PNEUMONIA. 69 



ence being announced in any way by the expectoration, which has 

 been all through either absent or devoid of character. 



When pneumonia terminates in gangrene, it is announced by the 

 expectoration of a liquid at first greenish, then of a dirty gray colour, 

 reddish at intervals, and exhaling a foetid odour, like that of the gan- 

 grene of external parts. 



At the commencement of this disease, the face is usually red ; 

 sometimes more so on the affected side than on the other. If the 

 dyspnoea be considerable, the face presents a livid tint ; and, when 

 the lung is infiltrated with pus, a characteristic paleness is usually 

 diffused over the entire face. 



Delirium is frequently present during pneumonia, and generally 

 manifests itself during the night ; in most cases where it appears 

 only at intervals, it is an unimportant symptom. But when con- 

 stant it is serious, as it shows there is a circulation of unoxidized 

 blood. 



The character of the piihe is very variable in this affection ; it is 

 most frequently quick and full ; but when the inflammation is very in- 

 tense, it is sometimes remarkably small, and this smallness disappears 

 after a copious bleeding. In some cases, particularly those occurring 

 in old persons, the pulse retains its hardness and strength ; in such 

 cases we may suspect that a hypertrophy of the left ventricle of the 

 heart exists. 



M. Andral observes, " Great frequency of the pulse announces 

 danger in this disease. It seldom happens that recovery takes place 

 when the pulse exceeds one hundred and thirty. The frequency of 

 the arterial pulsations is always in the direct ratio with the respiratory 

 movements ; however, in the last periods, it is often observed that 

 the pulse loses its frequency, and seems to have returned to its 

 natural state, though the respiration becomes more and more accele- 

 rated. This is invariably a fatal sign." 



Physical signs : First stage. — According to Dr. Stokes, an in- 

 tense puerility of respiration in the 'affected part will be found to 

 exist for some hours before the characteristic crepitus is heard. But 

 as soon as the first stage is fully developed, we know that where the 

 pain is manifested, the natural respiratory murmur has lost its clear- 

 ness ; it is mixed to a greater or less extent with the small crepita- 

 tion ; a sound caused by the breaking of minute bubbles in the air- 

 cells, or by the separation of the adherent walls of the vesicles in 

 inspiration, and resembling that caused by rubbing a lock of hair 

 between the finger and thumb close to the ear. This sound indicates 

 engorgement of the lung ; whilst it exists, it is a proof that in several 

 points at least, the inflammation has not passed the first stage. As 

 long as the natural respiratory murmur predominates over the cre- 

 pitation, we should infer that the inflammation is slight ; on the other 

 hand, when the crepitation prevails so as altogether to mask the re- 



