630 PNEUMONIA spring and autumn than in summer and win- ter, in cold and temperate than in tropical cli- mates. The prolonged exposure to cold is the cause to which it is most frequently attrib- uted, but in many instances careful research cannot assign an exciting cause ; it occurs oftenest among the ill fed, the intemperate, and those who suffer from crowding and want of ventilation ; consecutive pneumonia, as it is then termed, frequently arises in the course of typhoid, typhus, and eruptive fevers. In many cases the patient is feverish and unwell for three or four days before the actual inva- sion of the disease ; this is almost invariably marked by well defined rigor, followed by pain in the side, cough, accelerated breathing, and fever. The pain in the side, commonly felt beneath the nipple, is no guide to the seat of the disease; it is generally caused by ac- companying inflammation of the pleura, is lan- cinating, and increased by inspiration and by motion of the thorax; according to Grisolle, it occurred in 272 out of 301 patients. Accel- erated breathing is an invariable symptom, the respirations varying from 30 to 50 in a minute, though they may be as frequent as 80. The pulse does not increase in the same ratio as the respiration ; the ordinary relation of four pulsations to a single respiration is disturbed, and is reduced to three, two, ,or even less. Dr. Walshe says he has seen this perverted pulse ratio prove the first sign of pneumonia, appearing before crepitation or rusty expec- toration. Cough is an almost invariable symp- tom, occurring commonly at the commence- ment of the disease ; it is not paroxysmal, and is not aggravated at night. In a great ma- jority of cases the cough is accompanied by expectoration, which is pathognomonic of the disease. It is tenacious, semi-transparent, lit- tle aerated, and of a lemon, orange, or rust color, according to the amount of blood with which it is combined. When free blood occurs in the expectoration, according to Walshe, the pneumonia is complicated by the presence of tubercles. As the disease subsides, the expec- toration gradually becomes opaque and bron- chial. In some cases the expectoration is dif- fluent, watery, and of a dark color resembling prune or liquorice juice. This is always a se- rious symptom. The pulse is most common- ly frequent, full, and strong ; the skin is hot ; during the height of the disease the face is often deeply flushed, sometimes almost livid. The pathognomonic physical sign of the first stage of pneumonia is the crepitant rhonchus ; this is fine, dry, equal, and heard chiefly at the end of the inspiration. To distinguish it fully it is often necessary to make the patient cough. In a short time the crepitant rhon- chus is replaced by bronchial respiration ; the breathing is loud, blowing, and tubular, and when the patient speaks the voice has the dif- fused resonance called bronchophony. At the limits of the bronchial respiration, while the inflammation is extending, the crepitant rhon- chus is still heard. As bronchial respiration replaces fine crepitation, percussion becomes dull over the affected portion of the lung ; at the same time the vibratory thrill felt by the hand placed upon the chest when the patient speaks becomes more marked. When pneu- monia is central and the inflamed part of the organ is separated from the parietes by healthy lung tissue, both percussion and aus- cultation may give negative results. When the attack of pneumonia results in recovery, as the general symptoms diminish in intensity and the expectoration becomes white or grayish, the bronchial respiration becomes less strong- ly marked, and over the parts last attacked a coarser and moister crepitation recurs ; this is the redux crepitant rhonchus. With the return of the crepitant rhonchus the percus- sion note becomes clearer, until gradually the lung recovers its former condition. When on the other hand the attack is fatal, the general symptoms, with the exception of pain, persist, and are aggravated ; the expectoration becomes of a dirty gray color, striated, and finally per- haps wholly purulent ; the complexion grows pale, yellowish, and earthy looking; the skin is covered with a viscid sweat, and death is preceded by the tracheal rhonchus. In gen- eral the intelligence remains unimpaired to the last. In rare instances abscesses are formed in the lungs as a consequence of pneumonia. The duration of the disease is rarely less than 7 or more than 20 days. Very fatal in young infants and in old people, it is attended with but little danger between the ages of 6 and 50, when uncomplicated and occurring in pa- tients of good constitution. When pneumonia is double, when it is complicated with heart disease, with albuminuria, or with delirium tremens, when it occurs in constitutions de- teriorated by fatigue, privations, or excess, its gravity is very greatly increased. It some- times occurs as an epidemic, and is then severer than when it is sporadic. In strong, healthy, young adults, a single full bleeding will often relieve the breathing, remove the pain, and diminish the force and frequency of the pulse ; in other cases, where the pain in the side is severe, it is best to have recourse to cupping glasses. Afterward small doses of tartrate of antimony combined with morphia may be given every two or three hours. The patient should be kept in bed, the chest should be covered with an oiled silk jacket, and the diet should be bland but nutritious. Where patients are feeble, broken down, or advanced in years, general bloodletting is inadmissible, and even antimony must be used with great caution. A nutritious diet, and the administration of car- bonate of ammonia, and frequently of stimu- lants, form in such cases the appropriate treat- ment. Chronic pneumonia, except as an at- tendant upon tubercle or cancer, is exceed- ingly rare. In it the lung becomes dry, gray, reddish, or black, indurated, and impermeable to air. It may occur as a primary disease,
