 
patient. This opens a wide field for study and observation upon 
which I firmly believe it is the duty of the profession to enter. 
Thus far the most efficient and least harmful drug appears to be 
the salicylate of sodium, as employed by Liegel. As we have seen, 
seventy-two consecutive cases, many of them most unpromising, have 
been treated with it without a death. This is a very remarkable 
record, and certainly recommends the treatment most strongly for fur- 
ther trial. Apart from the experience of Liegel, it does not appear 
unlikely that a drug which is capable of producing such decided re- 
sults in acute rheumatism should be effective against an organism so 
sensitive as the pneumococcus. 
Liegel did not observe any depressing effect from the salicylate in 
the doses he employed (8 gm. daily), but such if apprehended could 
be guarded against by the use of strychnine, etc. 
Creosote has been found useful by several observers and deserves 
further trial. It may be given by the mouth or the rectum, or em- 
ployed by inhalation. The dose by the mouth is ten to fifteen min- 
ims every two or three hours, largely diluted; by the rectum twenty- 
five to forty minims in a clyster. By inhalation it is useful only as 
an adjunct. 
The following case, in which creosote was employed, was seen by 
the writer in consultation with Dr. Bainbridge, of this city, January 
9th, 1899. 
Miss C , aged 46, had suffered from influenza in November, 
1898, and from a second attack beginning January 1st, 1899. She was 
tirst seen by Dr. B. January 6th, when signs of pneumonia were pres- 
ent in the right base. On the seventh, there was complete consoli- 
dation at the right base with beginning signs in front over the right 
lower and middle lobes. Pain in bones, relieved by a few doses of 
phenacetin and salophen. 
On the 8th, nitroglycerin and sparteine sulphate were begun. 
Alcohol, which seemed to be indicated, caused marked cerebral ex- 
citement. The right middle and lower lobes were solid. 
On the 9th, the temperature reached 105° F. and the writer was 
called in consultation. The treatment agreed upon included strych- 
nine sulphate by the mouth, and creosote, 20 minims, with sodium 
bromide, 25 gr., by the rectum. This was repeated every four hours, 100 
SMITH—LOBAR PNEUMONIA. 
the creosote and bromide being mixed with the white of an egg to 
which three teaspoonfuls of brandy were added. 
On the 10th, a small area of beginning consolidation appeared 
at the angle of the left scapula, and a few rales were heard in the 
left axilla. The enemata causing discomfort, the bromide was re- 
duced to 20 gr. and the creosote to 10 minims. 
On the lltli, there were signs of pleurisy in the left axilla. Later, 
a brief attack of pulmonary oedema occurred, and the pulse rose to 
c. F. 
4-i.r 106J 
40.6* 105: 
40. 104' 
39.5' 103' 
389* 102: 
383" ioi: 
37.7* 10C 
37.2- 99 
36.6' 98 
130 and the respiration to GO. The attack yielded to brisk counter- 
irritation and inhalations of oxygen. During the night of 12tli-13th, 
the patient was greatly depressed and the heart was very weak. 
Stimulants increased. 
On the 14th, the patient was very comfortable; convalescent. 
Chart No. 6. 
In this case there was pseudo-crisis on the sixth day, with subse- 
quent rise of temperature and defervescence by lysis, the tempera- 
ture reaching the normal on the eighth day (see chart No. 6). 
Carbolic acid may perhaps be found to have some advantages 
over creosote. It is less disagreeable to take, and probably less 
irritating to the stomach. It is readily taken into the system, as 
is shown by its speedy appearance in the urine. The usual dos- 
age may be greatly exceeded with perfect safety. Wigglesworth 69 
gives as much as six grains every two hours day and night in the 
treatment of scarlatina, continuing it until the risk of infection dis- 
appears. Dr. Jackson, of Alnwick, Eng., in a letter to the writer, says 
that he gave to a patient suffering from charbon three drachms in the 
first twenty-four hours, two drachms in the second, and one and one- 
half drachms during each day thereafter till the end of the fortnight. 
It was retained when everything else was vomited, and no ill effect 
was experienced except a moderate albuminuria* which disappeared 
♦This may have been the result of the infection, and not of the acid. TREATMENT. 
101 
in a few weeks. The patient was rescued from an apparently hopeless 
condition. 
I have myself given one hundred and thirty to one hundred and 
fifty minims of the liquefied acid in twenty-four hours, for several 
days, without the least unpleasant result. The urine had a slightly 
greenish color when voided, and became perfectly black after stand- 
ing a few days, but contained no albumin. Declat cured intermittent 
fever with carbolic acid when quinine had failed, and if it is capable 
of destroying the plasmodium in the blood it would doubtless be 
capable of inhibiting the growth of the pneumonia germs in the alveo- 
lar contents. 
Corrosive sublimate is believed by many to act favorably in diph- 
theria when taken in quantity sufficient to act upon the whole mass 
of the blood, but yet within the limits of safety. We have already 
seen that there is evidence that calomel in a large dose may be very 
useful in pneumonia, and it is quite possible that still better effects 
might be obtained from the more soluble salt. Skoda employed it, 
sixty years ago, in pneumonia, with a mortality of 14.5 per cent.'2 
Almost immediately upon the discovery of the aiuestlietic prop- 
erty of chloroform, Clemens,70 of Frankfort-on-the-Main, employed 
it to relieve the pain and shortness of breath belonging to the early 
stages of pneumonia. His success with it was great, and he was still 
employing it at the date of his last communication in 1889. He 
claims that he has given it in every case of pneumonia occurring in 
his private practice since about 1850, and with such success that he 
has not lost a single patient. He attributes this to the soothing 
effect upon the nervous system, the lessening of shock, and the freer 
respiration resulting from the absence of pain. But he states that 
in addition to these effects there is often a marked hastening of the 
crisis, and that the average duration of the disease is lessened. His 
explanation is that the chloroform defibrinates the blood in the lungs 
and prevents hepatization. 
Baumgartner was one of the first to make extensive trials with inha- 
lations of ether and chloroform in pneumonia, and found that in this 
as in other chest diseases the feeling of constriction, the stitch, the 
expectoration, apd the sleeplessness were relieved. At the same time 
the abundant secretion from the bronchial membrane which, espe- 
cially in the case of ether inhalation, marked the beginning of the 
treatment subsided as the treatment progressed. Wuclierer pub- 
lished a pamphlet on the subject as early as 1848, and Varrentrapp 
and Thiele treated a great number of cases of pneumonia with inha- 
lations of chloroform. 
Oertel71 found decided benefit from inhalations of chloroform, 102 
SMITH—LOBAR PNEUMONIA. 
and refers to the experience of Baumgartner, Wucherer, and Varren- 
trapp, Thiele, and others which agree as to the relief which may be 
afforded by their use. Oertel employed them largely in Pfeiffer’s 
clinic in Munich, from 1860-1863, mostly in the advanced stages of 
the disease, about the fifth or sixth day, in cases in which there were 
extensive hepatization and marked involvement of the pleura, render- 
ing the breathing irregular, frequent, and superficial; when the expec- 
toration was more or less suppressed, and the viscid exudate obstructed 
the air tubes; when coarse rales were heard over large areas, and 
when rapidly increasing cyanosis indicated insufficient aeration of the 
blood. Frequently the inhalations were repeated as often as five or 
six times in twenty-four hours and pushed to commencing narcosis. 
The results were most satisfactory. The respiration became deeper; 
the pleuritic pain was relieved, the cough was lessened, and the sense 
of oppression in the chest disappeared. These results were main- 
tained for a longer or shorter period after each inhalation, and were 
not entirely lost during the intervals. The rales were diminished; 
a more or less free expectoration was established; cyanosis was less 
marked; and for the most part the treatment was successful in bridg- 
ing over the critical period. Oertel sums up his experience as fol- 
lows : “ I consider the inhalation of chloroform when the above indi- 
cations are present as a means of treatment in pneumonia that would 
be difficult to replace by any other.” 
As a contraindication he regards disposition to headache, ver- 
tigo with confusion, decided congestion of both lungs, and finally 
general depression. He insists that if the inhalations of chloroform 
are to be of real value in the treatment of pneumonia, they must be 
administered by the physician himself. 
Now in view of the hastening of the crisis and the shortening of 
the attack observed by Clemens, and the general improvement of the 
patient’s condition so strongly insisted on by Oertel, it may fairly 
be asked whether these inhalations of chloroform do not have a direct 
effect upon the exudate to render it an unfit medium for the culture 
of the pneumococcus. Experiments conducted by Dr. J. S. Tliaclier, 
Pathologist at the Presbyterian Hospital, New York, at the sugges- 
tion of the writer, showed that this organism was very sensitive to 
chloroform. The penetration of chloroform vapor to all parts of the 
lung is attested by the familiar facts of anaesthesia. Nor is it impos- 
sible that the whole mass of the blood should become so impregnated 
with the agent as to render the exudate from it an unfriendly medium 
for the growth of the coccus. VVe know how in the case of annes- 
tliesia by ether the whole body, solids as well as fluids, becomes per- 
meated by the odor, and how long a time elapses before it ceases to TREATMENT. 
103 
be apparent in tlie breath. Everything leads us to suppose that the 
diffusion of chloroform through the system is equally complete, 
though its odor being less powerful, we have not the same evidence 
of its presence. 
For the purpose in view it would by no means be necessary that 
the life of the organism should be destroyed, but only that its multi- 
plication should be prevented, something which is very much more 
easily accomplished. 
I have found that chloroform may advantageously be given in 
connection with oxygen by adding one or two drachms to the water 
in the wash-bottle. Though the chloroform settles at once to the 
bottom of the bottle, the agitation caused by the bubbling of the gas 
through the water insures the vaporization of enough to produce a 
considerable narcotic effect. Aside from any action upon the germs, 
the chloroform allays pain, soothes nervous agitation, and promotes 
sleep. This method of administration will be sufficient when only 
a moderate effect is desired, but if the abortive action of chloroform 
is aimed at, a more concentrated vapor will need to be inhaled. 
Other substances besides chloroform have been proposed as in- 
halants. Carbolic acid from its volatility as well as its germicidal 
property would suggest itself at once. So far from being an irritant, 
it is, when properly diluted, a local anodyne, and its vapor can be 
taken into the lungs in considerable strength without causing incon- 
venience. In some experiments I have made carbolic acid was used 
with chloroform, and apparently with good effect. 
The effect of quinine in doses has been already considered. 
It has been given for its antipyretic effect and as a tonic to increase 
the vital resistance. Much more powerful antipyretics and equally 
good tonics, however, have failed to exhibit the same beneficial action 
in pneumonia. But we know how quinine enters into the blood and 
destroys the malarial organism, and with this demonstration of its 
germicidal power we can well understand that other germs as well 
as the plasmodium may succumb to it. If given with a view to 
abort the attack the daily dose should be not less than 30 to 40 gr. 
If the resulting cinchonism is severe, it can be relieved by fidl doses 
of one of the bromides, preferably, in this case, the bromide of 
ammonium. 
The attempt to cut short an attack of pneumonia will be more 
likely to be successful the earlier it is begun. If it is determined to 
adopt this line of treatment it would be well to begin with the admin- 
istration of 20 to 30 gr. of calomel.* This will at least insure a thor- 
* The calomel should be placed dry on the tongue and washed down with as little 104 
SMITH—LOBAR PNEUMONIA. 
ough cleansing of tlie alimentary canal, and probably will also in- 
crease the secretion from the liver and facilitate the portal circula- 
tion. These will be points of vantage gained, and if, as will be likely 
to be the case, it is followed by a considerable fall of temperature, it 
will open the way to the use of other germicides. The choice among 
these will be decided by the preference of the individual practitioner. 
It need not necessarily be limited to a single agent. Thus sodium 
salicylate, which has more or less of a depressing tendency, may be 
given by the mouth, while at the same time the patient is receiving 
enemata of creosote, which in medicinal quantities is a stimulant. 
Or, while a germicide is taken by mouth or rectum, chloroform may 
be given by inhalation. This will be specially indicated in cases in 
which the pain is very severe or insomnia is present. 
While treatment of this kind is most likely to be effective if early 
resorted to, yet it should be attempted at any time during the py- 
rexia. For we can never appreciate how much of microbic activity 
may be going on outside of the hepatized area, either without physi- 
cal signs or with only the signs indicating congestion. 
It is not to be expected that an obvious result will be obtained 
within a few hours. In Liegel’s cases the temperature remained un- 
changed until the end of the first day, and when abortion has fol- 
lowed the use of other methods the same delay has usuall}7 been 
observed. Even if it were possible to immediately cut short the pro- 
duction of toxin, some time would be required for the elimination of 
that already in the blood, and meantime the fever would continue. 
Next to attempts to inhibit directly the growth of the bacterium 
and the formation of toxin, the local indication is to obviate as far as 
possible the effects of the obstruction of respiration and circulation. 
These two forms of obstruction are so closely allied in their results 
that for our present purpose they may properly be considered as one. 
They play a very important part in the history of pneumonia, caus- 
ing directly or indirectly a greater share of the mortality than is 
caused by the toxins circulating in the blood. 
Bloodletting.—In no disease was the lancet employed during the 
first half of the present century more freely and more indiscriminately 
than in pneumonia. The theory then in vogue as to the nature of the 
disease made this treatment seem natural, and it must be admitted that 
in the majority of cases many of the symptoms were alleviated for a 
time after a copious bleeding. When this was resorted to early, the 
pain was relieved, the breathing became freer and less frequent, and 
water as possible. By withholding fluids for about three hours the danger of exces 
sive purging will he avoided. TREATMENT. 
105 
tlie pulse lost tlie hard, tense character supposed to be so typical of 
inflammation. The temperature in those days was not noted. Then, 
too, the thickness of the “ buffy coat” and the “ cupping” of the clot 
were pointed to as showing how urgent had been the necessity for 
letting blood. Balfour7* gives a very vivid picture of this treatment 
in his presidential address before the British Medical Association, 
session of 1898. 
It cannot be said, however, that the testimony even of the writers 
of that day was very favorable to the practice. Thus it is recorded 
that in Berne, in 1782, ninety-five cases of pneumonia were treated 
by bleeding with eighty-five deaths, while of seventy-seven treated 
without bleeding only ten were fatal. But these bleedings were prac- 
tised for the most part early in the attack, and before the pulmonary 
obstruction became a prominent factor in the case. As a means of 
relieving this latter condition the practice is once more gaining in 
favor. 
Osier'23 says: “ To bleed at the very onset in robust, healthy indi- 
viduals in whom the disease sets in with great intensity and high 
fever is, I believe, a good practice. I have seen instances in which 
it was very beneficial in relieving the pain and the dyspnoea, reduc- 
ing the temperature and allaying the cerebral symptoms.” 
And although the lancet has so far passed out of use that many 
a practitioner of the present day would scarcely know how to open 
a vein, it is by no means certain that a good many lives might not 
be saved by such a timely and judicious bloodletting as would relieve 
the overdistended venous system and give a measure of ease to the 
laboring right ventricle. Many recent writers favor the practice 
under certain conditions. Osier took from 25 to 30 oz. of blood in 
cases which he thought it indicated, but adds that he had seen only 
one of twelve or fifteen cases so treated that recovered. Maragnioni 
Felice and Cantani resort to it sometimes for its hydraulic effects. 
Bianclii favors it, especially iu children, when great dilatation of the 
right auricle is present. Liebermeister upholds it when oedema 
occurs in the unaffected lung. Fowler73 says: 
“ Cyanosis and signs of overdistention of the right side of the 
heart with epigastric pulsation and prominence of the jugular veins 
and a small and irregular pulse, are indications for venesection, and 
relief is generally given when 6 to 8 oz. of blood have been withdrawn. 
The improvement is perhap>s most obvious in cases accompanied by 
or following bronchitis, but unfortunately it is as a rule of only short 
duration.” 
Were it not that much the same result may be brought about with 
less drain upon the system, as we shall see hereafter, the indication 106 
SMITH—LOBAE PNEUMONIA. 
would, no doubt, often be present for the abstraction of blood, and as 
it is, whenever it becomes evident that the right heart is unduly dis- 
tended and is beginning to flag in its efforts to force so large a mass 
of blood through the obstructed pulmonary capillaries, and when 
adequate relief is not obtained by diverting a greater proportion of 
the blood into the arteries, it is the duty of the physician to open a 
vein and allow blood to flow until the venous tension is relieved. In 
children, however, the indication may be better met by the use of a 
number of leeches proportioned to the age and strength of the patient. 
Still, bloodletting is, at the best, a measure to be adopted only in 
extreme cases, and, like any remedy so employed, cannot be expected 
to produce brilliant numerical results. But, if it saves only a few 
otherwise hopeless cases its use is amply justified. 
Nitrites.—Except in some extreme cases, however, most of the good 
and none of the bad effects of bleeding may be obtained by withdraw- 
ing blood from the veins and storing it up in the arteries. This is 
effected by the use of that class of medicines which have the power of 
relaxing the arterial system. Chief among these are the nitrites, but 
the property is shared in a less degree by numerous other remedies, 
notably by aconite, the value of which in inflammatory diseases accom- 
panied by high arterial tension is now universally admitted. It was 
in connection with this drug that the idea of “bleeding a patient into 
his own vessels” was first suggested, and the phrase well expresses 
the peculiar action of this class of medicines. By their specific effect 
upon the vasomotor nerves they cause a relaxation of the musclar coat 
and a consequent dilatation of the whole arterial system. The change 
in capacity which may be effected in this manner is much greater 
than is generally believed. On this point Binger says: “ It has been 
shown that the vascular system is always in a state of semicontrac- 
tion, and that by paralyzing the vasomotor nerves it is possible to 
double its capacity.” An effect much short of this would be suffi- 
cient to produce a vast difference in the dynamics of the circulation, 
and to afford a large measure of relief to the overdistended venous 
system. 
It is in this way, I contend, that we should direct our efforts in 
cases involving pulmonary obstruction. I am aware that there is an 
opinion prevalent that these drugs are contraindicated when there is 
feebleness of the heart’s action; and there are many practitioners 
who would regard with a feeling akin to horror the administration 
of nitroglycerin, for example, when the pulse is notably small and 
frequent. If the condition broadly but vaguely described as heart 
failure were thought to be impending, the administration of such a 
drug would be looked upon by them as a sort of coup de grace. And TREATMENT. 
107 
so it might prove to be if the feebleness of the pulse were clue simply 
to general adynamia. But the case is altogether different when it is 
a mechanical rather than a vital condition we have to deal with. By 
increasing the capacity of the arteries we relieve the veins by exactly 
the amount of this increase. Lessening the pressure in the veins 
lessens pari passu the pressure in the pulmonary circulation, and 
with it the tumefaction of the mucous membrane and the tend- 
ency to exudation into the air passages. Relief to the respiration 
and lightening of the labor of the right heart are the immediate 
consecpience. 
The most prompt in its action among the nitrites is that of amyl, 
but its influence is so brief that it is unsuited except for extreme 
emergencies. Nitroglycerin acts also with great promptness, espe- 
cially when given under the skin, and its effect is maintained for 
forty-five to sixty minutes. In doses of gr. -fo up to TV it may be 
given without hesitation, and repeated every half-hour if required. 
Its effect when cyanosis is present, and the chest is filled with rales, 
is often most satisfactory. The lividity clears up, the rales dimin- 
ish, the respiration becomes deeper and less frequent, and the pulse 
larger and slower. At the same time the sensorium recovers from 
its oppression. These results may be obtained to some degree in 
a period of not more than ten minutes. The dose may require to be 
repeated several times at intervals of fifteen to thirty minutes. 
With the remedy thus administered all the advantages of blood- 
letting may be secured and without the loss of vitality that bleeding 
necessarily entails. When the conditions calling for this form of 
relief are more permanent it is well to employ a more lasting influ- 
ence, such as is afforded by sodium nitrite. This salt is slower, but 
at the same time more persistent, in its action; and by doses of one 
or two grains every two hours the vessels may be maintained in a 
relaxed condition which can be added to at any time by supplement- 
ary doses of nitroglycerin should occasion require. I think it is 
difficult to exaggerate the value of this method when the right heart 
is in danger of breaking down under the strain imposed upon it. I 
have repeatedly seen patients rescued by it when death seemed imme- 
diately impending. 
As to the dosage of nitroglycerin, the drug may be given much 
more freely than it usually is, provided the patient has been found, 
by testing with small doses, not to possess an undue susceptibility to 
its effect. On this point Armstrong74 has contributed a valuable ar- 
ticle. He cites a case mentioned by H. C. Wood, in which gr. 
produced insensibility, and another case in which gr. -fo caused com- 
plete unconsciouness and loss of the radial pulse. Such cases are 108 
SMITH— LOBAR PNEUMONIA. 
due to idiosyncrasy of the patient, and not to the legitimate action of 
the drug. On the other hand, lie mentions instances in which enor- 
mous quantities, even to 76 grains in twenty-four hours, were taken 
with only beneficial results. Nitroglycerin is a remedy of which 
tolerance is rapidly established; and Armstrong is no doubt right 
in liis suggestion that tolerance is increased by a previous condition 
of vascular tension. 
Practiealljq in pneumonia, the dose must be graduated in each 
case by the results obtained. So long as there is evidence on the one 
hand of venous repletion, and on the other of relief of this condition 
by the use of the drug, we are safe in pushing it without much regard 
to the amount given. If under its use the color of the face and lips 
improves and the respirations become less frequent, the indication 
is to continue it in the doses necessary to maintain this effect. These 
will seldom exceed gr. -fa every hour, though in extreme cases tliis 
quantity or even more may be repeated every half-hour, or even 
oftener. 
Oxygen.—Inhalations of oxygen are now very commonly resorted 
to in chest affections when the dyspnoea becomes severe. The use of 
this agent was introduced into this country by the writer in 1860. 
By experiments on animals he had demonstrated that by enriching 
the atmosphere with additional oxygen, life could be maintained for 
long periods under conditions of tracheal obstruction that would be 
immediately fatal in common air. 
The introduction of compressed oxygen in cylinders for commer- 
cial purposes facilitated the use of the gas in sufficiently liberal quan- 
tities to test its real value as a therapeutic agent, and for the last 
twenty-five years it has occupied a prominent place in the treatment 
of respiratory affections and especially of pneumonia. 
Its value in this disease rests on a broader foundation than is im- 
mediately apparent. It is not alone that it tends to avert suffoca- 
tion. Indeed, it is very seldom that a patient with pneumonia dies 
directly from deprivation of oxygen. As a rule, before death from 
actual suffocation takes place, the heart, and particularly the right 
heart, gives out; and the fatal result is from asystole. This exhaus- 
tion of the right heart is a gradual process, and is brought about by 
the increased muscular effort required to propel the blood through 
the affected lung. The pulmonary ischaemia is made up of two fac- 
tors, one of which is the obstruction of the vessels, and the other and 
very important one is the sluggishness with which blood not duly 
aerated circulates even through unobstructed capillaries. 
It is in the relief of this latter condition that oxygen is most valu- 
able. The moment the arterialization of the blood is improved the TREATMENT. 
109 
circulation becomes easier and tlie labor of the right heart is light- 
ened. It is a serious error, however, to defer the use of oxygen until 
the dyspnoea has become urgent. By its timely employment the 
cardiac force can be conserved and congestion of the unaffected lung 
territory is in a great measure prevented. But inasmuch as blood, 
even under the most favorable conditions, will not take up an excess 
of oxygen, if we delay too long and suffer the access of air to become 
too much restricted, no addition of oxygen acting upon the limited 
quantity of blood circulating in the unaffected area will suffice to 
restore the balance and regain the ground which has been lost. 
While the results obtained from oxygen in the croupous form of 
pneumonia may not be so favorable as in the bronchial, still it is 
capable of rendering valuable aid in a large proportion of cases. A 
common source of disappointment lies in reserving its use until a 
period when, for reasons already considered, its value is compara- 
tively limited. Even in these cases it may serve to bridge over a 
time of special danger, but the best results are obtained when it is 
given more or less freely from the moment that it becomes clear that 
the case is one of more than moderate severity. Its good effects will 
be shown in lessened frequency of the pulse and respiration, a better 
color of the face and lips, and fewer moist rales in the chest. 
In using the compressed gas it is allowed to escape from the cyl- 
inder through a wash-bottle, the valve being so adjusted that the gas 
bubbles gently through the water. From the wasli-bottle the gas is 
carried to the patient's mouth through a flexible tube provided with 
a mouth-piece of glass or hard rubber. If the patient is in a condi- 
tion to hold this in his mouth, no more will be required. Otherwise 
it must be held by an attendant in such a position that the escaping 
gas will be drawn into the lungs with the current of inspired air. 
If the patient is comatose a small flexible catheter may be passed 
through one nostril into the nasopharynx, and connected with the 
wash-bottle. In this way very little of the gas is wasted. 
If it is desired to add any volatile substance to the gas inhaled, 
a solution containing it may be made to replace the water in the 
wasli-bottle. Chloroform may be employed in this way. 
There is no advantage in a lavish use of the gas, as the blood will 
take up only a very limited amount. If it escapes too freely, it adds 
to the sensation of breathlessness, as is the case when one faces a 
strong wind. 
Only pure oxygen should be employed. The addition of nitrous 
oxide with the idea that it is more soluble in the blood should be 
condemned, as the oxide is useless for the purpose of respiration and 
interferes with the proper interchange of gases in the lungs. 110 
SMITH—LOBAR PNEUMONIA. 
In pneumonia the indication for a resort to oxygen is present as 
soon as the respirations exceed thirty-five per minute, and earlier 
than this if mucous rales develop outside of the area of consolidation, 
or if the lips assume a dusky hue. Under these conditions it may 
be given continuously, or during a prescribed number of minutes in 
each hour. 
Treatment of the General Condition. 
To combat the toxaemia we have as yet no direct means, unless it 
be in serum therapy, the value of which is still sub judice. We may 
hope to lessen the production of toxin by means which we have al- 
ready considered, but for relief from the effects of what, in spite of 
our efforts, finds its way into the circulation, we must still rely upon 
the The chief of these are the skin, the kidneys, and 
the intestinal glands. The activity of these is best promoted by the 
liberal use of simple cold water. This should be given as freely as 
the patient will take it, or if he be delirious or unconscious it should 
be administered at intervals in the same manner as his food. 
Cathartics.—Additional stimulation of the intestinal glands may 
be advisable, employing cathartics selected especially with that view, 
and particularly calomel if it has not already been given for its abor- 
tive action. It is desirable that the bowels should be kept as free as 
may be without too great a drain upon the general strength, not only 
as promoting elimination, but as guarding against abdominal fulness 
and the consequent hindrance to respiration. 
Diuretics.—The kidneys often fail to excrete the normal amount, 
indeed the urine is generally scanty, and though of high specific 
gravity contains much less than the normal amount of solids. Thus 
the most important channel of elimination is choked and its efficiency 
greatly impaired precisely at the time when a depurative action is 
most needed. 
The importance of stimulating the kidneys during the pyrexia of 
pneumonia has not been recognized as fully as it should be. Whether 
with this object in view or not is not stated, but Nilsson75 treated fifty- 
eight cases of pneumonia with potassium iodide, and with only three 
deaths. His death rate with other methods had ranged in different 
years from twice to three times as great. He gave 1 gm. (15 gr.) every 
three hours day and night; on an average each patient consumed from 
40 to 50 gm. 
Potassium iodide in these doses is a most efficient diuretic and it 
does not irritate the kidneys, as is shown by the enormous doses 
given with impunity in syphilitic disease. It is therefore "well adapted TREATMENT. 
111 
for use in pneumonia when a diuretic is indicated. It can very well 
be given by the rectum, thus saving the stomach for other uses. 
Spirit of nitrous ether is also an available diuretic, and acts at the 
same time as a diaphoretic, a vasodilator, and a general stimulant. 
This combination of properties fits it admirably for use in the stage 
of pyrexia wdien the skin is dry, the urine scanty, and the pulse small 
and weak. It may be given in teaspoonful doses largely diluted with 
water, and repeated at short intervals. 
Diaphoretics.—If the skin remains hot and dry notwithstanding 
these measures, the wet sheet applied with a blanket over it in the 
manner recommended by Baruch should be resorted to. This seldom 
fails to excite perspiration, accompanied by some degree of reduction 
of temperature and a marked relief of the nervous and cerebral symp- 
toms. But the cold bath as applied in typhoid fever, with the sub- 
sequent exposure of the patient to the temperature of the room with 
only a sheet to cover his otherwise naked body, is a measure not to 
be recommended. A recession of the blood from the surface to the 
already congested interior can scarcely fail to be the result, and I 
have found the feet and legs cold under these conditions when the 
rectal temperature was in the neighborhood of 105° F. 
The diaphoretic action of the wet sheet may be aided by the ad- 
ministration of Dover’s powder. Pilocarpine has been recommended, 
but the danger that it may induce pulmonary oedema has prevented 
its being tested to any considerable extent. 
Aside from special modes of treatment, which will be considered 
hereafter, the general principles to be kept in view are to sustain 
the heart, facilitate respiration, and husband the nerve force. 
Cardiac Stmulants.—The tendency to death in pneumonia is in the 
direction of cardiac failure. This failure is due partly to direct toxic 
action upon the cardiac nerves and the heart muscle. Exhaustion as 
a cause of heart failure is limited principally to the right ventricle. 
The increased effort required to propel the blood through the ob- 
structed pulmonary vessels continued through several days neces- 
sarily fatigues the muscular fibre, and this fatigue often goes on to 
the extent of paralyzing the ventricle and causing asystole. 
The action of the pneumotoxin in inducing heart failure extends 
to the left heart as well as the right, but its effect upon the former is 
less disastrous as the labor required of the muscle is less severe; in 
fact, it may be abnormally light, owing to a diminished supply of 
blood received from the lungs. This is the case whenever pulmo- 
nary obstruction is a marked feature and dyspnoea a prominent 
.symptom. When the toxic influence is pronounced, there may be a 
paresis of the vasomotor system, as claimed by Komberg.78 His ex- 112 
SMITH—LOBAR PNEUMONIA. 
periments on animals lead him to believe that the circulatory embar- 
rassment in such cases is due not so much to primary impairment of 
the heart’s power as to vasomotor relaxation with secondary cardiac 
failure Avlien the blood pressure falls below a certain point. 
Van Santvoord,” in a series of cases of pneumonia observed in the 
winter of 1897-98, was able to verify the fact of this low pressure in 
strongly toxic cases, by means of sphygmographic tracings. He 
therefore claims that the first indication, viz., to sustain the action 
of the heart, is best met by the use of such medicines as increase 
arterial tension. Foremost among these he would place digitalis. 
But granting the low tension, the writer believes, for reasons al- 
ready given, that the condition is a conservative one, and that the 
welfare of the patient, so far from being promoted by a general nar- 
rowing of the arteries, would be distinctly jeopardized thereby. If 
the object in view were solely or principally the increase of arterial 
tension ergot would be the better agent. * 
As a heart stimulant in these cases strychnine takes the foremost 
rank. Its use in small doses may be begun quite early with advan- 
tage. At first not more than gr. yV may be required, to be repeated 
every four hours. Later, Ar> An sVj and even ¥V may be advan- 
tageously employed. If necessary the remedy may be pushed to the 
point of producing muscular twitching. Short of this point the de- 
gree to which the nervous system is under the influence of the drug 
may be roughly estimated by noting to what extent the knee-jerk is 
increased. 
When extreme cardiac stimulation becomes necessary and strych- 
nine cannot be further pushed, Horatio Wood recommends to alternate 
it with cocaine. 
A good article of tincture of strophantlius will give all the desir- 
able effects of digitalis without its action upon the vasomotors. Its 
power is expended upon the heart muscle and not upon the vessels. 
* As to any aid to the heart to come from increase of arterial tension it is difficult 
to see by what mechanism this aid is to be attained so long as the venous blood is 
dammed up in the lungs. Doubtless increasing the power of the circular fibres, or 
what is the same thing, diminishing the calibre of the arteries, will enable the left 
ventricle to transmit the force of its contractions more directly to the capillaries 
and through them to the venous system. But what is the advantage of this when 
it serves only to distend the veins more completely and adds nothing to the power 
that moves the venous current? For we know thater/Z the blood in the body can be 
accommodated in the venous system alone, and is so accommodated from the mo- 
ment the heart ceases to beat. Since, then, the simple retractility of the elastic 
coat, without any muscular aid, is sufficient to empty completely the whole arterial 
system, why force the muscular coat to aid in doing what is already only too effec- 
tively accomplished ? TREATMENT. 
113 
It is much quicker in its action than digitalis, its effect upon the 
pulse rate being noticeable within an hour. Fraser78 considers its 
action upon the heart to be many times greater than that of digitalis. 
It possesses a very decided diuretic power, which is of no small 
value when the urine is scanty and the kidneys are not active in car- 
rying off the toxin accumulated in the blood. 
Tincture of strophanthus may be given in doses of four to eight 
drops, hypodermatically if necessary. Indeed, in all urgent cases, 
the cardiac stimulants capable of being administered in this way 
should be so employed. 
Delafield, in his lectures at the College of Physicians and Surgeons, 
New York, asserts his belief that convallaria exerts a relatively 
greater action upon the right side of the heart, and he therefore recom- 
mends its use when the pulmonary circulation is obstructed. 
Other cardiac remedies are caffeine, sparteine, adonidine, theo- 
bromine, etc. Caffeine is capable of rendering good service, the others 
are seldom employed. A clyster of half a pint of hot strong coffee, 
strongly recommended by Beverley Kobinson, I have often found ex- 
tremely useful. From the first the use of coffee as a beverage is to be 
encouraged unless contraindicated by sleeplessness. 
Belladonna is of special value at the crisis to combat the tendency 
to collapse with cold perspiration that seems to be brought about by 
withdrawal of the stimulus of fever. It is indicated wdienever the 
hands are cold and moist, the pulse is small, the senses are dulled, 
the brain is torpid. It is best administred as atropine, and hypoder- 
matically. 
Alcohol.— In all cases with an asthenic tendency alcohol should 
be resorted to in good season. The dose at first may be small, perhaps 
only two or three drachms of brandy or whiskey or an equivalent 
amount of wine, every two or three hours. But if the pulse grows 
smaller, and its frequency rises out of proportion to the temperature, 
the quantity should be increased so long as by so doing these symp- 
toms are held in check. Particularly in subjects habituated to the 
use of alcohol a liberal use of this stimulant will be required. There 
can be no greater mistake than to put a patient suffering from pneu- 
monia upon half an ouncer of whiskey every two or three hours when 
he is accustomed in health to consume the better part of a pint every 
day of his life. The very frequent supervention of delirium tremens 
in the course of pneumonia is probably due to the shock of infection 
acting upon the brain cells already enfeebled by the chronic effect of 
alcohol. It is not safe to attempt its management under these circum- 
stances by withdrawing the stimulant, as is usually done in uncom- 
plicated cases. Enough alcohol must be given to avert the collapse 
Vol. XVI.—8 114 
SMITH—LOBAR PNEUMONIA. 
which will ensue if to the depressing effect of the toxaemia a marked 
reduction of the accustomed stimulation is added. Each case must 
be studied by itself. Tremor, wakefulness that cannot be overcome 
by a reasonable use of hypnotics, a dry tongue, a rapid, feeble pulse, 
coarse rales in areas not invaded by the pneumonia, all these call for 
a liberal yet cautious use of alcohol, supplemented, of course, by the 
drugs already mentioned. 
The same is true of marked delirium apart from alcoholism. 
This symptom nearly always calls for alcohol when it occurs after 
the first two or three days. Delirium at the outset of an attack of 
pneumonia may depend upon individual peculiarity and have little 
significance. The routine practice of applying an ice-bag to the 
head in every case in which there is active delirium is scarcely to 
be commended. Not seldom the cerebral excitement is the result of 
anaemia or ischaemia of the brain, and it will then be made worse in- 
stead of better by the application of cold. 
Yery large quantities of alcohol are sometimes given with good 
effect in apparently desperate cases. It is remarkable that no intoxi- 
cating effect is produced by an amount that would overwhelm a per- 
son in health not habituated to its use. It seems scarcely possible 
that the benefit in these cases comes from the sthnulant effect alone. 
It is more likely that the alcohol acts directly upon the microbe by 
mingling with the medium in which it grows, or that it has an anti- 
dotal effect upon the poison already in the circulation. 
Squire7J reports a case of pneumonia occurring in hospital practice 
in which the patient became apparently moribund and was given up 
as hopeless. Brandy was given steadily bjr the interne and nurse 
until in twenty-four hours thirty-two ounces had been taken with de- 
cided benefit. By following up this treatment the patient recovered. 
Abbott80 reports a case of double pneumonia in a young woman of 
eighteen years, the lower half of both lungs being consolidated. All 
nourishment was refused, even milk, but she was induced to swallow 
brandy properly diluted, and was carefully watched for any evidence 
of overstimulation. Sixteen ounces of brandy were given her daily 
for three successive days. On the fourth day whiskey was substituted, 
and of this she was given twenty-four ounces dailj' four days in suc- 
cession without evincing symptoms of discomfort or overstimulation. 
On the morning of the eighth day she was much improved and refused 
absolutely to take further stimulants. These were, therefore, discon- 
tinued, and she then took milk and other light nourishment without 
objection and made a prompt and complete recovery. 
I have myself employed very large doses of alcohol in several 
cases and sometimes with marked benefit, TREATMENT. 
115 
Digitalis in recent years has held a prominent place in the treat- 
ment of pneumonia. With the recognition that the chief danger is 
from heart failure, it is natural to expect benefit from the use of a 
drug that is of such great service in cardiac diseases in restoring the 
rhythm of the contractions, reducing their frequency, and giving them 
greater force and efficiency. 
But the mechanical conditions in the two affections are as differ- 
ent as is possible to imagine, and the action of digitalis as an arterial 
constrictor, which in the one case is so beneficial, serves in the other 
case only to add to the labor of the organ which we are striving to 
sustain. Theoretically, then, digitalis scarcely seems to be indi- 
cated, and practically, while it is much employed, we have little or 
no evidence that it is useful as generally administered. Personally 
I do not resort to it unless there is cardiac arrhythmia, when I have 
sometimes found that the pulse became regular under its use. On 
the other hand, I am positive that I have often seen distinctly harm- 
ful results from its exhibition, at first in my own practice, and later 
in the practice of others. I have seen the evidences of dilatation of 
the right cavities become more marked, the lips more livid, and the 
chest rales more abundant; and I have seen these conditions subside 
when the digitalis was withdrawn, and its effects upon the peripheral 
circulation counteracted by the free use of nitroglycerin. Indeed, 
with my present views I consider the use of the drug in pneumonia 
without the simultaneous employment of an arterial dilator a highly 
dangerous and indefensible measure, and one that has contributed in 
no slight degree to the fatality of this disease. 
Sturges and Coupland * remark: “For ourselves we desire to say 
that having used it frequently in pneumonia when in want of a cardiac 
stimulant where there was much dyspnoea, cyanosis, and other signs 
of auricular distention we have not found digitalis efficacious in re- 
moving those symptoms.” 
Larrabee81 remarks that digitalis stimulates a weak heart by con- 
tracting the arteries and arterioles and throwing the blood back upon 
the heart itself. If there is no pulmonary obstruction the action is 
prompt and efficient, but the very condition which is killing the pa- 
tient in pneumonia is rendered still more dangerous by such an agent. 
Nevertheless, in the past ten years there has accumulated evi- 
dence to show that digitalis employed by a peculiar method may be 
of service in pneumonia. Beginning in 1888, a series of articles have 
been published by Petrescu, of Bucharest, in which he advocates the 
use of enormous doses of digitalis leaves, and claims for the method 
results that far surpass those of any other plan of treatment yet sug- 
gested. His daily dose reached the startling figure of 60-120 gr. of 116 
SMITH—LOI5All PNEUMONIA. 
the dried leaf. So far from any poisonous effects resulting lie claims 
that in nearly every case a very prompt and decided amelioration of 
all the symptoms takes place, and that in six hundred cases the mor- 
tality has been less than two per cent. 
Belotti and others have published articles confirming the result 
obtained by Petrescu. Such a remarkably successful treatment, and 
withal one so easily carried out, should, it would seem, have received 
universal favor. Admitting its claims to be well founded, we must 
seek a rational explanation first of the impunity with which such 
large doses are taken, and second of the beneficial effects obtained. As 
to the first point, it is to be observed that the preparation of digitalis 
employed is the infusion. Recent investigations show that of the four 
active principles obtained from digitalis, viz., digitalin, digitoxin, 
digitonin, and digitalein, the first is almost insoluble in water, 
the second quite so, while the other two are freely soluble in this 
menstruum. All are soluble in alcohol. Now in an infusion prepared 
without the addition of alcohol, such an infusion, for example, as that 
of the British Pharmacopoeia (the United States Pharmacopoeia pre- 
scribes ten per cent, of alcohol), there is a very small amount of the 
digitalin and no digitoxin, while the full amount of the digitalein 
and digitonin contained in the leaf is represented. Digitalin seems 
to possess to a remarkable degree the power of contracting the periph- 
eral vessels, since Porter found that the capillary circulation in the 
web of a frog’s foot was completely arrested by the application of a 
solution of 1:30,000. It is probably this principle, therefore, that 
gives to digitalis its power to raise the blood pressure. Its exclusion 
to a large extent from a purely watery infusion would therefore lessen 
the injurious effect that would otherwise result from the increased 
labor required of the heart to overcome increased peripheral resist- 
ance. 
Digitoxin is supposed to be the most poisonous principle con- 
tained in the leaf. To its action is probably due the vomiting so 
often excited by the tincture or other preparations containing alco- 
hol. Its beneficial action, if it possesses any, is not yet determined. 
It seems, therefore, that the remarkable effects obtained by Petrescu 
may fairly be attributed to the digitalein and the digitoniu which 
the watery infusion contains. That this preparation will act to steady 
an irregular heart, and to give force and efficiency to the beat, as 
well as to increase the flow of urine is a matter of frequent observa- 
tion. In a case of cardiac dilatation now under treatment by the 
writer the arrhythmia was excessive and the x>ulse extremely small, 
while the daily excretion of urine was only twenty ounces, yet under 
six daily doses of two drachms of the watery infusion the rhythm was TREATMENT. 
117 
nearly restored, the pulse became larger and stronger, and the urine 
increased in two days to seventy ounces. 
Statistics from military sources, like those of Petrescu, are open 
to this fallacy that the conditions, at least in time of peace, are pe- 
culiarly favorable for recovery. In Continental European armies the 
soldiers are all young men from eighteen to twenty-five years of age. 
Men recover in larger proportion than women to begin with, and 
younger men more frequently than the average subject. The soldier 
is not likely at his age to have damaged kidneys or an impaired 
heart as something acquired after entering the army, and before that 
time such a condition if present would prevent his enrollment. The 
same is true of syphilis and other cacliexise. The subjects of the 
disease, therefore, are almost as if they were selected with reference 
to their ability to resist an attack of pneumonia. But this is not all. 
Garrison duty is irksome, and the young recruit is glad to escape 
from it on the slightest pretext of illness. Hence at the first symp- 
tom he reports to the surgeon, and the hospital is immediately at 
hand to receive him. This secures the advantage of early treatment 
and avoids the dangers of removal to a hospital after the disease is 
in progress. How potent the last two factors are may be judged 
from the statistics of the United States army, which being main- 
tained by enlistment and reenlistment contains many men past the 
middle period of life and many alcoholics. Yet despite these unfa- 
vorable conditions and the hardships of frontier campaigning and 
Indian fighting, pneumonia is only about one-third as fatal in mili- 
tary as in civil practice. 
Taking all those points into consideration, we should expect a 
very low rate of mortality from pneumonia in Continental armies in 
time of peace. Yet with allowance for all this, the results obtained 
by Petrescu are remarkably favorable, and it is singular that the 
special advantages of his treatment have not won for him a more en- 
thusiastic support. 
It is only fair to say, however, that other observers following his 
plan have not attained his success. Havas,*2 for example, has given 
the method a trial and reports against it. 
Application of Cold.—The high temperature attending many cases 
of pneumonia naturally suggests the use of cold applications either 
locally to the chest or to the surface generally. But the popular idea 
that pneumonia is usually if not always the result of catching cold, 
and the resulting prejudice against what would be considered a repe- 
tition of the exciting cause, have prevented its use to a great ex- 
tent in private practice and even in hospitals. And it must be ad- 
mitted that theoretically a long-continued impression of cold upon 118 
SMITH—LOBAE PNEUMONIA. 
tlie surface, contracting the peripheral vessels and forcing the blood 
into the interior, does not commend itself as a plan of treatment in a 
disease in which vitally important internal organs are already en- 
gorged. Nor does the result of practice favor such a use of cold 
with the idea chiefly of reducing the temperature. In fact, experi- 
ence shows that when pneumonia occurs in the course of typhoid 
fever, the bathing, which before was not only well borne but was 
obviously beneficial, becomes a source of danger unless employed 
with the utmost caution. But these considerations do not apply 
to the local application of cold in proper cases, nor to its general 
application in such measure as to insure a prompt reaction with 
accompanying nervous stimulation and more active cutaneous circu- 
lation. 
Already in 1888 Liebermeister upheld this method, and showed 
that when properly applied it not onljr was devoid of the dangers 
formerly attributed to direct refrigeration of the surface, but that 
the patient breathed more deeply, expectoration was freer, and a 
beneficial nervous stimulation resulted. The bath was usually given 
at 68° F. and was ordered when the temperature reached 104° F. The 
duration of the bath was about ten minutes. Cold sponging was re- 
sorted to between the baths if the temperature showed a tendency to 
rapid increase. - He referred to one hundred and fifty cases treated 
by him in this way at Basle, with a mortality of ten and a half per 
cent, as against twenty-five per cent., his average under the older 
methods. 
A case treated with cold sponging at the Presbyterian Hospital 
is illustrated by the chart on opposite page. 
Different observers, and especially Mays, have found marked 
benefit from the use of ice bags or ice poultices to the affected side 
of the chest. The effect of these applications cannot be directly 
to lower the temperature of the diseased structure. Gilman Thomp- 
son has shown that ice applied to the surface of the abdomen does 
not sensibly affect the temperature of the corresponding interior sur- 
face of the abdominal wall. Much less could ice in contact with the 
chest, although affecting to some degree the general temperature, be 
expected to abstract an appreciable amount of heat from the under- 
lying lung. But this does not preclude a reflex influence that may 
affect powerfully the vascular action in the organ involved, as it is 
well known that the supply of blood to a viscus may be controlled to 
a marked extent by impressions produced within areas nervously re- 
lated to it. In any case, there is abundant clinical testimony to the 
value of cold applied in this manner. The results of a collective in- 
vestigation instituted by Mays,83 and covering one hundred and ninety- TREATMENT. 
119 
fo Vo 
'o y- J-e 
?6 36, 
ft, tv 
/CD 3i 
/of 36 
'c-o va 
'ov 3/r 
/»< *« 
/CD X6 
/»i Zy 
/oz yz 
/cl Z6 
//■Z VV 
/oy 36 
'or 3i 
"* 3-1 
'»V 36 
/oT 3* 
>/* Si 
/06 Zf 
/OD -?f 
ica 
/„r 
/ o-o 2-t, 
/rv Z y 
ft, -iv 
/or sr 
/OD 3 -C 
ft IT 
?r 
ft *6 
/»0 36 
ft. J-Z 
to 3t 
ft 3* 
ft 30 
6t 3o 
fo 33 
6,0 Zy 
3~C 30 
L* ZO 
U /T 
\3rO 
*\ 
Chart No. 7. 
Hour. 
Temp.... 
C. F. 
41.1° 106° 
40.5° 105° 
40.0° 104° 
39.4° 103° 
38.8° 102° 
38.3° 101° 
37.7° 100° 
37.2° 99° 
36.8° 98° 
36.1° 97° 
K 
~P~ 120 
SMITH—LOBAll PNEUMONIA. 
five eases, however, had to do with private practice, where the mor- 
tality is relatively small. The figures are not therefore so favorable 
as they appear to be at first sight. 
The method consists simply iu packiug bags, filled with chopped 
ice and covered with towels, about the affected side of the chest. 
The pain is relieved, the breathing becomes deeper and less frequent, 
the temperature and pulse decline, delirium ceases, and a general 
improvement begins, which in most cases is permanent. 
The general application of cold, however, has its modern advocates. 
Baruch,84 following Liebermeister, advises the cold bath or the cold 
pack, but so administered as to arouse the nervous system and stimu- 
late the cutaneous circulation rather than with a view to direct reduc- 
tion of temperature. The bath, therefore, is of short duration, and 
is accompanied by brisk friction, or if the pack is used, blankets are 
placed outside, so that the impression of cold is quickly followed by 
reaction and perspiration. 
Peabody85 considers the use of the tub bath precisely as in typhoid 
fever as marking the most important advance in the treatment of 
pneumonia for many years. My own experience in this line is lim- 
ited to the use of the wet sheet about the trunk. In a number of 
cases this has seemed to be serviceable. 
Antipyretics.—From what has gone before, it will be seen that 
there is not much room for antipyretics simply as such. The cases 
are rare in which benefit can be expected from merely forcing down 
the temperature by the use, for example, of the coal-tar prepara- 
tions. Yet when with hyperpyrexia there are great discomfort and 
much nervous disturbance, such as headache, jactitation, insomnia, 
delirium, etc., and there is a fairly good condition of the pulse, one 
of these agents may be cautiously employed, its use being suspended 
so soon as a measure of relief has been obtained. The main thing is 
not to follow the indications of the thermometer alone, but those 
afforded by the general symptoms plus the thermometer. 
The high temperature is not of sufficient duration to threaten of 
itself the integrity of the heart fibre, as it does in the case of a con- 
tinued fever. The risk is from the local action of the toxin, and we 
add to this risk when we resort to antipyretic drugs. We are thus 
confined to a discriminating choice of evils. 
As to which of the coal-tar products is to be preferred, while 
plienacetin is much in use, my personal choice is acetanilid. A com- 
bination of three grains of this and a like quantity of Tully’s powder 
has given me much satisfaction. The small amount of morphine inten- 
sifies the soothing effect, and with the camphor acts as a stimulant to 
the heart, and at the same time tends to promote the action of the skin. TREATMENT. 
121 
Belief of Pain.—When the pain is severe, nothing else will tako 
the place of a properly apportioned dose of morphine given liypo- 
dermatically. It not only relieves the suffering, but it promotes 
deeper, slower, and more efficient respiration, and thus lessens the 
tendency to capillary stasis in the affected portion of the lung. But 
large doses are to be avoided, and it should be used very cautiously 
when there is any considerable loss of respiratory surface or any 
tendency to somnolence. A quarter or a third of a grain will usually 
be enough, and the dose may be cautiously repeated. In a doubtful 
case it may be more safely used in combination with a full dose of 
caffeine. 
If in any case the use of morphine is deemed inadvisable, the pain 
may be alleviated by the application of an ice bag or ice poultice. In 
sthenic cases wet-cupping, or the application of a dozen leeches, may 
accomplish the immediate purpose, and at the same time exert a 
favorable influence on the progress of the disease. When the pain 
is less severe the application of dry-cups, sinapisms, etc., may suffice. 
Poultices, formerly so much used, are now less in favor. They are 
inussy, troublesome to apply, apt to become cold and clammy, and 
unless iu the hands of a very faithful and assiduous nurse, are likely 
to do more harm than good. Even the time-honored oiled-silk jacket 
is now seldom seen, and will doubtless soon become obsolete. The 
jacket, made by quilting cotton batting between thicknesses of cheese- 
cloth, has the negative merit of being comfortable and cleanly, and is 
at least unobjectionable. 
When the pain is low down, a single broad strip of adhesive 
plaster, drawn tightly around the affected part, allowing the ends 
to extend an inch or two beyond the meridian line, will give very 
marked relief. Higher up, where the movement of the ribs is less, 
this expedient is less useful, but it is still not entirely without 
benefit. 
Relief of Cough.—In some cases the cough is out of proportion 
to the material to be expectorated, and exhausts the patient with no 
corresponding benefit. Worse than this, convulsive coughing tends 
to aspiration of the sputum into the unaffected portions of the lung, 
thus increasing the area of infection. 
For both these reasons it is important that an irritative cough 
should be held in check. This may be accomplished by the moist 
inhalations already mentioned; but if these are not sufficient, small 
doses of codeine or morphine will be required. The new drug, heroin, 
which is a substitution-product of morphine, seems to have a special 
power to control cough, while not producing in the same degree the 
other effects of the parent drug. In doses of about gr. it has 122 
SMITH—LOBAR PNEUMONIA. 
given me great satisfaction, a single dose sometimes moderating the 
cough for several hours. 
(Edema of the Lungs.—The supervention of pulmonary oedema 
during the progress of pneumonia is a very grave occurrence. It is 
indicated by abundant coarse rales over the whole chest, very rapid 
and superficial breathing, frequent and small pulse, more or less 
cyanosis, and profuse and often cold perspiration. It may appear 
with comparative suddenness, and be very promptly fatal, the patient 
dying of suffocation. 
The treatment must be prompt and vigorous. The chest should 
be covered with dry-cups, or enveloped in a huge mustard poultice. 
A small hypodermic injection of morphine, not more than gr. will 
do more than anything else to restore the pulmonary circulation and 
check the excessive secretion, which sometimes wells in white or pink- 
ish foam from the mouth and nostrils. In the same injection should 
be included gr. of nitroglycerin and gr. of strychnine. Oxygen 
if obtainable should be given freely by inhalation. Half a pint of 
very strong hot coffee should be thrown into the rectum. By these 
means some apparently desperate cases may be carrried through suc- 
cessfully. As a last resort, artificial respiration may be employed to 
aid in pumping the air and oxygen into the lungs. 
Resume. 
In tlie view of tlie writer, tlie treatment of pneumonia should em- 
brace the following points: 
An attack upon the pneumococcus through the medium of the 
blood, the object being that the exudate when it escapes into the air 
cell shall be impregnated with a substance that will unfit it to serve 
as a culture medium. 
Stimulation of the emunctories to throw off the poison as it forms. 
Sustaining the vital powers and particularly the heart—cardiac 
stimulants. 
Relieving the pulmonary circulation—vasodilators, venesection. 
Compensation for loss of respiratory surface—inhalations of 
oxygen. 
Reduction of excessive temperature—cold to surface, antipy- 
retics (?). 
Relief of incidental symptoms. 
Antitoxin Treatment. 
Id all probability tlie pneumonic process as we see it from the 
moment of invasion to the crisis implies infection by the agency of 
a continually changing set of microbes. Welch has shown that the TREATMENT. 
123 
virulence of the pneumococcus is inversely as its age, the organisms 
taken from the centre of a pneumonic focus having very little po- 
tency, while on the edge of a patch which is still spreading they are 
most active. From this we infer, and the inference is supported by 
the behavior of artificial cultures, that the infection of the system is 
not maintained through the whole period of pyrexia by the same 
microbes, but by a constant succession, the older ones becoming 
inert, and fresh once carrying on the work of supplying the toxin. 
This supply fails soon after the local process has ceased to spread, 
simply because there are no longer any young bacilli to maintain it. 
But while it would seem as if this might afford a sufficient explana- 
tion of the phenomena of defervescence by crisis, yet the observa- 
tions of the Klemperers and others make it reasonably certain that 
there is an antitoxin produced that has its share in the result. 
Whether this antitoxin is the product of the pneumococci or is sim- 
ply the result of changes going on in the leucocytes preparatory to 
their disintegration is not yet determined. We are apt to think of 
the process of absorption by which resolution is ultimately effected 
as beginning after the crisis, whereas it is in operation from the first 
moment of the disease, as is shown by the early infection of the gen- 
eral system which it brings about. Up to the point of consolidation 
the rate of deposition is far greater than that of removal, and a rapid 
accumulation of exudate takes place in the air cells. This exudate, 
however, is not permanent in constitution. It immediately begins a 
process of change, and as we have seen, the organisms contained in 
it change their properties also. As time goes on, there comes a pe- 
riod when the deposition of fresh infective material is less active 
than the absorption of that which is older. At this point an anti- 
toxic effect becomes apparent, and in the cases terminating by crisis, 
a rapid fall of temperature takes place. In the cases terminating by 
lysis, either the deposition of fresh material is protracted by the 
invasion of new territory, or the absorption of the older material is 
for some reason less active. 
As early as 1888, Netter rendered mice and rabbits immune to 
pneumonia by injecting them with fluid prepared from the dried 
spleen of infected animals. Later he experimented with an old x>leu- 
ritic exudate containing pneumococci, and at last the sputum of 
a pneumonic patient, which had ceased to be virulent after the 
crisis.88 
Pursuing this line of investigation, Foil found that the injection 
of an attenuated culture of the diplocoecus of pneumonia into an 
animal gave immunity against the disease for several months. He 
produced the injection serum by precipitating the culture broth con- 124 
SMITH—LOBAR PNEUMONIA. 
taining the diploeocci with ammonium sulphate and filtering repeat- 
edly. The filtrate Avas injected into the veins of rabbits daily for 
three or four days. Subsequently he made an extract of the muscles 
and viscera of a rabbit which had died from pneumonia, precipitated 
it in the same way, and found that it gave the same immunity. The 
extract from a healthy rabbit when injected gave no immunity. 
He next turned his attention to the immune animal, drawing the 
blood and allowing it to coagulate, when the serum was used to in- 
ject another animal. This also became immune. As a control ex- 
periment, he injected a rabbit with blood from a man dead of pneu- 
monia; death resulted. He states that several species of virus are 
formed, one seeming to act on the nervous system, another on the 
blood and tissues. 
The Klemperer brothers verified these results.1,7 Their report is 
briefly as follows: Two rabbits were injected each with 20 c.c. of 
pleuritic exudate taken from a pneumonia patient and which by cul- 
ture was shown to be free from living bacteria. Fourteen days later 
both were inoculated with a virulent culture. Both survived, while 
the control animal died. Later, they immunized animals with pneu- 
monia sputum taken before the crisis and heated so as to destroy the 
poison. The same result was obtained by heating to 00° C. a glyc- 
erin extract of pneumococci. The bacteria were washed from agar 
cultures with sterilized glycerin, which was exposed to heat for one 
or two hours and filtered They found that immunity 
resulted from doses proportioned in quantity to the strength of the 
preparation. It was employed subcutaneously. 
They found further that dogs can be immunized against pneu- 
monia, and can also be cured of the disease. This cure takes place 
through the serum of immune animals, immunized by taking in the 
products of the activity of the pneumococcus. This immunizing 
serum does not cure by killing the cocci in the system, for after four 
days’ contact with the serum the bacteria injected into an animal 
caused death. In fact, the bacteria in contact with this serum in- 
crease in number. At the same time the serum if injected prevents 
the formation of the poison in the body of the animal. This may be 
explained in one of two ways, either the serum hinders their power 
of forming poison, or the cocci go on forming poison, and the serum 
counteracts its effects, or through chemical changes renders it inert. 
At any rate, the cocci become harmless to the animal, their evil in- 
fluence being destroyed by the reaction of the body cells, especially 
the white blood corpuscles. 
If pneumotoxin and curative serum be mixed and injected into 
an animal, there is no rise of temperature and no effect from the TREATMENT. 
125 
poison, while toxin alone kills the animal, with symptoms of septi- 
caemia.* 
They next inquire whether the pneumonia cured in animals by 
the serum is identical with pneumonia in man. Their autopsies in 
animals dead of pneumotoxin injections did not show the fibrinous 
exudation in the lungs characteristic of pneumonia, but diplococci 
were found in the blood. However, it is not the pneumococci them- 
selves, but the poison that they produce that gives the septiceemic 
symptoms. This poison when formed at the seat of injection reaches 
the blood sooner than the cocci themselves. Also if we filter out the 
cocci, the poison remaining in solution kills the animal injected as 
effectually as the original culture. 
In contradistinction to animals, man is only slightly susceptible 
to the pneumococcus. Living cocci can exist on healthy mucous 
membranes without doing harm, and are found in the sputum of 
healthy men. If we inject men subcutaneously, what results do we 
get? The Klemperers experimented by injecting themselves, and 
found that no reaction resulted from small amounts; from larger 
ones a local swelling with rise of temperature and febrile symptoms 
resulted, passing away in a few days. Hence, they conclude that 
men are much less susceptible than dogs to the same relative doses. 
They conclude that in man it is not the exudation in the lung that 
renders the disease so grave, but the general infection from absorp- 
tion into the circulation actiug on the heart and vital centres and 
producing febrile symptoms. In the animals injected, the poison 
enters the blood stream directly and produces fever at once. The 
poison increases for some days, and then antitoxin is produced and 
immunity results. Serum taken from pneumonic patients after the 
* In this connection maybe mentioned the observations of Fochierof Lyons, who 
recommended the production of abscesses by subcutaneous in jections of turpentine 
in certain cases of puerperal infection. This recommendation was carried out 
in pneu nonia by Lepine and others with gratifying results. Pinna215 in observa- 
tions already referred to (see page 44) shows that pure sterile pus has an antitoxic 
effect in pneumonia, and that this may be made available by Fodder’s method, 
viz., the injection of 1 c.c. of essence of turpentine beneath the skin, thus inducing 
the formation of a sterile abscess. He treated in this way a patient, fifty-five years 
of age, suffering from apyretic and adynamic pneumonia of seventeen days’ stand- 
ing, in whom the diagnosis was based upon physical signs and the presence of 
pneumococci in the expectoration. The day following the injection the pulse rose. 
The temperature went suddenly up to 102.2° and the dyspnoea was relieved. 
Within a few days the temperature fell again to normal, and the pulmonary phe- 
nomena subsided. Meantime an abscess had formed at the site of the injection 
which when opened gave issue to 50 c.c. of perfectly sterile pus. 
While this practice is not likely to find many imitators, the observation is of 
value in the discussion of the phenomena of antitoxin production. 126 
SMITH—L013A11 PNEUMONIA. 
crisis is found to cure pneumonia in dogs. They conclude that from 
pneumotoxin in man is produced antitoxin at the time of the crisis, 
and this counteracts the effects of the toxins. Thus the so-called 
crisis in man is the beginning of the formation of the antitoxin, and 
though the cocci remain for some time in the blood they are no 
longer harmful.* 
They then question whether immunity in man results after the 
crisis, and conclude from researches and experiments that it does 
occur, but is only temxiorary. 
With regard to the treatment of pneumonia, they say : At present 
we use supportive measures, awaiting the formation of antitoxin. 
But the aged and weak succumb. They suggest that by using the 
immunizing serum from animals, we may hasten this process and 
save lives. They have treated some cases in this way with apparent 
benefit, as shown by fall of temperature and sknving of pulse and 
respiration. But not enough have as yet been treated to arrive at a 
definite and final conclusion as to the value of the treatment, f 
An important discussion on this subject took place at the Acad- 
emy of Medicine in Turin, December 2d, 1892.88 
Lara, chief physician of the Hospital San Giovanni, reported the 
results of ten cases of pneumonia under serum treatment. Five of 
these cases were double, five single. Eight of the patients were 
young persons, two advanced in years; six were robust, four of de- 
bilitated habit. The serum was in some cases from immunized rab- 
bits, in other cases from dogs, and in still other cases a glycerin 
extract made from the viscera of refractory animals was employed. 
In no case was there any local reaction. The glycerin extract pro- 
duced no observable general symptoms. Serum from dogs caused 
nervous excitement; that from rabbits produced general agitation 
and a temporary aggravation of the disease. In all but three cases 
there was reduction of temperature, not sudden, but after an interval. 
A change in the character of the pulse was observed without a 
reduction in the number of beats. There was no immediate change 
in the respiration, but after a time it became somewhat slower. The 
crisis took place in from three to five days. The convalescence was 
rapid and complete; complications were rare and of little gravity. 
The reporter considered the results encouraging. 
* This statement is not in accord with more recent observations which show that 
cases in which cocci are found in the blood generally prove fatal. 
f Pana and di Renzi, of Naples, have produced a serum by inoculating animals 
with pneumonia bacilli, and have employed it in some 32 cases with 29 recoveries 
and 3 deaths. In respect to all of the latter the autopsy showed the presence of 
other diseases of a fatal nature. Maragliano experimented with this serum in five 
cases with success in all (Antonio Fanoni81®). TREATMENT. 
127 
Bozzoli reported five cases treated with serum from rabbits pre- 
pared by a special process not described. There was rapid fall of 
temperature in every instance. Four of the patients recovered and 
one died after defervescence. The kidneys were unaffected. 
Di Ilenzi reported that during the past year he had treated ten cases 
of pneumonia with antipneumococcic serum, prepared as follows: 
The animals were inoculated with a non-lethal quantity of pneu- 
monia virus, the dose of which was gradually increased until a strong 
immunity was produced. Serum from these animals was injected into 
the patient. Only severe cases were selected for treatment. In every 
case cure resulted. In one case the temperature came down on the 
third day, although there were signs of diffuse hepatization. Of five 
other cases admitted during the year, and not treated with serum, one 
died. Although the author admits that his cases might have recov- 
ered without the serum treatment, he considers his results decidedly 
encouraging, as pointing to a real and efficient treatment of pneu- 
monia.89 
Wiesbecker90 reports five cases of pneumonia treated with injec- 
tions of serum obtained from patients recovering from the disease. 
While there was no uniformity in the results so far as the objective 
signs were concerned, these becoming more and more severe in some 
cases after the injection, while in others the severity abated, there 
was in every instance a most remarkable improvement in the sub- 
jective conditions. This improvement was almost instantaneous, in 
one case being manifest within one and one-half minutes after the 
injection. But for one instance in which the patient was a child 
only three years of age, we should be inclined to refer these marvel- 
lous results to suggestion, especially as they did not conform to the 
physical conditions present at the moment. Difficulty of breathing, 
pleuritic pain, malaise of every description disappeared as if by 
magic; recovery took place in every case, though not always with 
remarkable promptness. The quantity of serum in each case was 
10 c.c. 
Similar to this was the experience of Fourriere01 in a single case 
treated by injections of goat’s blood. The patient, a person past 
middle age, was recalled to life from an unconscious, fairly mori- 
bund condition, and though death occurred after several days, there 
was an interval during which danger seemed to be over and recovery 
assured. 
In 1897, Waslibourn, of Guy’s Hospital, published his researches 
on antipneumococcic serum. His method was essentially that em- 
ployed in producing diphtheria antitoxin. A pony was the animal 
selected, and after nine months’ treatment, first with living and then 128 
SMITH—LOBAR PNEUMONIA. 
with dead cultivations, the serum was found to possess marked pro- 
tective powers. By using a special method of cultivation, it was 
found possible to maintain the virulence of the pneumococcus at a 
given level for a period of sixty-six days. To maintain the virulence 
of this culture it must be kept in an incubator at a temperature of 
37.5° C. He claims that under these conditions the antipneumotoxin 
can be accurately standardized. “a 
Several cases of pneumonia have been treated by Waslibourn and 
others with this serum. While its influence cannot be distinctly 
traced, it can be fairly considered to have contributed to the favor- 
able result in some extremely unpromising cases. 
We cannot avoid the conclusion from this resume of the achieve- 
ments of orrliotherapy in its application of pneumonia, that up to the 
present time they can scarcely be said to amount to more than an 
encouragement to further effort. No really decisive results have been 
obtained. In some cases the effect seems to have been favorable, but 
in view of the variable course of pneumonia under all forms of treat- 
ment, it is impossible to assign to the injections any positive share 
in the r.esult. It can be only by the accumulation of a large number 
of observations that a conclusion as to the value of the treatment can 
be arrived at, and, unfortunately, the difficulties in the way of ex- 
tended observation are such as to deter most investigators from pur- 
suing the subject. 
The first difficulty is found in the short life of the pneumococcus 
and its feeble power of resistance. Cocci that are virulent at the 
beginning of an investigation cease to be so as the investigation pro- 
ceeds. On the other hand, toxins that are expected to produce only 
a moderate reaction when injected sometimes display an unlooked- 
for virulence. Animals apparently progressing normally towards im- 
munity most unexpectedly succumb to septicemia from a dose of 
toxin supposed to be entirely within the limits of safety. Again, 
animals that were readily immunized at first lose their immunity in 
spite of renewed inoculations, and the serum obtained from them 
ceases to be reliable. This variation in the conditions under which 
experimentation is conducted is liable to vitiate the most carefully 
drawn conclusions. If this be true under the favorable circumstances 
of the laboratory, what must it be in the exigencies of ordinary prac- 
tice? If before employing a therapeutic agent we must resort each 
time to experiment to test the value of the specimen in hand, the use- 
fulness of the agent will be very limited. 
It is to be hoped that this difficulty has been overcome by Wash- 
bourn’s method already mentioned, and that it will be possible in the 
future to command a supply of reliable antitoxin for the treatment of PNEUMONIA IN CHILDHOOD. 
129 
pneumonia, as we already do for the treatment of diphtheria. Efforts 
to produce such a supply are now being made by the Health Board 
of New York. Should they be successful, the value of the method 
will soon be determined. 
Both Bonardi and Griffiths succeeded in isolating crystallizable 
substances which were supposed to represent the active principle of 
the pneumotoxin, the first from cultures in artificial media, and the 
second from the urine of pneumonic patients. But their conclusions 
seem to have been negatived by subsequent investigations carried out 
at the Institute for Experimental Hygiene at Borne, by Alfredo An- 
dreini,03 so that we are still ignorant of the chemical properties of the 
poison, and as far as ever from the brilliant therapeutic results which 
it was thought were about to be realized. 
Pneumonia in Childhood. 
Pneumonia in childhood differs in some respects from the diseaso 
as occurring in adults. 
As young children do not expectorate, the study of pneumonia in 
them is deprived of the aid to be derived from the examination of the 
sputum, so useful in the case of older persons. As most cases end 
in recovery, the opportunity for autopsical research is limited. For 
these reasons our knowledge of pneumonia as it occurs in childhood 
is relatively incomplete. 
In the Kaiser und Kaiserin Friedrich Kinderkrankenliaus at Ber- 
lin, Schlesinger found that in children up to fourteen years of age 
genuine fibrinous pneumonia occurred iu the proportion of thirty- 
seven to two hundred and seventy cases of bronchopneumonia. 
Holt93a states that after three years of age nearly all primary cases 
of pneumonia are of the croupous variety. During the first two years 
twenty-five per cent, of the cases are croupous and seventy-five per 
cent, bronchial. 
Croupous pneumonia appears in earliest childhood, it has been 
even recognized at birth. It attains its greatest frequency in the 
fourth year, after which the morbidity decreases until puberty. 
From earliest infancy, when t}ie mode of life is the same in both 
sexes, boys are more frequently attacked than girls, in the propor- 
tion of eleven to seven (Schlesinger,94 Morrill96). Children of vigor- 
ous constitution are not more exempt from attack than the less robust. 
Zymotic disease and acute gastritis play an important part as excit- 
ing causes. The season of the year has the same influence as in 
adults. 
Symptoms.—In about half the cases the attack begins with vomit- 
ing; in about seven per cent, with convulsions (Holt). 
Vol. XVI.—9 130 
SMITH—LOBAR PNEUMONIA. 
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Chart No. 8.—Showing the Intermittent Temperature Quite Common in Children. 
HOUR. 
Temp.... 
C. F. 
41.1° 106° 
40.5° 105° 
40.0“ 104° 
39.4° 103° 
38.8° 102° 
38.3° 101° 
37.7° 100° 
37.2° 99° 
36.6° 98° 
36.1° 97° 
R 
P 
As a rule, the younger the child the higher the temperature range, 
and the more frequently the fever assumes an intermittent or remit- PNEUMONIA IN CHILDHOOD. 
131 
tent form, contrasting in tliis with the comparatively even tempera- 
ture observed in the adult. In pneumonia of the upper lobe the fever 
generally is higher and more constant than when the lower lobe is 
the seat of the disease; but there are exceptions to this rule, as in 
the case of which a chart (No. 8) is here presented. Morrill96 found 
the highest temperature in seventy-two cases to be 106.5°F., lowest 
maximum 101' F. Average critical day in fifty-four cases, the 
eighth. 
As compared with adults defervescence by lysis occurs less fre- 
quently in children, in proportion as the pneumonia is purely lobar 
and not bronchial, and the fall of temperature at the crisis is more 
marked. Especially in very young children, and in disease of the 
upper lobe subnormal temperature after the crisis is the rule, some- 
times to the extent of 2° or 3° F. 
Procrisis as distinguished from pseudocrisis appears to be a 
peculiarity of childhood. 
While the disease is at its highest the temperature, pulse, and 
respiration remain nearly parallel with each other. At the crisis, 
the first two fall abruptly, while the respiration sinks more gradu- 
ally. After the crisis the relative frequency of pulse to respiration 
not uncommonly falls below 2:1°. This, in children, is very rarely 
the case before defervescence. Excessive rise, the pulse, for instance, 
above 170 and the respiration above 75, is rare in croupous pneu- 
monia, as is also a slowing of the pulse to below 80 after the crisis 
is past. 
The lesion of croupous pneumonia does not observe the boun- 
daries of the lobes nearly so accurately in children as in adults. 
Much more frequently the invasion of a neighboring lobe remains 
only partial. Dulness on percussion is more marked than the aus- 
cultatory signs, and will often be apparent in cases that without it 
would be overlooked. It is never safe to exclude pneumonia in a 
child simply because we fail to get bronchial breathing and bronchial 
voice. The percussion should be light and with a single finger. 
Holt observes that when the appearance of physical signs is de- 
layed, we should look for them in the axilla) and in the mid-clavicu- 
lar regions in front. 
Double pneumonia is less frequent in children than in older per- 
sons, while an attack limited to a single upper lobe is relatively com- 
mon. When several lobes are invaded it is usually in succession, 
and there is an ascending scale in the severity of the attack. In 
twenty cases observed in the New York Foundling Hospital* the 
* Private note from Dr. Kauenhoven. 132 
SMITH—LOBAR PNEUMONIA. 
right lower lobe was primarily involved in seven, the left lower lobe 
in eight, the right upper lobe in three, the left upper lobe in two. 
The age of the youngest child with distinct signs of lobar con- 
solidation was five months. There were three cases in children six 
months old and under. In all cases with only one lung involved de- 
fervescence took place on or before the sixth day. All uncomplicated 
cases terminated in recovery. Of the two fatal cases one was com- 
plicated with rachitis and one with croup. Both were in children 
under one year of age. 
Morrill06 gives the location of the lesion as follows: right middle 
or lower lobe, 40 per cent.; left lower, 25 per cent.; right upper, 10 
per cent.; left upper, 8 per cent.; right apex, 5 per cent.; left apex, 
4 per cent.; both lungs, 5 per cent. Mortality, 5 per cent. 
Kesolution progresses more rapidly than in average cases in the 
adult. Unresolved pneumonia is rare, and the issue in gangrene or 
in phthisis is almost never encountered. 
The normal course of pneumonia in childhood is more severe than 
in adult life. Bight-sided cases are more severe than those on the 
left, but pneumonia of the upper lobes is not more serious than that 
of the lower. After a prodromal stage of one or two days which in 
children is not infrequent, the disease develops without marked ini- 
tial symptoms. These, however, are seldom wanting when the attack 
is sudden and without prodromes. A pronounced cliill is much less 
frequently observed than in grown persons (Morrill found it present 
in only five per cent, of one hundred cases), while vomiting is very 
common. Convulsions are rare and occur for the most part only in 
very young children, and in right-sided attacks. Just before the 
crisis the child often is much sicker than at any previous stage. The 
contrast then with the subsequent rapid improvement is most striking. 
Still in a small fraction of cases the recovery does not begin at 
once with the fall of temperature, but a day or two days of exhaus- 
tion and depression intervene. 
Abortive Pneumonia.—Baginsky”7 describes under this title a form 
in which the attack sets in suddenly, giving rise to the suspicion of 
croupous pneumonia by the type of the respiration, the temperature, 
and the pulse, and yet does not come to the hill development of the 
physical phenomena. Bather, the process seems to be arrested half- 
way ; before it comes to actual consolidation the fever breaks, and the 
morbid conditions disappear as rapidly as they arise. He considers 
these as undoubtedly cases of pneumonia that have retrogressed in 
the stage of engorgement which always precedes consolidation. In 
his practice such cases are not very infrequent. 
Under the title of “wandering pneumonia,” he observes that 133 
PNEUMONIA IN CHILDHOOD. 
while it is not very common that pneumonia spreads from lobe to 
lobe or invades in succession the entire lung, yet such cases do occur. 
By physical examination it is possible to follow these several devel- 
opments. The cases divide according to the temperature curve into 
those in which the fever remains constant, and those in which there 
is a decline of temperature followed by another rise. While we have 
to do in the first case with a single protracted attack, the other repre- 
sents the recurrent type of pneumonia in which a new section of lung 
is invaded. All attacks of this kind have a long duration and follow 
a severe course. 
Baginsky also recognizes a type which he terms “gastric pneu- 
monia.” In this form the gastrointestinal phenomena are in the fore- 
ground, while the affection of the lung, until shortly before the critical 
appearance, assumes but little prominence. These cases are apt to 
begin with vomiting, and diarrhoea is a leading feature. Only when 
the disease has made considerable progress does the pulmonary im- 
plication appear in its true character as the essential element in the 
case. 
Among the anomalies in the progress of the disease, an abortive 
action is observed more frequently in distinct but circumscribed in- 
filtration than when only the stage of congestion is reached. The 
most dangerous anomaly in children is the migratory tendency. The 
difference in the varieties it occasions lies in the duration of the inter- 
vals between the several migrations. A recurrence of pneumonia is 
as rare in children as in adults, though relapses may occur and the 
attack is greatly prolonged in consequence. Stockton98 reports a 
case in which the entire duration was sixty-eight days. 
The most frequent of the abnormal developments is “cerebral 
pneumonia.” A convulsive, a comatose, and a delirious form are 
distinguished. The cause of the brain symptoms may be found in 
the pyrexia, in the severity of the infection, in an otitis media, or 
finally in an individual peculiarity of the child. A genuine menin- 
gitis as a complication of pneumonia is apt to follow an almost latent 
course. 
The examination of the blood shows that the leucocytosis follows 
essentially the same course in the pneumonia of children and of 
adults. 
Complications. —A slight bronchitis is often observed in the begin- 
ning of the attack in a child, being apparently a continuation from 
the prodromal stage. Later it is of rare occurrence, but of more seri- 
ous moment. Pleurisy is the most frequent complication, especially 
in pneumonia of a lower lobe. It is even more frequent than in the 
adult. For the most part it follows a favorable course, seldom pass- 134 
SMITH—LOBAR PNEUMONIA. 
mg into empyema. It influences the fever but little, but even when 
it is slight, it delays more or less a complete recovery. Albuminuria 
is remarkable for the relative rarity of its occurrence in the pneumo- 
nia of children. When present it is slight in amount and of short 
duration. 
Herpes is relatively uncommon. Icterus is lighter and less fre- 
quent in childhood than in later years. 
Otitis media is especially a complication belonging to childhood. 
Its course is generally severe, and often accompanied by cerebral 
symptoms. It aggravates the fever very materially. As regards the 
ear itself the inflammation usually runs a favorable course. Otitis oc- 
curs for the most part during the first three years of life and in cases 
of pneumonia affecting the right side. 
Prognosis.—The mortality of pneumonia in children is markedly 
less than in adults, in round numbers about one-tliird as great. Mor- 
rill gives the mortality in seventy-two cases as 1.5 per cent. The 
fatal cases are largely the result of complications of which the most 
important are meningitis, purulent pericarditis, and bronchopneu- 
monia. As affecting the prognosis, the constitution and, in a less 
degree, the age, are to be taken into account. 
As to the diagnosis, many of the peculiarities in the course of 
pneumonia in childhood spring from its relation to bronchopneu- 
monia, which has yet to be sharply differentiated from it. The sec- 
ondary pneumonias are very seldom croupous. 
In the treatment a constant progress towards greater simplicity is 
the modern tendency. Energetic measures are less frequently re- 
sorted to. For lowering the temperature cold packs are coming into 
favor as against the use of the coal-tar preparations and other in- 
ternal antipyretics. While the latter depress the already weakened 
heart, the former, if judiciously applied, improve its innervation and 
arouse its flagging energy. It is, moreover, to be recognized that 
up to a certain point the increased temperature is a useful factor in 
the struggle of the organism against the specific infection, and that 
if it is not excessive its forcible reduction is to be deprecated. A 
proper use of tonics and stimulants, including alcohol, will be of 
service. 
Bronchopneumonia. 
Lobar pneumonia in children is ever prone to take on more or 
less of the characteristics of bronchopneumonia, that is to say, it is 
apt to appear in different localities and to be accompanied by signs 
and symptoms of bronchitis. The distinction between the two forms 
is not always sharp, and both may be present at the same time. PNEUMONIA IN CHILDHOOD. 
135 
This subject has been studied recently by Samuel West." The fol- 
lowing is a resume of his paper: 
The author believes that under the one term “ bronchopneumo- 
nia” several different conditions are included, and that many of 
them are pneumococcus inflammations; in other wrords, that some of 
the bronchopneumonias of children are really the same disease as the 
common pneumonia of the adult, or to put tlie proposition in another 
form, that the only difference between tlie pneumococcus disease of 
the adult and that of the child is that in the one case the consolida- 
tion which, results is lobar or massive, and in the other lobular or 
patchy. 
Speaking generally, bronchopneumonia is showm to be associated 
with several varieties of pathogenic organisms; for example, the 
streptococcus, staphylococcus, Friedlander’s bacillus, the tubercle 
bacillus, and others; but chief among them all is the pneumococcus, 
which, taking all cases together, is present either alone or in associ- 
ation with some of the others named, in at least fifty per cent. Thus 
Netter examined forty-two cases, and found: 
Pneumococcus alone in 10 
With others in 9 
19 = 45 
Per cent. 
Streptococcus alone in 8 
With others in 15 
23 = 60 
Staphylococcus alone in 5 
With others in 8 
18 
Friedlander’s bacillus alone in 2 
With others in 4 
45 
6 
Weicliselbaum, in 15 cases, found tlie pneumococcus in 7, strepto- 
coccus in 6, Friedlander’s bacillus in 1, and streptococci and staphy- 
lococci in 1. Horton Smith, in 11 cases, found the pneumococcus 
alone in 5, with others in 3—that is, in 8 out of 11, and in only 3 
cases was it absent. Mosny examined 4 cases of primary broncho- 
pneumonia, and found the pneumococcus in 3 and the staphylococcus 
in 1. In 13 secondary cases the pneumococcus was present alone in 
1, and associated with the streptococcus in 1. The streptococcus was 
found alone in 5, and associated with other bacilli in 5 more. Fried- 
lander’s bacillus was present in 1, and an unknown bacillus also in 1. 
So far as the evidence goes it seems to show that in secondary 
bronchopneumonia the streptococcus is the most frequent organism, 
and in primary bronchopneumonia the pneumococcus, and that among 
the latter the pneumococcus is almost as common as it is in lobar 
pneumonia of adults. 
It is now well known that the microscopical distinctions often 136 
SMITH —LOBAR PNEUMONIA. 
drawn between tlie minute lesions of lobar and lobular pneumonia 
cannot be regarded as absolute, and that for example even the fibrin 
network which is so common in lobar pneumonia is not uncommon 
in acute bronchopneumonia, while it may be absent in lobar pneu- 
monia. 
The conclusions to which this evidence points are obviously these: 
1. That the primary and secondary bronchopneumonias have a 
different bacteriological origin. 
2. That secondary bronchopneumonia is for the most part due to 
streptococcus infection, derived from some source in connection with 
the air tubes, throat, or mouth. 
3. That primary bronchopneumonia is of pneumococcal origin. 
4. That pneumococcus inflammation occurs with almost equal 
frequency in the child and in the adult. 
5. That pneumococcal inflammation takes a different form in 
each, in the adult producing massive consolidation and in the child 
disseminated patches of consolidation; in other words, that there are 
no real pathogenic distinctions between lobar pneumonia of the adult 
and primary lobular pneumonia of the child. 
To sum up, the author is of the opinion that the term “broncho- 
pneumonia” would be best reserved for those inflammations of the 
lungs which follow antecedent affections of the bronchi, and that 
their exciting cause for the most part will be found to be other or- 
ganisms than the pneumococcus, while, on the other hand, the pri- 
mary bronchopneumonia of children is really croupous pneumonia 
occurring in a disseminated and patchy form instead of a massive 
consolidation. 
Bibliographical References. 
1. Loomis : Pepper’s System of Medicine, vol. iii. 
2. Sturgis and Coupland : Pneumonia. 
8. Fowler and Qodlee : Disease of the Lungs, Article on Pneumonia, London, 
1898. 
4. Eisner : Medical News, January 8, 1898. 
5. Syers: Westminster Hospital Reports, vol. ii., 1886, p. 177. 
6. Huglilings Jackson : The Lancet, December 22, 1894. 
7. A. F. Plicque : Le poumon dans la pneumonie. La Presse Medicale, Paris, 
March 16, 1898, p. 138. 
8. Francis Hawkins: Transactions of the Clinical Society of London, 1896- 
97, vol. xxx., p. 11. 
9. Stienon : La Presse Medicale, Paris, 1895, p. 262. 
10. F. Pick: Miinchener medicinische Wochenschrift, November 17, 1898; 
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