CROUPOUS PNEUMONIA. 187 



hydrocephalus. Children with violent fever, brain-symptoms, and hur- 

 ried respiration, must be frequently and carefully auscultated. The risk 

 of confounding the pneumonia occurring in old and greatly-depressed 

 subjects with typhoid fever is guarded against by the absence of the 

 tumor of the spleen, the eruption, the tenderness in the ileocaecal region, 

 the initiatory chill, above all, by the physical examination of the chest. 



The differential diagnosis between pneumonia and pleurisy will be 

 more appropriately considered after we have made ourselves familiar 

 with the symptoms and course of the latter. 



Valuable for the diagnosis of pneumonia as we have seen physical 

 examination of the chest to be, it nevertheless is not of itself sufficient 

 to prove more than the existence of infiltration and filling of the air- 

 vesicles. The character of the infiltration is to be ascertained from the 

 history of the case. 



PROGNOSIS. The prognosis, first of all, must depend upon the ex- 

 tent of the disease. Double pneumonia is justly regarded as the most 

 dreaded form. The prognosis, however, depends much more upon the 

 accompanying fever, since, as we have seen, exhaustion from fever ter- 

 minating in general palsy is the cause of death in the majority of fatal 

 cases. An elevation of temperature above 106 F., an increase in the 

 frequence of the pulse above one hundred and twenty beats, renders 

 the prognosis bad. 



Pneumonia is an extremely dangerous disease to aged persons ana 

 to drunkards, owing to their intolerance of even moderate degrees of 

 fever ; and while but a small proportion of middle-aged patients die of 

 it, the mortality from this disease among old people amounts to between 

 sixty and seventy per cent. 



Complications of pneumonia with tuberculosis, disease of the heart, 

 Bright's disease, as well as the occurrence of endocarditis and pericar- 

 ditis, should cause us to fear an unfavorable result. 



Among the individual symptoms, the sputum furnishes a clew to the 

 prognosis. The absence of all sputa must, in the beginning, be regarded 

 as unfavorable, as must also the appearance of very dark, brownish-red 

 (prune-juice) expectoration. This signifies a poor state of nutrition and 

 fragility of the pulmonary capillaries, and, as a rule, denotes a cachectic 

 condition of the individual. Very copious liquid oedematous sputa are 

 ominous of evil. Scanty expectoration during resolution of pneumonia, 

 if the dulness continue to disappear, is of smaller importance ; but ab- 

 sence of expectoration, accompanied by gurgling sounds in the chest, 

 signify palsy of the bronchi, oedema of the lung, and approaching disso- 

 lution. Delirium at the beginning of the disease is a matter of no 

 gravity, and is due to the derangement of nutrition in the brain, or to 

 the high temperature of the blood which flows through the brain. At 



