or engorgement, seen in the first twenty-four hours. The stage of red hepatization, of from four to five days' duration. The stage of gray hepatization, of from six to ten days' duration. The stage of resolution, of from six to ten days' duration. Congestion is the stage in which the lung is engorged with blood, yet permeable to air. It is an active congestion of the lungs. Stage of red hepatization. The term hepatization is <Callout type="important" title="Hepatization">given on account of the liver-like appearance of a lung on section.</Callout>. In this stage the lung is dark red in color, and of very firm consistency. This is caused by the air-cells being filled with what is known as a croupous exudate. This exudate is composed of red blood-corpuscles from the capillaries surrounding the alveoli and exfoliated epithelial cells which line the walls of the air vesicles, all massed together by fibrin. The croupous exudate excludes the air from the alveoli affected. This gives rise to a consolidation of the lung, which normally is permeable to air. This condition is called a pneumonic consolidation. The size of the area consolidated depends upon the number of air-cells filled with the croupous exudate. In croupous pneumonia a whole lobe or more is usually affected. It can be understood to what extent the function of the lungs would be impaired under such conditions, and also the tremendous extra strain thrown upon the heart, which has to pump the blood through the consolidation just as through the normal lung. The stage of gray hepatization is so called from the appearance of a lung on section. It is grayish and still firm and liver-like. The grayness is due to the air-cells being filled with white blood-corpuscles, the red blood-corpuscles and fibrin having been withdrawn. The pneumonic consolidation still remains, as the affected area is still impermeable to air. The whole pneumonic consolidation has become softened in this stage by degeneration, and is in preparation for the stage of resolution. The stage of resolution is characterized by the liquefaction of the croupous exudate, part of which is expectorated and part absorbed. Resolution generally begins when the temperature falls to normal and lasts about a week. Delayed resolution is the term applied to a slowly resolving pneumonia, which may be prolonged from a week to a month. The pleura adjacent to the pneumonic area is nearly always involved. Symptoms. — The disease is ushered in suddenly with high fever, prostration, acceleration of the respiratory rate, and increase in the pulse-beats. In children vomiting often attends the onset. Pain in the side is also quite <Callout type="warning" title="Pain">common; a decided chill is not as characteristic as it is in adults.</Callout>. The child appears profoundly sick from the beginning. The skin is hot, the face flushed, often more so on the side corresponding to the pneumonic consolidation. The temperature reaches 104° F. to 105° F. within twenty-four hours. The pulse is full and strong, averaging 120 to 130 per minute, the respirations are labored and from 40 to 50 per minute, which in severe cases may be as high as 80 to 100. The signs of dyspnea are present, the breathing is not always regular, and there is a characteristic catch of the breath or moan at the end of each expiration. Cough develops early and is hard, catchy, and partially suppressed. There is no expectoration. The urine is scanty. The temperature remains continuously high with slight daily fluctuations. Herpes develops on the lips, the child may be delirious, more often at night than at any other time. Cyanosis may be present, but it is not nearly so frequent as in bronchopneumonia. The danger of respiratory failure is practically absent; on the other hand, the chances of heart failure are vastly increased. In a day or two the cough becomes loose. In children under four years of age there is no expectoration, as the mucus is swallowed. Older children may have the rusty sputum seen in adults. The position in bed (decubitus) is also characteristic; the patient will lie on the side affected to give the sound side a chance for increased expansion. Leukocytosis is usually present, the white blood-corpuscles being increased from 6000 to 10,000 or 20,000 or more, per cmm. All these symptoms continue unchanged for from five to nine days, when, if recovery takes place, a sudden drop in the temperature occurs, often accompanied by free perspiration, while a state of comparative comfort succeeds to that of great distress, and it may be followed by a long and refreshing sleep. This is known as the crisis. It may be preceded by a fall of temperature a day or two earlier, which is again followed by a rise. If there is a fall of this description it is called pseudocrisis. The fall in a crisis is sometimes as much as seven degrees in a single twenty-four hours, and the minimum is often slightly subnormal, from which it rises rapidly to the normal. Sometimes the temperature falls by lysis. From this point onward convalescence is rapid; in a week the child is out of bed and in a month is out of doors. Pneumonia either ends in resolution, abscess, gangrene, interstitial or fibroid pneumonia, phthisis, or, if fatally, usually by heart failure. Abscess from introduction of pus organisms; gangrene from engorgement of pulmonary vessels; interstitial pneumonia from overgrowth of connective tissue from exudate becoming organized; phthisis from introduction of tubercle bacilli. The symptoms of heart failure are coldness of hands and feet, then of the legs and arms, a rapid, compressible, and sometimes irregular pulse, muscular weakness and pallor, but usually no cyanosis. Death usually occurs at the time of the crisis, so if the child can be kept alive until this time has passed, it is practically saved. Prognosis.— Mortality is about 4 per cent. The difference from pneumonia in adults is at once apparent when it is known that the adult mortality is from 20 per cent to 40 per cent. When complicated by meningitis and endocarditis it is usually fatal. Cerebral pneumonia is a form of the disease characterized by severe nervous symptoms. Convulsions occur in about 5 per cent of the cases, and in the more severe forms arching of the back (opisthotonus) may be found. At times the pain is referred to the region of the appendix and appendicitis is simulated. Pleuropneumonia.— Children are especially prone to have pleurisy, and nearly every case of pneumonia could be called pleuropneumonia. Usually under this term are included cases with excessive amount of pleurisy, the two processes uniting to form a single clinical type of disease. There is little to distinguish a case of pleuro-pneumonia except the severity of all the constitutional symptoms. The temperature is often higher, the prostration greater, and the patient in every way impresses one as being more seriously ill than with ordinary pneumonia. Hypostatic pneumonia, like hypostatic congestion, is caused by the venous stasis, owing to the child's recumbent position. For this reason the position of a patient in bed should be frequently changed. Aspiration pneumonia is due to the inhalation of some foreign substance into the lungs, which gives rise to an inflammation. Such foreign material may be diphtheric membrane, food, etc. The symptoms are those of croupous pneumonia. Chronic interstitial pneumonia, as said before, is sometimes a sequel to croupous pneumonia, but in children it is usually associated with phthisis. It is due to an overgrowth of fibrous tissue, with subsequent retraction of the lung tissues. It is generally characterized by chronic cough, slight dyspnea, and scanty expectoration. Bronchiectasis sometimes results when there is the characteristic fetid sputum, which occurs in gushes. Gangrene of the lung is sometimes seen following pneumonia. The bacteria of putrefaction gains access to the diseased area and cause necrosis. It is fatal. Symptoms. — Children have the characteristic symptoms of inflammatory disease of the lungs, such as cough and dyspnea, together with profound prostration and the expectoration of very offensive sputum. Abscess of the lungs is more common than gangrene. Small abscess may be seen in bronchopneumonia. Sometimes an empyema (purulent pleurisy) will rupture into the lungs, causing a secondary abscess. The symptoms here will be those of any lung affection (fever, cough, dyspnea, and expectoration) plus the characteristic symptoms of pus, namely high and irregular fever, rigors, sweats, and pallor. Embolic septic pneumonia or a metastatic abscess of the lung is caused by a septic embolus. Such a septic embolus may arise at the seat of some putrid inflammation or suppuration, such as a wound of an operation or a compound fracture. This embolus lodges in the small capillaries of the lung and starts a point of suppuration, from which there will arise all the symptoms of pus. It is generally only one of the lesions of pyemia. Treatment. — Pneumonia, both bronchopneumonia and the croupous form, are diseases which for a favorable outcome depend not so much on the remedies given as upon the general hygienic measures employed. These measures are grouped under the term general nursing. Since in the treatment of bronchopneumonia very little can be done for the disease and very much can be done for the patient, and since croupous pneumonia is a self-limited disease having a strong tendency in childhood to recovery regardless of the treatment adopted, the plan of treatment of both diseases is practically the same. Nursing. — The indications are, so far as possible, to make the child comfortable during his illness, to prevent complications, and to treat the individual symptoms as they arise. Bronchopneumonia is frequently a complication of one of the infectious fevers, such as measles, whooping-cough, and influenza; so in the nursing of these conditions prophylactic measures must be employed. Perhaps in the majority of cases of pneumonia in childhood hygienic treatment is all that is required. The patient should be kept in a large well-ventilated room, and, if possible, changed from one room to another two or three times a day, to allow thorough airing. Older children should be kept in bed, infants can be held in the nurse's arms for a considerable part of the time. A frequent change of position is essential. The bed covers should never be tucked in tightly. Food should be given at regular intervals, and when the child is restless, fretful, sleepless, or nervous, sponging with tepid water usually makes him comfortable. Severe nervous symptoms require the application of ice, either in the form of a cold bath or an ice-bag. Pain is usually relieved by the application of mustard paste or turpentine stupes. In bronchopneumonia an oiled-silk jacket is sometimes worn throughout the attack, and, if necessary, counter-irritation maintained by mustard paste. Hot poultices of flaxseed may be employed. When new poultices are applied the old poultice is first rolled back from one side, and the new one is placed in position; then the other side is covered in the same way. This prevents exposure. Amber oil is also useful. Fever in itself means nothing, as it only indicates the severity of the lesions. Since a temperature of 105° F. is characteristic of pneumonia, it is not necessary to do much for it unless it becomes higher. The nervous symptoms call more often for treatment than the fever, and as the two go hand in hand, it is customary to keep the fever under control. The best means for this end is cold. It may be used by a graduated bath for small children, a cold pack for older ones, or a simple sponging <Callout type="tip" title="Fever Control">and an ice-bag.</Callout>. Warm baths (100° F.) are often ordered in bronchopneumonia. They relieve nervousness and help the lung condition. It is the emergencies which arise in pneumonia with which the nurse has to contend. In respiratory failure, atropin ½ gr., caffein, ¼ gr., and strychnin, ⅛ gr., may be injected hypodermically, in a child two years of age. Oxygen should be administered; gentle friction of the sides of the chest sometimes stimulates the respiratory muscles. When there is great cyanosis a mustard tub is advantageous. If the heart is collapsing, nitroglycerin is perhaps the best stimulant to use. Give a child two to four years of age 100 gr- hypodermically, and whiskey as much as necessary. As a moist atmosphere is the best for pneumonia, a croup tent with steam atmosphere medicated with compound tincture of benzoin generally relieves the dyspnea, especially if there is much bronchitis associated with the pneumonia. In an ordinary case a child should remain in bed for about a week after the normal temperature has been reached. The temperature, pulse, and respirations should be taken every three hours.
Key Takeaways
- Pneumonia in children progresses through stages of congestion, red hepatization, gray hepatization, and resolution.
- Symptoms include high fever, prostration, rapid breathing, and cyanosis; heart failure is a significant risk.
- Treatment focuses on general nursing care to prevent complications.
Practical Tips
- Keep the child in a well-ventilated room and change their position frequently to avoid complications like hypostatic pneumonia.
- Use cold therapy for fever control, such as sponging or a cold pack, but monitor closely to ensure it doesn't drop too low.
- Maintain a moist atmosphere with a croup tent to relieve dyspnea, especially if there is significant bronchitis.
Warnings & Risks
- Be cautious of respiratory failure; administer oxygen and chest friction as needed.
- Watch for signs of heart failure, which can be more dangerous than respiratory issues in children.
- Avoid overcooling the child, as this can exacerbate symptoms or cause hypothermia.
Modern Application
While the historical techniques described here may seem archaic, many principles still apply to modern survival preparedness. Understanding the progression and symptoms of pneumonia is crucial for recognizing early signs in a crisis situation. The emphasis on general nursing care and maintaining a clean environment remains relevant, even if specific treatments have evolved.
Frequently Asked Questions
Q: What are the stages of croupous pneumonia described in this chapter?
The stages of croupous pneumonia include congestion (engorgement), red hepatization (liver-like appearance with dark red color and firm consistency), gray hepatization (grayish, firm lung due to white blood corpuscles filling air-cells), and resolution (liquefaction of exudate).
Q: What are the common symptoms of pneumonia in children according to this chapter?
Common symptoms include high fever, prostration, rapid breathing, flushed face, cough, and difficulty expectorating. The child may also experience cyanosis, herpes on the lips, and severe nervous symptoms.
Q: How can a nurse prevent respiratory failure in a child with pneumonia?
To prevent respiratory failure, nurses should administer oxygen, perform gentle chest friction to stimulate breathing muscles, and be prepared to use emergency treatments like mustard tubs or nitroglycerin if the heart is collapsing.