SPECIAL SYMPTOMS.—Pain is a symp tom of great frequency, and is always present when the lesion extends to the periphery of the lung. It is sharp, bing, agonizing in character, and is usu ally referred to the region of the nipple of the affected side. Its possible tion to other points, however, such as the abdomen or beneath the shoulder-blade, must not be overlooked. It is probably due to the pleurisy associated with ripheral lesions, and for this reason is commonly absent in central and seated pneumonias. It is aggravated when the patient coughs and upon deep inspiration. Pain occurred as a promi nent symptom in 191 of 285 cases at the Philadelphia Hospital.
Case in which abdominal pain and other symptoms in this region were so marked that the diagnosis of appendi citis was made by a consultant, and an operation performed. The autopsy showed pneumonia with empyema, the abdomen being normal. E. Palier (N. Y. Med. Jour., Sept. 16, '99).
The danger of mistaking a case of so called "abdominal pneumonia" in chil dren for one involving the abdominal organs emphasized. Two eases person ally witnessed in which the abdomen had been opened by experienced sur geons, because appendicitis was supposed to be present. This is apt to occur in cases in which the pulmonary physical signs may not be recognizable for sev eral days. An acute onset, with high temperature and the rate of respiration increased out of proportion to that of the pulse, even should suggest pneu monia. J. L. Morse (Annals of Gynec. and Pediatry, Nov., '99).
A special form of pneumonia must be distinguished, namely: that to which the name "appendicular pneumonia" has been given, owing to the predomi nance of the symptoms simulating ap pendicitis. These symptoms only occur in the early stages of the disease, and rarely persist longer than the fourth day. Miraude (Med. Press and Circular, June 5, 1901).
Dyspncea is a prominent feature. In the early part of the disease it is due to the intense pain that attends deep in spiration; so that as a result each respi ratory movement is partly suppressed. Later in the course of the disease, when pain usually ceases to be a marked feat ure, dyspncea is to be ascribed to the limi tation of air-space due to the pulmonary lesion. Respirations may be increased to forty or sixty, or even higher in the min ute. As before stated, the inspirations
are extremely shallow, while expiration is accomplished by a grunt. This expira tory grunt was noted in 79 of the Phila delphia-Hospital cases alluded to. Cough is a symptom of great constancy; its pres ence was noted in 201 of the same series. It is attended with great pain, and is therefore short and half-suppressed. Early in the disease it is hard and un productive and is probably caused by the lesion and the associated bronchitis. Ex ceptionally it is slight or even absent alto gether when the lesion is limited or latent, as in the aged and in alcoholics, or when the disease develops in those enfeebled by some pre-existing disease. The sputum is characteristic and of diag nostic value. It is viscid and tenacious, so that it adheres to the vessel into which it is expectorated. It is stained with blood and possesses a reddish or yellow ish-red color, giving to it the character istics known as "rusty." As the disease develops this rusty dis coloration becomes more marked, and in some cases the expectoration consists of pure blood. In the later periods of the disease the sputum becomes more fluid and loses its tenacious, hmmorrhagic character. In the aged and alcoholics the sputum may possess the character istics known as "prune-juice," being thin and abundant and dark brown in color. In some instances it is greenish in color: a condition demonstrated by von Jaksch to be due to the transformation of ha:mo globin into bilirubin. Prune-juice ex pectoration occurred in 5 of the cases of the Philadelphia-Hospital series. Ex pectoration may be absent altogether, especially in children and in the aged. It is not infrequently absent in drunk ards. In 37 cases of the Philadelphia Hospital series its absence was noted. Microscopically the sputum contains numerous red blood-corpuscles variously changed, but the corpuscular elements of the blood may be absent, the discol oration of the sputum under these cir cumstances being due to the solution of its coloring matter. Leucocytes and swelled, degenerated alveolar epithelium are present. It may also contain fibri nous casts of the smaller bronchial tubes, and alveoli. Various bacteria are found upon staining: the pneumacoccus, as, well as other micro-organisms.