ACUTE LOBAR PNEUMONIA IN CHILDREN. By CHARLES W. TOWNSEND, M.D., Boston. Bead before the Suffolk District (Massachusetts) Medical Society, October 27, 1888. [Reprinted from. Archives of Pediatrics, March and April, 1889. ] ACUTE LOBAR PNEUMONIA IN CHILDREN. Papers and statistics on pneumonia in children commonly include both lobar, otherwise known as croupous or fibrinous pneumonia, and broncho-pneumonia, also called lobular or catarrhal pneumonia, two diseases entirely distinct in their etiology, course, and prognosis, but both having the seat of their lesions in the lungs. Lobar pneumonia, it seems to me, is best considered as an acute specific disease, while broncho-pneumonia is always sec- ondary to bronchitis, and is due to an extension of the inflam- matory process. Death certificates are generally signed pneu- monia, without further specification, a fact which very much diminishes the value of statistics made from their returns. Thus, in 1887, the Board of Health of Boston reports 795 deaths from pneumonia, 25 from broncho-pneumonia, and 7 from pleuro-pneumonia; but it is, of course, evident that many cases of broncho-pneumonia are included among the 795 cases of pneumonia. The value of these records would be much increased if physicians would exercise more care, and a list of names of diseases, published from time to time by boards of health to conform to scientific nomenclature, and distributed among physicians, would aid in securing more exactness and uniformity. It is generally considered, and it is taught in many of the text-books, that in young children the form of pneumonia is usually lobular, and that true lobar pneumonia occurs only in older children and adults. Thus Vogel* says, "Lobar pneu- monia, with the exception of the metastato-pysemic form, * "Diseases of Children," 1885. 2 Townsend : Acute Lobar Pneumonia in Children. occurring in lying-in and foundling hospitals, is remarkably rare in the nursling." And J. Lewis Smith* says, " In chil- dren over the age of three years pneumonitis differs but little in form or phenomena from that of the adult. ... In those under the age of three years it is, on the other hand, as a rule, a secondary affection, and limited to a part of a lobe." From both of these latter views I beg to differ; for, in the first place, lobar pneumonia is far from uncommon under the age of three years; and, secondly, the symptoms in children, even up to the age of eight or ten years, are often very different from those of the adult suffering from this disease. Henoch f says that even in the first two years of life pneumonia is by no means rare, and Holt J speaks of " its great frequency in early life." Loomis § says " that from a number of statistical papers it ap- pears that croupous pneumonia is five times more frequent during the first two years of life than in the succeeding eighteen." Moellmann, || of 944 cases of croupous pneumonia observed by him, found 353, or 37 per cent., in children under ten years of age. I have records of 42 cases of acute lobar pneumonia in chil- dren under ten years of age attended by myself, all but two occurring in a dispensary district, and therefore among the poorer classes. Of this number 2 died and 40 recovered. Of the two that died, one, a male three months old, a patient at the Sea-Shore Home, was debilitated, having a large super- ficial abscess of the chest. He died on the third day of the disease, and the autopsy showed red hepatization of both lower lobes. The second case, a girl one year old, feeble and rachitic, died in thirty-six hours with double pneumonia. Another case, on which I made the autopsy, but which I did not see during life, a patient of Dr. Edward Reynolds, to whose kindness in allowing me to report the case I am indebted, was a male infant eight days old, who died after an illness of thirty-six hours. The post-mortem showed red hepatization of the entire left * " Diseases of Children," 5th ed., 1881, p. 573. f Henoch, Kinderkrankh., 1883. J Holt, N. Y. Med. Rec., April 7, 1888, p. 385. § Pepper's " Syst. of Med.," vol. iii. p. 314. || Berlin Klin.Woch., 1887, p. 754. Townsend : Acute Lobar Pneumonia in Children. 3 lower lobe, which was enormously distended and completely solidified. Of the 42 cases, 5 were under one year of age (one of these being under six months), 5 were between one and two years, and 7 between two and three years, making a total of 17, or nearly one-half of the whole number, during the first two years of life; 2 were three years old, 3 were four, 2 were five, 5 were six, and 4 were seven years old ; from eight to ten years inclusive there were three cases for each year; 26 were males, 16 females. The site of the pulmonary lesion was as follows in order of frequency: left base, 15 cases; right base, 13 ; right apex, 7 ; both lungs, 4; left apex, 3. Before going further it will be interesting to compare these statistics with those to be obtained from the Collective Investi- gation Record on pneumonia, published in 1884, of 1066 cases of lobar pneumonia collected from the private practice of nu- merous English physicians. Of these cases, 170 were in chil- dren under ten years of age, 157 of whom recovered and 13 died. Of the 13 fatal cases, 8 involved portions of both lungs, of which 1 occurred at the same time with, and another im- mediately followed, an attack of measles, and 1 was compli- cated with double empyema; 3 were under one year, 3 were one year old, 1 three years, and 1 four years; the remaining 5 were between six and eight years of age. Of the 170 cases, 25 were under three years of age, 71 between three and six years, and 72 between seven and ten years. The comparatively small number of cases reported during infancy is due, I think, not to its infrequency at that age, but to the fact that pneu- monia in infants is frequently overlooked. The portions of the lung affected in these 170 cases, in the order of their frequency, was found to be as follows : left base, 48 cases; right base, 41; both lungs, 39; right apex, 16; left lung whole, 10 ; left apex, 8 ; right lung whole, 3. This order corresponds with that of my cases with the exception of the large proportion of cases of double pneu- monia, which makes me suspect that some of these were in reality broncho-pneumonia. Although acute lobar pneumonia in infants and young chil- dren is frequently not recognized, and the child is thought to 4 Townsend : Acute Lobar Pneumonia in Children. have a febricula, or meningitis, or possibly only a tonsillitis, the physician finding redness and slight swelling of the fauces, and knowing that a slight throat-trouble in a child will often cause a high temperature, yet it seems to me there is no disease which in most cases is so distinctly marked, if we can -watch the case from beginning to end, can have a complete tempera- ture record, and are not forced by an importunate family to make a diagnosis at the first visit. In the adult there are five cardinal symptoms which are nearly always present,-namely, sudden onset, marked by a rigor, or, at least, chilly sensation, pain on the affected side, generally in the region of the nipple, cough, characteristic viscid, rusty, or bloody expectoration, and, lastly, a continued high temperature. Those who look for this collection of symptoms in infants and young children, in order to make a diagnosis, will generally be disappointed. The sudden onset is characteristic of pneumonia in the child as well as in the adult; but in the former the nervous disturbance, instead of taking the form of a chill, appears most frequently in the form of vomiting, and occasionally as a convulsion. Initial vomiting occurred in 31 of my 42 cases, convulsions in 3; chilly sensations were noticed in 9, and a true rigor in only 3,-2 boys of ten years, and 1 of seven years. It is interesting to note here that in one case, a boy of two and a half years, where convulsions occurred, there were also slight trembling movements, which the parents thought resembled a chill. In the British collective cases, vomiting or "sickness" at the onset occurred in 45, convulsions in 4, rigor in 79, and chilli- ness in 4. The large number reported to have had a rigor is rather surprising, and also that of these, 22 were under six years of age, 9 being five years old, 1 four, 3 three, as many as 7 only two years, and 2 one year old. It is generally sup- posed that rigors at these ages are very rare, and my observa- tions confirm this. Holt* states he has not seen a rigor in a child under seven years of age. The second symptom, of pain localized in the affected side, so constant in adults, is very often wanting in children. That * N. Y. Med. Rec., 1885, xxvii. p. 174. Townsend : Acute Lobar Pneumonia in Children. 5 pain is present in pneumonia in children is evident from their fretfulness and look of suffering ; but even if the child is old enough to talk and understand our question relative to the seat of pain, its answer is often misleading, as it refers the pain to some other region. That the pain is in reality in the same place as in the adult is, of course, probable, but the difficulty is that the power of localizing sensations seems to be deficient in the child. In 14 of my cases pain, although evidently present, could not be localized. These cases were all under two and a half years of age. In 25 cases the site of pain is mentioned, in 7 of which the pain was referred to the affected side alone, all of these children being six years old or older. In 8 the pain was referred to the abdomen alone, and all were under seven years of age. In 3 others-2 ten years old and 1 four years old-the abdomen was the chief seat of the pain, but they also complained at times of pain in the affected side; 1, eight years old, besides abdominal pain, which was chiefly epigastric, complained also of pain in the axilla of the affected side. A boy of seven complained at first of epi- gastric pain, later of pain in the side. A boy of nine per- sisted in complaining of pain all over his body, but most in- tense in the epigastrium ; and 2 infants, between two and three years old, localized the pain in the substernal and epi- gastric regions. Thus, 16 out of the 25 cases complained more or less of abdominal pain. A large number complained of headache, and 2, aged respectively three and five years, said the pain was in the head and nowhere else. How different this is from what occurs in the adult, where pain in the affected side, often in a small space in the region of the nipple, is a symptom rarely absent! The symptom of cough was present at some time in all of my cases, being generally a slight, moderately frequent, hack- ing one, with a rather characteristic loose sound, and is so de- scribed in my notes in 22 cases. In 7 other cases it was at times very frequent, becoming an incessant slight hacking, very distressing to the patient. In 4 cases the cough was very infrequent, in 1 of which, a boy of ten years, coughing occurred scarcely more than a dozen times during the whole course of the disease, and this would not have been noticed if I 6 Townsend : Acute Lobar Pneumonia in Children. had not directed the parents' attention to it. In 6 cases no cough at all was noticed at the onset, in 3 of these that symptom ap- pearing on the third day, in 1 on the second day, and in 2 not till the fourth day. The cough, as a rule, became more frequent as the termination of the disease was approached, and generally continued for two or three days after the fall of temperature. The viscid, rusty expectoration so characteristic of pneumonia in the adult did not occur in my cases. Indeed, expectoration rarely occurs in children under eight years of age, except in whooping-cough, where, owing to the violence of the paroxysms and the large quantity of the secretions, some is not infre- quently allowed to run out of the mouth or is actually expec- torated, and children with chronic lung diseases or pharyngeal catarrh sometimes learn at quite an early age to expectorate. In pneumonia the mucus, if it be coughed up into the mouth, is generally swallowed unconsciously, the child not knowing enough to spit it out. Of all my cases, expectoration occurred in only three patients, aged respectively seven, eight, and nine years, and in none of these cases was the mucus rusty or tinged with blood. The last symptom mentioned in the list of adult symptoms- namely, the continued high temperature-was a characteristic feature of these cases, and one which is of much importance in making the diagnosis. With the exception of a few of the earlier dispensary cases, where my temperature records are imperfect, I was so fortunate as to obtain a complete morning and evening chart of the cases, through the valuable assistance of the district nurse. Of 37 cases, 29 ended by crisis and 8 by lysis, the proportion of those ending by crisis being con- siderably greater than is usually found in statistics of cases in adults, and is indeed greater than in the British cases before referred to. Here, in 154 cases in children, 87 ended by crisis and 67 by lysis, and it is possible that some cases of broncho- pneumonia included in the list may account for this difference. Henoch,* of 45 cases, found 37 to end by crisis and 8 by lysis. The critical fall of temperature in my cases occurred in 2 on the third day, in 3 on the fifth day, in 5 on the sixth, in 11 on * Loc. cit., p. 352. Townsend : Acute Lobar Pneumonia in Children. 7 the seventh,-which was, therefore, the favorite day,-in 3 on the eighth, in 1 each on the ninth, twelfth, and fourteenth days, and in 2 on the thirteenth day. The temperature reached normal by lysis in 1 each on the eighth, tenth, fourteenth, and fifteenth days, and in 2 on the eleventh and also the twenty- first days. In the British cases the favorite day for the crisis was also the seventh, the drop of temperature occurring in 18 on this day. In 13 cases crisis occurred on the sixth day, and in the same number on the eighth day. In 11 the crisis occurred on the fourth day, in 8 on the fifth and also the ninth day, in 5 on the third day, in 4 on the tenth day, in 3 on the eleventh day, and in 1 each on the second, twelfth, thirteenth, fourteenth, and twenty-sixth days. An examination of my temperature charts shows the con- tinued high temperature, generally about 104°, with little or no remissions. The highest temperature reached was 106.2° in one instance. Only five failed to reach 104°, and all but one of these were seen for the first time only the day before the crisis, and it is possible the temperature may have been higher previously. None failed to reach 103°. Several tem- peratures after reaching normal by crisis rebounded once or twice nearly as high as they were before. In many the tem- perature was subnormal for a day or two after the crisis. The change in the spirits of the little child on the fall of tempera- ture was often very sudden, and it would be found sitting up in its crib laughing and playing with its toys, while on the day before it had been in a state of fretfulness and suffering. The cough meanwhile would continue as before, or even be more frequent for a day or two, and the physical signs in some cases were to be found unchanged. An examination of my records when this was determined, shows that the physical signs disappeared on the same day that the temperature reached normal in 5, on the day following in 5, two days following in 2, three days in 3, four days in 1, five days in 1, nine days in 1, and in 1 case resolution was delayed for sixty-four days or two months after the fever, which lasted twenty-one days, had ceased. Goodhart * says of these prolonged cases: " Acute * "Diseases of Children." Revised by Starr, 1885. 8 Townsend : Acute Lobar Pneumonia in Children. pneumonia, running a rather more chronic course than we think it should do, arouses our fears only to dispel them." Henoch * speaks of these cases under the head of chronic pneumonia, and relates a case almost identical with mine, of a child six years old where fibrinous consolidation of the right lower lobe lasted for two months, the initial fever lasting fourteen days; later a slight rise of temperature occurred at times. He considers this prolonged course more common in children than in adults. Prolonged cases of broncho-pneu- monia with consolidation of an entire lobe are also not un- common, and are to be distinguished by their history from cases of the true lobar form. In these prolonged cases young children frequently learn to expectorate, and the sputa may be streaked with blood. Phthisis is, of course, always to be feared, and without the diagnostic tubercle-bacilli we can only wait for time to show the nature of the disease. Remembering, therefore, the possibility of chronic pneumonia, whether' fibri- nous or catarrhal, in children, our diagnosis and prognosis in chronic cases of lung consolidation should be guarded and not necessarily unfavorable. In one of my cases the physical signs disappeared twenty- four hours before the final crisis. Henoch relates a similar case, and quotes Sidlo f and Grisolle J as saying that this clearing up of the physical signs before the fall of tempera- ture occurs in a certain proportion of the cases. Physical signs are, on the other hand, often tardy in show- ing themselves in children, owing to the fact that the lesion may at first be small and centrally situated, coming to the surface so as to be recognized only at a later stage. In 25 of my cases the physical signs were present at the first visit, which was on or after the second day. In 6 of the remaining 16 cases the signs did not appear till the third day, in 6 till the fourth day, in 3 till the fifth day, and in 1 each not till the sixth and seventh days. Careful thoracic examinations were made daily until the signs were found in all cases. It some- * Loc. cit., p. 358. f Deutsches Archiv f. Klin. Med., xiv. p. 348. J " Traite de la Pneumonie," p. 307. Townsend : Acute Lobar Pneumonia in Children. 9 times happens that the respiratory sounds are only slightly broncho-vesicular and free from rAJes while the child is breathing quietly, but on deep inspiration, caused, for example, by the child's crying, respiration becomes plainly bronchial and rales are heard in abundance. This was noticed particu- larly during the days when the signs were clearing up. The true crepitant rale is not so often heard as in the pneu- monia of the adult. Lewis Smith* says that in the majority of patients under three years of age the crepitant rale is not observed. For local fremitus and resonance crying must be depended on, if the child will not or cannot speak. The large size of the liver in infants should be remembered. A tight belly-band or a violent expiration may force the liver up so that dulness is obtained nearly as high as the spine of the scapula on the right side. Charts I. and II.f are inserted as typical examples. Chart III., a boy two years old, who was seen from the first day, began with a consolidation of the right base, the temperature running from 103° to 105° and dropping suddenly to 100.4° on the eighth day. It went up again that night and a lesion of the left base showed itself. On the seventh day of this attack the temperature dropped to 97.8°, but again rose the following day, and the right apex was then found to be involved. On the eleventh day of this third attack the temperature fell to normal, where it remained, and the child regained perfect health. One case (Chart IV.), a boy of seven years, was seen on the second day after the initial vomiting, and was found to have a temperature of 104.6° and no signs in the lungs; the next day the temperature fell to 100°, between which point and 98.5° it remained till the ninth day, when it remained normal. Signs, of consolidation of the left base were found only after the fall of the temperature to 100°, and these * Loc. cit., p. 583. f Note the " inversion of the thermic curve" in this case,-i.e., a higher morning than evening temperature. This is the only one of my cases where it was observed, but it has been noticed occasionally by others in the pneumonia of children. Vide Coriveaud, " Sur 1'inversion de la courbe thermique dans certaines pneumonies infantiles," J. de Med. de Bordeaux, 1885, xv. 391; also Keating, Archives of Pediatrics, iii. 76. 10 Townsend : Acute Lobar Pneumonia in Children. CHART I. CHART II. Townsend : Acute. Lobar Pneumonia in Children. 11 CHART III. 12 Townsend : Acute Lobar Pneumonia in Children. CHART IV. Townsend : Acute Lobar Pneumonia in Children. 13 CHART V. signs were very unmistakable. In a child of two and a half years (Chart V.), a sudden attack of vomiting was followed by fever, which lasted five days, without the appearance of physical signs; on the fifth day the temperature was normal, the child feeling very well, and I supposed that I had had to deal with a bronchitis with considerable fever or a case of abortive pneumonia. The next day, however, the tem- perature rose to 105°, where it remained for five days, and complete consolidation of the left base was found. It is possible that in the first attack there had been some small central lesion of another lobe, which could not be detected by physical examination, or which I had overlooked. It seems very probable, therefore, that some of the unexplained febricu- las of children are in reality due to acute lobar pneumonia. In my note-books I have 32 cases in children diagnosticated as febriculas. Of these, 16 were of a mild typhoid type, of brief duration ; some of them undoubtedly should have been called typhoid fever. In 2 others urticaria was a prominent symptom. In 4 nervous symptoms with headache were marked. In 1 case the temperature remained up for a day, following a 14 Townsend : Acute Lobar Pneumonia in Children. convulsion. Three cases were thought to be caused by a short acute bronchitis, dilatation of the alee nasi and expiratory moan being noted in 1, with pain in the epigastrium. In this case the temperature fell from 103° in the morning to 100° in the afternoon of the first day of the attack, and was normal on the next day. This case certainly strongly suggests abortive pneumonia. Five cases began suddenly with vomiting, had a slight cough in all but 1 case, with a temperature reaching 105° in 1 case, 103° in the others, and ending by crisis on the sixth day in 3, on the fifth in 1, the remaining case ending by lysis on the sixth day. In one of the cases herpes labialis also occurred. In none of the cases could physical signs in the lungs be detected, and although, for lack of positive proof, I have not included them in my list of cases of pneumonia analyzed above, still I am inclined to think that some of them were true cases of lobar pneumonia. Of course I may have over- looked definite signs, or the lesion may have been so centrally situated and covered by healthy lung-tissue that signs could not be obtained. It is interesting to note that in the same room with the last case spoken of above, a child of five years, without definite symptoms or signs, had a temperature reach- ing 103.8°, lasting two days. The infectious nature of pneu- monia and the occurrence of several cases of the disease in the same house is a subject of great interest, which I will not discuss now. D'Espine* speaks especially of these cases of pneumonia where the physical signs are late, obscure, or lacking. He classes them as central or congestive cases, and says they are frequent in children, and generally not recognized. The abor- tive form, where the fever lasts only two or three days, he also considers of frequent occurrence. Cadetf divides pneumonia into, first, cases with physical signs from the start; second, cases with tardy physical signs; third, cases without any physical signs, the lesion remaining central. My cases would certainly fit into this classification very well. Dilatation of the alse nasi and an expiratory moan or grunt * Rev. de Med., February, 1888. f Vide Ashby, Med. Times and Gaz., March 25, 1882. Townsend : Acute Lobar Pneumonia in Children. 15 are often mentioned as characteristic of pneumonia in chil- dren, and these symptoms may occur in children both in broncho and lobar pneumonia. Occasionally, when the respi- rations are increased in rapidity from any cause, as in ab- dominal colic, the nostrils dilate and the expiratory moan is heard, and I have noticed these symptoms not infrequently in these cases, and also in simple bronchitis, especially at times of nervous excitement. They are, therefore, not to be de- pended on in making the diagnosis. In 11 of my cases no mention is made in my notes of these symptoms; in 8 they were stated not to occur, all but 1, who was five years old, being in children seven years old or older. In 23 one or both symptoms occurred ; thus in 12 the expiratory moan and dilatation of the nostrils occurred and in 11 others only the dilatation of the nostrils was observed. Of those who moaned all were under three years of age except 3, whose ages were four and a half, six, and seven years. Of those whose nostrils alone dilated, 1 was nine years old, 1 eight, 1 seven, 1 six, and 1 five, the others being under that age. It is an interesting fact that children with acute pneumonia will breathe quietly but rapidly at times, without either dila- tation of the nostrils or moaning, but any nervous excite- ment increases the frequency of the respiration and brings these On; and of the two, dilatation of the nostrils is more easily induced than the expiratory moan. In the case of a boy of six years it was several times noticed that in his sleep his respirations would sometimes change suddenly from forty to sixty in a minute without any apparent cause, the alae nasi dilating with this change in the rate, and at times the expira- tory moan would occur. An examination of the charts shows that in all the respira- tion reached the rate of 40 in a minute at some time during the progress of the disease, and that the highest rate reached was 85. In only two cases did the pulse fail to reach 130, and in one case a pulse of 180 is recorded. The follow- ing table is a result of an analysis of the charts on these points: 16 Townsend : Acute Lobar Pneumonia in Children. Highest No. of Pulse-Rate. Cases. 180 1 160 6 150 5 140 4 130 10 120 1 110 1 Highest Respi- No. of ration-Rate. Cases. 85 1 80 1 75 1 65 4 60 6 55 4 50 2 45 2 40 8 A peculiar character is given to the lobar pneumonia of children by reason of the highly-strung nervous organization of these little patients and the frequency of nervous disturb- ances. So much is this the case that the term cerebral pneu- monia is frequently used to describe cases of the disease in children. As has before been remarked, convulsions may take the place of the initial chill, and vomiting, as we have seen, is a frequent cerebral symptom. Beginning with a convulsion and going on to delirium or semi-stupor, with pain in the head and abdomen, with little or no cough, no expectoration, and no chill, the physician is often put off the track, and imagines he has a meningitis to deal with. In 11 of my cases delirium was present, in 3 of which-children aged re- spectively six, eight, and ten years-it was violent; in the others it -was mild. In 8 of these cases the pneumonia was basal, in 3 the lesion was situated at the apex. Seven other children with the lesion at the apex had no special nervous symptoms, a fact which is at variance with the common idea that cerebral symptoms are more apt to accompany an apex lesion. At times a state of semi-stupor may occur without pre- ceding convulsions. In a girl ten years of age the delirium began on the first day and continued, often noisy and violent, with occasional short rational intermissions, till the fifth day, when, at 4.30 P.M., she began to perspire freely, and became suddenly per- fectly rational; her temperature was then 103°,-it had been 102° in the morning,-and was still 103° at 6 p.m. She had a good night, sleeping quietly, and her temperature was found to be 98° in the morning. The sudden return to reason here preceded by several hours the drop in temperature. The con- Townsend : Acute Lobar Pneumonia in Children. 17 solidation in the lung continued twenty-four hours after the fall in temperature. The patient's decubitus at times during the delirium was on her face and knees, spoken of as the decu- bitus en chien de fusil. This case illustrates well the difficulty of making an early diagnosis. She was seen first on the second day of the illness, which began suddenly with vomit- ing and chilly sensations and pain in the abdomen, which was at times very severe; later she occasionally complained of pain in the right side of the chest. No cough had occurred at the time of my first visit. Nothing abnormal was found on ex- amination of the chest, and the only significant sign was an increase of the respirations to 40, with the pulse at 132. This increase in the proportion of the respiratory- to the pulse-rate is, of course, a most valuable diagnostic sign. I put in my note-book that it was a question of acute pneu- monia, scarlet fever with delayed eruption, simple febricula,- meaning by that a reflex rise of temperature from some un- known nervous disturbance,-or meningitis. Typhoid fever in children sometimes begins quite acutely, and this should also be considered. Cough did not occur in this case till the third day, was slight throughout the sickness, and was never accompanied by expectoration. A careful examination of the chest each day failed to show signs of consolidation till the fourth day of the disease, when the right apex showed slight signs. These became very marked on the .fifth day,-namely, dulnessjloud bronchial respiration, bronchophony, and subcrepi- tant rales, at the right apex down to the fourth rib behind. Herpes occurred in only three of my cases, of the lips alone in two, involving also the nose very extensively in the third case. Although hypersemia of the tonsils and fauces was seen in some of my cases, none of them presented an erythema of the skin spoken of by Henoch,* or the measles-like rash de- scribed by D'Espine f and Cadet. Neither did I observe any forms described by Henoch as pneumonia migrans, when the seat of the lesion wanders in the course of five or six days from the lower lobe behind around the side and up to the apex. Slight diarrhoea occurred in three or four of the cases. One * Loc. cit., p. 349. f Loc. cit. 18 Townsend: Acute Lobar Pneumonia in Children. case of pneumonia occurred during the course of typhoid fever, another during an attack of measles, and two others during the course of whooping-cough. In these last two dis- eases we are more apt to have broncho-pneumonia from an extension of the existing bronchitis. The differential diagnosis from broncho-pneumonia can generally be made from the history. In the lobar form the sudden onset occurs, while in broncho-pneumonia there is the history of a preceding bronchitis, from which the pneumonia was more or less gradually developed. In some cases, it is true, the diagnosis is difficult, or almost impossible, when the history is imperfect, or where, as sometimes happens, a true lobar pneumonia arises during an attack of bronchial catarrh. In both diseases we may find consolidation of an entire lobe, with evidence of bronchitis elsewhere, although in broncho- pneumonia the consolidation is more apt to be in smaller patches,-lobular,-and is generally bilateral. The symptoms of rapid respiration, moaning, dilating nostrils, and cough are present in both diseases. The temperature in lobar pneumo- nia is, however, generally more continuously high, while in broncho-pneumonia it is, as a rule, not so high, runs a more irregular and prolonged course, and never ends by crisis. The consolidation in the latter disease is apt to extend gradu- ally and to vary in amount from day to day, and a fatal ending is not uncommon. Henoch * says that " between the characteristic cases of fibrinous, lobar forms on the one side, and broncho-pneumonia on the other, lies an intermediate form, which cannot be de- fined with certainty," and he thinks it impossible to distinguish both forms of lung inflammation existing in the same case during life. The following case illustrates very well the diffi- culty. A little girl of two years, after a slight bronchitis of a week's duration, suddenly grew worse, vomiting, and having a high fever and rapid pulse, and, three days later, when first seen by me, a measles rash appeared. At this time her tem- perature was 104° and respiration 72, while nothing but a few scattered rales were to be found in the lungs. Another * Loe. cit., p. 347. Townsend : Acute Lobar Pneumonia in Children. 19 child, in the same house, had measles ten days later, confirm- ing the first diagnosis. The next day dulness and bronchial respiration appeared at the right base, the signs of consolida- tion spreading gradually over the whole right back, and, ten days later, similar signs appeared in the left back. Two or three days before death, which occurred on the nineteenth day, both lungs were filled with rales, and both backs were dull over the lower halves. The temperature ran an irregular course, coming down to normal once on the eighth day, and afterwards oscillating between 101° and 103°. The compara- tively sudden onset suggests lobar pneumonia, but the pre- ceding bronchitis, the prolonged and irregular temperature, and the gradual extension of the trouble in the lungs are very characteristic of broncho-pneumonia. The onset of the measles adds an additional confusing element. The coexistence in the same patient of both lobar pneumonia and cerebro-spinal meningitis is not very rare during epidemics of the latter disease. Here we find, in addition to the symp- toms of pneumonia, persistent retraction of the head, arching of the fontanelle, severe headache, and frequently-recurring convulsions and coma. The respirations and pulse may be slowed, and may become irregular and intermittent, although this is not always the case. The prognosis in uncomplicated cases of acute lobar pneu- monia in children and infants, with the exception of those under two or three months old, is, I believe, always favorable, unless the patient is debilitated from some cause. Both of the fatal cases in my list were in but a poor condition to withstand an acute disease,-one a feeble, rachitic child, the other de- bilitated by a large superficial abscess, which had burrowed widely under the skin of the chest-walls. The case I saw only after death-the baby of eight days-gives rise to the question as to whether pneumonia is necessarily fatal at such an early age. Schuyler* says the prognosis in children, " including patients of one year, where the disease is uncomplicated and the patients are otherwise robust, is decidedly goodbut he adds that in the very young-the new-born-and in found- 20 Townsend : Acute Lobar Pneumonia in Children. lings the disease is very fatal. D'Espine* gives the case of a child of six weeks with acute pneumonia ending in recovery. There are a number of cases on record of children born with acute pneumonia begun in utero, all proving fatal. Grisollef reports one case and mentions three others observed by Billard. Another case is reported in the Lancet of November 6, 1886. D'Espine considers pneumonia in children essentially benign, and that it tends to get well unless harmful methods of treat- ment are employed. Of a considerable number of cases seen by him in fourteen years in Geneva, he has had only two fatal cases. Ashby J says " the prognosis with regard to acute pneu- monia in children, when uncomplicated, mostly points to a favorable termination. The percentage of deaths is small,- smaller, perhaps, than in any acute disease which attacks chil- dren*" And Henoch says that the prognosis in fibrinous pneu- monia, uncomplicated by diseases like nephritis, typhoid fever, or tuberculosis, is most favorable. The following table of cases of acute lobar pneumonia in children, collected from various sources, shows a mortality of 28 in 1138 cases, or only a little over two per cent.: Observer. No. of Cases. Deaths. 60 4 Meigs and Pepper || 66 2 Barthez 212 2 Holt** , 73 2 Pendleberry Hospital ff 234 3 Ziemssen J J 201 7 Cadet gg 70 0 AshMII 26 0 Juergensen 110 4 Henoch *** 44 2 Townsend 42 2 Total 1138 28 * Loc. cit. j- Loc. cit. J Med. Times and Gaz., March 25, 1882. g Deutsche Med. Wochenschrift, 1880, vi. 556. || "Diseases of Children," 7th ed., 1882. fl Brit. Med. Jour., December 24, 1864. ** New York Med. Rec., April 7, 1888, p. 385. ff Quoted by Holt, loc. cit. Xt Quoted by Juergensen, loc. cit. Quoted by Ashby, loc. cit. |||| Loc. cit. flfl Ziemssen's " Cyclop. Americ.," ed. 1875, vol. v. p. 138. *** Loc. cit. Townsend : Acute Lobar Pneumonia in Children. 21 I have not added the British collective cases to this list, believing that some of them are cases of broncho-pneumonia. Unfortunately, lobar and broncho-pneumonia are so frequently classed together that the idea prevails that pneumonia in chil- dren is a very serious and fatal disease. While this is true of broncho-pneumonia, it is, as we have seen, far from being the case with lobar pneumonia. Of this unnecessary confusion, a re- cent admirable paper by Holt * is an example. Here, under the head of prognosis, he states that there was a general mortality of twenty-two per cent, in his 173 cases; but, on looking back, we find that of these 173 cases 100 were broncho-pneumonia with 34 deaths, and 73 were lobar pneumonia with only 2 deaths. For treatment, considering the favorable tendency of the disease, all active debilitating measures should be avoided, and our attitude should be one of watchful expectancy. Dr. Minot,f in an article on the treatment of acute pneumonia, says, " I would plead for little children, who like nothing so well as to be left undisturbed by officious ministrations." Nourishment the child can take only in the liquid state, and milk in small quantities at frequent intervals is the best and most convenient form. At times the child persistently refuses all food and cries only for water. As the course of the disease is short, it is not necessary to systematically feed the patient, as in a long, debilitating disease like typhoid fever, and the child will generally take all the milk that is necessary. Where relapses occur, thus prolonging the illness, more atten- tion to the diet is required. Stimulants are rarely called for. Nine only of my cases received them, most of these being my earlier cases, when I thought it was more necessary. Attention to ventilation of the chamber is, of course, of great importance in a disease where the lungs are involved, and the inhalation of oxygen gas is undoubtedly of great value. Medicine of some sort all my patients received, but this was given, not so much for the patient, but as a placebo for the mother's mind. Carbonate of ammonia in small doses was given in twenty- * New York Med. Rec., April 7, 1888. f Boston Med. and Surg. Jour., ex. p. 169. 22 Townsend : Acute Lobar Pneumonia in Children. five cases, nitre and bromide of potash in six each. None of these drugs, it seemed to me, influenced the course of the dis- ease, and their administration was often rebelled against by the little patient. Antifebrin was used in four cases, in all reducing the tem- perature temporarily, with, in one case, a cessation of the delirium for four hours, but having no effect, beneficial or otherwise, on the general course of the disease. In one case where it was given two relapses occurred, but it is hardly fair to consider the drug responsible for these. D'Espine* puts antifebrin and anti pyrin among the harmful means of treat- ment for pneumonia in children, and considers them dangerous. Morphine in small doses was given in six or eight of the cases, and was decidedly beneficial in quieting the pain and restlessness. This drug, given occasionally and with judgment, seems to me of much value in this disease; but it is, fortu- nately, not needed in all cases. In the 212 cases treated by Barthezf in the Hospital St. Eugenie, with only two deaths, there was no treatment in one- half the cases, in a large number it was insignificant, and in one-sixth only was it active. Previous to this, when he had employed bleeding and other debilitating forms of treatment, one-seventh of the cases in his hospital practice had died. Of local applications, the old-fashioned plan of putting on a jacket poultice is to be avoided. It is heavy, making the already difficult breathing still more difficult, while our ob- ject is to make the patient as comfortable as possible; a small poultice over the seat of the pain is, however, decidedly bene- ficial, and, strange as it may seem, I found that a poultice over the abdomen, when the pain was seated there, frequently gave great relief, and procured a comfortable night's rest. As a rule, when the pain could not be localized, I had a poultice applied over the lower part of the chest in front and the upper part of the abdomen, with good results. The softness and moisture of a hot poultice seem to make it preferable to a hot-water bag. In a few cases a tight swathe to restrain the movements of the chest-wall seemed to be beneficial. * Loc. cit. f Loc. cit. Townsend : Acute Lobar Pneumonia in Children. 23 Knowing that pneumonia generally gets well of itself in children, and that it often runs a short or abortive course without treatment, one is inclined to smile at the cases re- ported as aborted or cured by means of drugs. To summarize: Acute lobar pneumonia in children is carefully to be distinguished from lobular or broncho-pneu- monia, from which it differs widely in etiology, course, and prognosis. Lobar pneumonia, although often unrecognized, is of frequent occurrence even in the youngest children. The cardinal symptoms found in the adult, of rigor, local- ized pain in the affected side, cough with bloody expectoration, and a continued high temperature, all may be obscured or lacking, with the exception of the high temperature which generally ends by crisis. The onset is sudden, with vomiting, and occasionally a con- vulsion, very rarely a rigor. Pain, if it can be localized, is frequently seated in the abdomen, or diffuse on the affected side. Cough is sometimes absent during the first two or three days. Expectoration in children under eight years of age is usually lacking. Cerebral symptoms are often marked. Dilatation of the nostril and moaning on expiration are frequently present, but also occur in other diseases. Physical signs are often tardy in revealing themselves. The prognosis is very favorable except in the new-born, unless the child be debilitated from some other reason. Active or debilitating treatment should be avoided, as the natural tendency of the disease is to recovery. ARCHIVES OF PEDIATRICS A MONTHLY JOURNAL DEVOTED TO THE DISEASES OF INFANCY AND CHILDHOOD. EDITED BY • WM. PERRY WATSON, A.M., M.D., Attending Physician to St. Francis's Hospital and to the Central Dispensary (Department of Pediatrics); Consulting Physician to St. Michael's Orphan Asylum, etc., Jersey City, N. J. THE ONEY MEDICAL JOURNAL IN THE ENGLISH LANGUAGE DEVOTED EXCLUSIVELY TO THE DISEASES OF INFANTS AND YOUNG CHILDREN. Containing nearly 800 large octavo pages per annum. The contents of each number will be arranged as follows, viz.: three or four scien- tific articles by the ablest teachers of pediatrics in this country and in Europe. The remaining space will be devoted to a brief, practical of the current pediatrical literature of the world, distributed in the following departments, viz.: I. Hygiene and Therapeutics. 2. Medicine. 3. Surgery. 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