§ 131. Pneumonia, peripneumonia, pneumonitis.

An inflammation of the lungs generally commences with chilliness, which frequently increases to a shaking chill followed by heat. During the heat the patients generally first experience a pressure deep in the chest, which soon-dncreases to an intense seated pain. The pain may be various, acute, burning, cutting, sticking, aching, dull, oppressive, constrictive, and is generally accompanied with anxiety. . The pain is felt in the region where the inflammation is seated. If both lungs should be inflamed, the pain extends over both sides of the chest; if but one lung should be affected, the pain is felt on one side of the chest only, but extends farther in proportion as the inflammation continues to spread. The breathing is impeded, frequent, painful, anxious, superficial, and is carried on only with the uninflamed portions of the lungs; or, if both lungs should be inflamed, with the abdominal muscles and the diaphragm, but not by raising the thorax. There are cases of pneumonia where the pain is entirely wanting, and where the existence of pneumonia can only be inferred from the breathing, but not always with certainty. Pneumonia is almost always attended with a deep cough, which is at times dry, at times accompanied by expectoration; at times it is spontaneous, at times excited by deep breathing, talking or even swallowing. The expectoration is tenacious, sticky, at first semi-transparent, slimy, afterwards bloody, saffron or rust-coloured. The patients generally lie upon their backs.

* In phlegmonous inflammations accompanying a remittent fever, Aconite is the specific remedy, even in the suppurative stage: see my Essay on the present internal condition of the Homoeopathic School. - Hempel.

The fever, which is very acute, and scarcely ever leaves the patient at the commencement of the disease, sometimes assumes an intermittent type, disappearing in the morning, together with a great many troublesome symptoms, until the heat and other symptoms of inflammation return in the evening. The pulse, which was soft in the morning, again becomes hard and bounding, the cough becomes again violent, and denotes danger. These paroxysms indicate the synochal or erethic character of the fever. The fever may, however, assume a typhoid form after the inflammation has reached its climax, or in compound pneumonia, or when the meningeal membranes are affected, in which case the patients are delirious.

The face of the patient is intensely red, the head is dull and painful. The patient craves cooling drinks, and emits a small quantity of dark-red urine.

It would be unsafe, without resorting to percussion and auscultation, to infer the existence of pneumonia from the above-mentioned symptoms; nor is it possible to determine, without percussion, whether the inflammation is still confined to the stage of inflammatory engorgement, or has passed to the stage of hepatization.

§ 132. At the commencement of pneumonia, when the organic tension of the pulmonary cells is diminished in consequence of the exudation of bloody serum, percussion yields a tympanitic sound, which is at first clear and full, but becomes much less so as the condensation of the pulmonary tissue in consequence of the congestion increases. As soon as the process of hepatization commences, the percussion-sound becomes dull, insonorous and hollow. When exudation has set in, the so-called crepitant rattle is heard during an inspiration, and during cough. When a portion of the lungs, into which one of the larger bronchial tubes opens, hepatizes, the communication between the air in the lungs and the column of air in the trachea and larynx is interrupted; this gives rise to peculiar sounds termed bronchial respiration, bronchophony and consonant rattle. These three sounds are not heard when the bronchus is stopped up, or when the voice and respiration of the patient are very feeble. Over the hepatized portion we always hear a peculiar whiffing, bronchial respiration, but never the vesicular murmur.

§ 133. Anybody may be attacked with pneumonia, though it occurs more rarely in childhood, and most frequently between the 17th and 50th years of age. Females are less liable to pneumonia than males, for the very reason that the lungs of the former are much less developed than those of the latter. Predisposing causes are: a tuberculous diathesis, previous pneumoniae, suppressed discharges of blood.

Exciting causes are: atmospheric influences, northeast winds. Hence it is that inflammations of the lungs occur most frequently at the end of winter and the commencement of spring, or also in summer, when the air suddenly becomes cool after sultry heat; they occur likewise on taking cold after having got heated by dancing or running, or by sounding musical instruments; they may be occasioned by mechanical and chemical irritants, sharp, sour, oxydizing vapours, vapours of muriatic or nitric acid, arsenious vapours, by inhaling plaster, lime, pebble, coal, flour, or wool-dust, in consequence of fracturing a rib, or penetrating stab or shot wounds.

Patients can recover from pneumonia in every stage. The general and local symptoms disappear gradually; the fever, pain and cough abate, the sputa again becomes normal, and the respiration easy and regular.

In spite of these favourable changes, we know from auscultation and percussion that there are still some morbid phenomena remaining, inviting the patient to be on his guard lest he should have a relapse. Unfavorable terminations are, 1, when the plastic exudation changes to tubercles; 2, when an abscess forms; and 3, when the hepatization has lasted too long to admit of resolution. Death takes place by excessive congestion, or by complication with an affection of the heart, or in consequence of some secondary disease.

The prognosis is more favourable in young and vigorous subjects, and in persons who are attacked for the first time, than in old people. It is likewise more favourable in simple than in compound pneumonia, or when the inflamed lung was already partially hepa-tized, or otherwise morbidly affected. A good deal, however, depends upon the treatment, even in unfavourable cases.