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 ^>ttuM>O.W-V I "^ 
 
 - * c - ±4, 
 
 LOBAR PNEUMONIA IN A CHILD AGED THREE, HIGH AND PROLONGED 
 
 PYREXIA AFTER ALL PHYSICAL EYIDENcE OF THE 
 
 PNEUMONIA HAD DISAPPEARED. 
 
 UY 
 
 JAMKS STEWART, M.D., 
 
 Professor of Medicine, Mc(JiIl University ; Pliysician to the Royal Victoria Hospital. 
 
 AND 
 
 D. C. McCALLUM, M.D., 
 Resident Physician to the Royal Victoria Hospital. 
 
 (Reprh-led /row the Movlntil Midicol Jmirnal, May, 1808.) 
 
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 W^ 
 
 LOBAR pnp:ttmonia in a child aged three, high and 
 
 PROL(JN(iEl) PYREXIA AFTER ALL PHYSICAL EVI- 
 DENCE OF THE PNEUMONIA HAD DISAPPEARED. 
 
 UY 
 
 .Iamkh Stkwart, M.D., 
 Professor of Medicine, MeGii! University ; Physician to the Royal Victoria Hospital . 
 
 AND 
 
 D. C. McCai.i.um, M.n., 
 Resident Physician to the Royal Victoria Hospital. 
 
 The fullowiiig ca.se of pneumonia pre.seuts several iVatnros of more 
 than ordinary interest. The cour.se of the (lisea.se may he brieHy 
 summar'zed as follows : 
 
 A previously healthy child, aged 8 years, was suddenly taken ill on 
 the 3rd of December, 1807. The general symptoms were those of an 
 acute pulmonary affection. 
 
 On admi.ssion to hospital on tlu(4thof December, and on subsecpient 
 examinations, it was definitely determined that we had to deal with 
 a lobar pneumonia of the left lower lobe. On the Gth day of the 
 disease the temperature .suddenly dropped to below normal, where it 
 remained for about three days. 
 
 In the coui-se of the next few days the physical signs of consolidation 
 gradually disappeared, but the temperature began to present the 
 features of a marked and characteristic septicaemic process. For a 
 period of six weeks it varied frotn subnormal to 108°. 
 
 On several occasions the latter point was reached. In spite of the 
 high pyrexia, the child took nourishment and stimulants freely, and 
 did not appear to suffer particularly. He was bright and cheerful 
 throughout his prolonged illness. When the temperature rose after 
 the crisis, it was naturally thought that we had to deal with a pneu- 
 mococcus pleuri.sy but repeated tappings proved negative. Repeated 
 cultures from the blood were also negative, as was also Widal's test 
 for typhoid. We were unable to discover any likely focus for the 
 septicsemic process. There was no evidence of unusually delayed 
 resolution or of any pleural, pericardial, peritoneal or meningitic 
 complication. 
 
 C. H., aged 3, was admitted to the Royal Victoria Flospital on 
 December 4th, 1897, complaining of pain in left side of chest (2), 
 cough (3), sore throat. 
 
 IN 
 
2 
 
 Histori/ of Recent Illvess. — From his tiiotlicr it was It-anitMl that he 
 had been well till Fi-'-lay, .'inl Decemher, when she noticed that he 
 seemed out of sorts and said that the left side of his chest and neck 
 were sore. That night he was restless and cried with pain in left side 
 of chest. He also hegan coughing <luring the night. Cough was fre- 
 (|Uent and caused considerable ])ain. The throat was also painful 
 during the night. No chill or rigor occurred. 
 
 Pcrs<»iiil Hisfori/. — Horn in Montreal three years ago. Has always 
 lived here. Has always been a healthy child. Except for an attack 
 of acute lobar pneumonia, which involved the lower lobe of right lung 
 in April, 1M)7, has never .sutt'ered from any disease. 
 
 Faiinli/ H'ldori/. — Father alive and well. Mother had pleurisy Hve 
 years ago, but is healthy. Other children are well. No history of 
 rheumatism or tuberculosis. 
 
 On admi.ssion patient was a well nourished child of average size. 
 Visible nnicous memhranes of fair cofjjjur. Face flushed. Frequently 
 unilateral Hushing was noted ; the left cheek was principally involved. 
 No hei'petic eruption was present. Child assumed the dorsal decubi- 
 tus and lay (luietly, v'xcept when paroxysm of coughing ensued. The 
 cough was hard and dry and cau.sed considerable pain in left side of 
 chest. He slept well and took nourishment in fair (]uantity. Tem- 
 perature 108° ; pulse, 12(S ; respiration, GO. 
 
 Respirator y Si/stem — Respirations were short and (juick. (Respira- 
 tion ratio, 2 — 1). There was no cyanosis of face or finger tips. At 
 times expiration was accompanied by a short grunt. The cough 
 was hard and dry and came on in paroxysms. There was no expec- 
 toration. 
 
 Anteriorly. — Expansion of chest was fair, but was decidedly limited 
 at the right apex and infraclavicular region. Expansion behind at 
 the apex was also diminished. Local fremitus could not be elicited. 
 
 Percussion note was impaired from apex to upper border of 3''d 
 rib anteriorly. 
 
 Posterioi'ly, note was impaired to mid .scapula in left side. Note 
 ovei- right lung was slightly hyperresonant, but otherwise normal. 
 
 AuscidUdion — Blowing lireathing was heard over the whole of the 
 dull area, and posteriorly a few dry rales were heard with expiration. 
 Right lung, breath sounds normal. 
 
 Cardiac Vascular Sydem. — Pulse 129, of good volume ; tension 
 high ; regular in rhythm. 
 
 Heart — Apex beat visible and palpable in 6th interspace. Dulness 
 was not increased. Sounds at apex normal, at base the second pul- 
 monary sound was accentuated. 
 
 I 
 I 
 
 i 
 
8 
 
 I 
 
 I 
 
 I 
 
 Digestive System. — Lips dry aiul covered with sordes. Teeth in 
 fair condition. Tongue heavily coated on dorsum with yellowish fur. 
 Breath was foul. Throat, slight redness of left tonsil and left pillar 
 of fauces. Left tonsil was slightly erdarge<l. Appetite fair. Thirst 
 increased. There was no vomiting. 
 
 Abdomen. — Skin hot and dry. Abdomen full hut not distended. 
 Neither liver nor spleen was palpable. 
 
 LocoiiLotar Si/Nleiti, — Skin hot and dry. Face flushed unilaterally. 
 No herpes on lips or nose. Vaccination mark seen on left arm. Sub- 
 cutaneous fat present in fair amount. Muscles of good size and mus- 
 cular power good. Bones and joints normal. 
 
 NervoitH ISijstcru. — Litelligence good. Mental state normal. Sleep 
 rather disturbed. Child restless during both day and night. 
 
 Siihueijuent Events. — Condition was much the same with distres.sed 
 respiration and cough till Hth December, when a drop in temperature 
 occurred to normal from 104f°. The cough was less troublesome antl 
 the child seemed .somewhat better. The condition of the lungs was not 
 changed, save tliat the blowing breathing was less distinct. On the 10th 
 the piitient was much brighter. Respiration 34. Cough less severe. 
 
 The ttinperature did not remain normal, but began gradually to 
 rise, ranr^ing from normal to 101^°. The general condition was some- 
 what i) iproved and the child was brighter, Respiratory rate was 
 28 — 30. Cough no longer present. 
 
 E.xaiuination of chest showed slightly impaired note from base of 
 left lung to angle of the scapula, with weak voice and breath sounds. 
 A needle was inserted on several occasions, but no fluid at any time 
 withdrawn. 
 
 During the last week in December the temperature was very irre- 
 gular, on several occasions reaching 108°. The general condition of 
 the child did not suffer. He was bright and the mental state was 
 normal. The Widal test was negative, as were also cultures taken 
 from the blood on several occasions. 
 
 Throughout January the same irregularity of temperature was 
 noted. The child lost in weight, but did not seem to suffer any 
 inconvenience from the pyrexia. The ui'ine on repeated examinations 
 was normal. 
 
 Earh'^ in February the temperature became less elevated. The child 
 rapidly gained in flesh. Appetite was excellent. Examination of 
 chest showed that the dullness had entirely cleared up. He was dis- 
 charged on 27th February, 1898.