CROUPOUS PNECTMONIA. 183 



Caseous infiltration, as a sequel to pneumonia, is by no means con- 

 fined to patients in whose lungs old deposits of tubercle already exist, 

 but may also take place in subjects previously in good health. Espe- 

 cially is this the case with emphysematous persons when attacked by 

 croupous pneumonia of the lungs, which is rare. In such cases, 

 although the fever moderates somewhat upon the critical day, it does 

 not subside so completely as when it terminates in resolution. The pa- 

 tients do not improve, the cough and dyspnoea remain. In the evening 

 the pulse is more frequent ; auscultation and percussion reveal a persist- 

 ent condensation of the parenchyma of the lung. After some time, 

 the infiltration dissolves, causing vast destruction of the lung, the symp- 

 toms of which we shah 1 examine more closely when considering the sub- 

 ject of pulmonary consumption. 



For the termination of croupous pneumonia in induration or cirrhosis 

 of the lung, see Chapter XIL 



Physical signs of Croupous Pneumonia. Inspection gives nega- 

 tive results as regards the contour of the thorax. Both sides of the 

 chest preserve their normal dimensions, and the intercostal spaces pre- 

 sent their proper shape of shallow furrows, a condition of great impor- 

 tance in distinguishing pneumonia from pleuritis. There is, however, a 

 decided modification of the respiratory movements, since at the begin- 

 ning of the attack the patient favors the affected side on account of the 

 pain ; and, as in the later stages of the disease, the vesicles are filled 

 with exudation, and hence are impervious to the air. It is often possi- 

 ble to recognize the side upon which the pneumonia has its seat at the 

 first glance, as the healthy side heaves normally, while the inflamed 

 side, as it were, lags behind. When both lower lobes are infiltrated, 

 the diaphragm cannot descend ; and the epigastrium does not project 

 upon inspiration. The patient breathes by dilatation of the upper part 

 of the chest alone (costal type). 



The first point which strikes the attention, upon palpation, is an 

 intensification of the impulse of the heart, and (what is very important 

 hi distinguishing between pleuritis and pneumonia) the heart-shock is 

 felt in its normal situation. Palpation also reveals that, during the 

 period of engorgement, and often during that of hepatization, the vibra- 

 tions of the chest are unusually distinct and strong, when the patient 

 speaks that the pectoral fremitus is strengthened. This important 

 diagnostic sign may grossly mislead any one, who is ignorant of the 

 fact that, in almost all healthy persons, the pectoral fremitus is stronger 

 upon the right side than upon the left. This is probably due to the 

 circumstance that the right bronchus is wider, shorter, and stands 

 almost at a right angle with the trachea, while the left is longer, and 

 narrower, and passes off from the trachea more obliquely. (Seitz.) 



