1868 The Lancet  
ASSISTANT-PHYSICIAN TO THE CHILDREN'S HOSPITAL, ETC. LECTURE III. MR. PRESIDENT AND GENTLEME}r, -Our programme this evening includes two diseases of the lungs, pneumonia and pleurisy, which will illustrate quite as forcibly as any that we have yet taken up the need for considering the conditions of childhood as affecting morbid process. As regards the true or lobar pneumonia of children, I have observed that gentlemen who attend our practice in Great Ormond-street after having become familiar
more » ... g become familiar with the diseases of grown-up people at other hospitals, appear to pass through two phases of belief before they appreciate the characters of this disease. They come prepared to recognise it by its indicia in the adult, and they find multitudes of children suffering from cough, rapid breathing, fever, and some physical signs of consolidation; and they regard pneumonia as being a very common and a very fatal disease. Presently they come to see post-mortems of these cases, and they meet with-not the hepatisation of a lobe that they expect, but-the evidence of bronchitis with collapse, and of the further changes in collapsed lobules that I described in my last lecture as constituting lobular pneumonia. And, seeing in the dead-house nothing but this state of lung, and having constantly shown to them the significance of the symptoms and physical signs of which I spoke, they pass to the next stage of belief, and are disposed to ignore altogether the existence of true lobar pneumonia in early life. In this they are wrong; yet they are much more advanced on the way to be right than they were at first. After a time they learn to recognise the existence of a disease of primary character that has nothing to do with bronchitis, but is wholly comparable with the ordinary pneumonic consolidation of adults; and soon they see the extreme practical importance of the experience they have gained. Genuine lobar pneumonia in children begins almost always in the same acute fashion as the disease of after-life. Occasionally-and this too may sometimes be seen in older persons —a general ailing or a slight catarrh ushers in the more marked symptoms, but commonly the prodromata are few or none. Rigors of more or less severity, often replaced in younger children by convulsions, are generally the first sign; and along with them, vomiting and headache are observed, as well as the more local signs of short breath, pain in the chest, and dry hacking cough. This stage is followed in a few hours by a very characteristic condition of acute pyrexia. The child lies quietly on its back, with red cheeks and glistening eyes, its pain being indicated by the expression of its face at each act of coughing. Its breathing is quick and superficial, its nostrils moving strongly with inspiration. But neither this symptom nor the action of the muscles of the neck expresses an amount of dyspnoea so excessive as in broncho-pneumonia, in which also the paleness of the skin, the lividity of the lips, the restlessness and anxiety of countenance, give quite a different aspect. In the course of the first or on the second day the fever increases to a maximum, and thenceforth remains pretty steady in amount, with only a trivial remission in the early hours of the morning. The temperature reaches 104° F., or even a higher point, and the pulse is very frequent and full. Other pyrexial symptoms are, injected conjunctive, red tongue, loss of appetite, constipation, and scanty high-coloured urine. On the second or third day, in the usual case of hepatisation of a lower lobe, the physical signs of the disease may be established. Dulness on percussion, with increased vocal fremitus (or rather fremitus from cry) over the affected lobe, and bronchial respiration and bronchophony, are found. The early period at which these signs are noted after the commencement of illness is a distinction, it will be observed, from catar-rhal pneumonia. As the disease is reaching its height, we may sometimes find, but more usually we fail to detect, some fine crepitation. The cough remains, but loses its painful quality; the expectoration, if it be presented, as often it may be after vomiting, has the rusty or apricot tints that characterise pneumonia of the adult. In this condition the child continues, with little or no change, until suddenly, at a time averaging a week from the onset, the state of matters undergoes complete change. The flush on the cheek loses its vivid redness, the skin breaks out everywhere into a profuse sweat, the breathing becomes less rapid, and the child commonly falls into a long quiet sleep. When he wakes he is dull and immovable, takes no notice or stares in a vacant, placid way; his bodily powers, that have been taxed to resist the disease, now that the end of it has come, insist on rest. It is found that the temperature, maintained till now five or six degrees above the normal, has sunk to, or even below, the standard of health. The frequency of pulse and respiration is also reduced. The manner in which the disease takes its departure is to an inexpert eye sometimes suggestive of anything but amendment. The prostration and apathy are so intense, and the pallor and pinched face are so peculiar, that friends are apt to take them as foreboding an imminent dissolution. But with knowledge of the disease, the evidences of remission of fever and of commencing resolution of the local state, enable the practitioner to put the true interpretation on these phenomena, and to assure the parents that in a few days their child will be well. The physical signs do not disappear with the critical change of symptoms. The bronchial breathing and bronchophonic resonance do indeed become considerably less ; but the respiratory murmur remains indistinct, and the percussion dulness over the affected lobe remains. And now muco-crepitation, of the sort we call redux in the adult, appears, this being very commonly the first time that any crepitation has existed. Corresponding with this physical sign, the cough gets looser, and running from the nose also gives evidence of increased mucous secretion. For a week after the resolution of the disease has begun, some physical evidence of it will be found in the chest ; but this does not prevent a very rapid recoverymuch more rapid than in grown persons. The child regains spirits and strength, and in a few days there seems little the matter with him but emaciation and incapacity for sustained play or exertion. Pneumonia affecting more than one lobe, or affecting the upper lobe of the lung, has commonly a rather more slow course than is here described as the type. Resolution is postponed until the second week, sometimes even to the end of it. When two lobes are affected, the suddenness of amendment is less marked, the pulse and temperature fall by several successive steps, and the sweats are suspended for a while to break out again in a few hours ; and thus the commencement of convalescence is postponed for some twenty-four to thirty-six hours. When the upper lobe suffers, the course of the disease may be altogether similar to its ordinary progress elsewhere; but more commonly it runs a very slow course, the inflammatory products appearing to be much more slowly deposited, and with more difficulty absorbed. The febrile state is prolonged, and has not a very definite or rapid cessation. The few cases of lobar pneumonia that end fatally have a sort of remission like the rest about the end of the first week; but it is incomplete, and next day the fever is as high as ever. Death either occurs in the second week, after the supervention of acute pleurisy, meningitis, or some other complication; or else, what is still less common, the chilri wastes, chronic consolidation remains, a softening process goes on in the lobe, and death takes place after some weeks of illness. In fatal cases, the temperature and pulse are maintained to the end at the high point they reached in the first week of illness, or may even mount up higher than this. This lobar pneumonia, altogether analogous to the ordinary inflammation of the lung in the adult, is one of the least fatal of the group of diseases with which these lectures are cencerned. It will be in your memory that for lobular pneumonia of the secondary kind the most favourable estimate confessed to about one death in three cases. In lobar pneumonia the deaths are certainly not more than one in twenty. Nothing more need be said to lend interest to the next part of our inquiry-How are we to recognise the disease from the other more fatal conditions that simulate it ? A disorder that begins by vomiting and convulsions, with fever, evidently presents many points of similarity to meningitis ; and it is indeed often necessary to defer until a second or third visit a positive judgment as to the significance of these symptoms. Cough and dyspncea, with the commence-
doi:10.1016/s0140-6736(02)32070-1 fatcat:va4st3lbsfddnnyqkxrk6uptgy