Pa2715 ill the CheSt are on an average less than in adults and are fre quently absent, especially in involvement of the upper lobe and in cen tral pneumonia. Older children complain of them next to the sternum when the middle lobe is affected. During the first two years the symp tom of local pain is frequently absent, and sometimes percussion is un pleasant. Children of from three to years of age very often refer the pain to the epigastric region. These gastric and abdominal pains are decidedly characteristic of croupous pneumonia. Not infrequently, these pains simulate an appendicitis, to which also the vomiting, the absence of physical signs in the lungs, and the appearance of grave clinical manifestations in the midst of perfect health, are added in a mis leading manner. They have led to operation in these eases of "pneu monic pseudo-appendicitis." The abdomen, however, is not sensitive to pressure.
The cough is often slight or may be entirely absent in central and cerebral pneumonia. It. is painful, and for this reason, short, suppressed, and is frequently followed by crying. The cough is most marked and frequent during and after deferveseence. The sputum is absent before the eighth or the eleventh year. Sometimes, vomiting produces the typical rusty sputum.
From what has been stated, the general symptoms in croupous pneumonia in younger children are frequently less prominent, and the three cardinal symptoms of this disease in adults, chill, pain in the side, and red sputum, may be absent. It is, therefore, of greater importance in children, to make repeated, careful, daily. physical examinations. In this connection several important points in general must be mentioned which frequently do not receive sufficient attention.
Auscultation is the most important part of the examination, and often renders a diagnosis possible earlier than by percussion. On ac count of the pleuritic pains. patients breathe superficially, so that vesicular breathing and illes are frequently marked and become prominent only on forced respiration. It is, therefore, of unusual ad vantage to examine the lungs of an infant during crying or coughing. Ziemssen (1862) has emphatically pointed out that the auscultation of the voice in children is very important, and that bronchophony is a much more valuable sign than bronchial breathing and tympanitic rttles. In painful and, for this reason, superficial breathing the sounds in young children often cannot be determined; while on the other hand during crying and coughing the voice is well transmitted to the periph ery of the lungs, provided there is no occlusion of the bronchi. For this reason we can examine for bronchophony much easier and earlier than for bronchial breathing.
Now, as far as an auscultation in croupous pneumonia in particu lar is concerned we find that crepitant rales are only seldom heard in the beginning, but on the other hand, very frequently during the stage of resolution at the time of the crisis. Over the affected lobe the puerile respiration is at first diminished or increased, and undetermined. If the inflammation affects a lower lobe, bronchophony and bronchial breathing are heard primarily on the second or third day-, more rarely as early as the first day, or after the fourth day, usually along the vertebral column in the region of the root of the lung. In pneumonia of the upper lobe, bronchophony and bronchial breathing are generally, heard posteriorly over the spine of the scapula, and may be absent until the fourth or sixth day, in certain cases even until after the crisis. Frequently also,
bronchial breathing is very distinct during inspiration. In central pneu monia dulness is often absent and bronchophony is the only certain sign of consolidation. Otherwise, the extent of a pneumonia may be more accurately mapped out by bronchophony than by percussion (Ziemssen), In the region of the upper dorsal vertehr and to the right thereof, bronchophony and bronchial breathing are heard normally to a varying degree, and still more so when enlarged bronchial glands are present. Experience and daily comparative auscultation where there is a suspi cion of pneumonia protects against error under these circumstances. In very extensive pneumonia of the one side, one occasionally- also hears bronchophony and bronchial breathing on the sound side. One must never neglect to examine also the sides of the thorax, as in the region of the in particular, many pneumonias first manifest themselves. After the crisis, bronchial breathing and bronehophony usually disap pear in the course of a week.
In percussing, we must percuss lightly and strongly alternately, in order to recognize both superficial and deep seated areas. In central pneumonia so frequent during childhood (pneumonia very often begins or remains central especially- in the upper lobes) percussion may remain negative or uncertain during the whole course of the disease. Usually, however, tympanitic, and soon diminished tympanitic, resonance ap pears over the area of one or more lobes of the lung. Indeed, like the aus cultatory phenomena, it appears, as a rule, earlier in pneumonia affect ing a lower lobe, and is then more distinct at first towards the root of the lung. It appears later in pneumonia of the upper lobe where it is first heard distinctly over the spine. During the further course of the disease, dulness becomes more and more marked, more resisting, and no longer sounds tympanitic. It again becomes tympanitic only diming resolution, and usually disappears cotnpletely during the first week after the crisis. The dulness often corresponds to the border of a lobe, the anterior portion of which may, however, remain free. The resistance is not so marked as in pleuritic effusion. A tympanitic percussion note is frequently found normally over the lungs of children, often transmitted from the stomach (in this instance it, may also be metallic), or from a gut distended with gas. It has not as great significance as in the adult. The tympanitic resonance is often very distinct in front below the clav icle in pneumonia of the posterior portion of the upper lobe or of the lower lobe. The vocal fremitus is often increased over the consolidated lung, provided the bronchi are not occluded. It is obtained by placing the inner edge of the hand on the chest, or by auscultation. The exam ination is rendered difficult from the fact that under normal conditions fremitus is not distinct with ordinary voice in children under six to eight years of age, at least not posteriorly where it is of the most importance. During severe crying or coughing, on the other hand, fremitus is obtained even in infants, and, indeed, is often increased over a consolidation.