The influenza double pneumonia occasionally was characterized by a remarkably rapid course and a rapid dissemination over several lobes. While such cases occur in ordinary times, they were particularly frequent during the influenza period. In our lectures we called attention to the cases of a boy nine years of age, of a girl eight years of age, and of a girl eighteen years of age who all died from asphyxia due to a croupous pneumonia, through infiltration of all the lobes. ***

On the other hand, there occurs not infrequently an abortive rudimentary pneumonia ("pneumonia fruste"); cases characterized by their acute nature, chill, sharp rise of temperature, lancinating pains, and dyspnea, with distinct signs of a lobular or lobar engorgement (crepitation) or also of a firm infiltration (bronchial breathing), and terminating in permanent resolution in from one to three days (pneumonia ephemera, biduana). As an example of such pneumonia we would refer to the following case, quoted in our lectures:

* Influenza lectures, p. 50. ** Compare our influenza lectures, p. 38.

*** Loc. ext., p. 48.

" H. B., twenty two years of age, was taken with a chill on December 21, 1889, together with all the symptoms of influenza. Moderate fever to December 24. On this day there were complete defervescence and euphoria. On December 25 renewed chill, with high temperature, rising to 40.7° C. Furious headache, with maniacal delirium. Marked dyspnea. Physical examination: Dulness with profuse fine crepitation, with some pleural friction during expiration. Bloody sputa. December 26 critical fall of temperature, sweating, entirely normal mental condition, and convalescence."

Many observers very correctly call attention to the numerous cases of influenza pneumonia characterized by an intermittent course, together with corresponding remittent or intermittent temperature curves (Landgraf). The cause of this condition is the successive involvement of the lobular inflammatory areas, and therefore occurs most frequently in bronchopneumonia, but by no means infrequently, and in a similar manner in croupous pneumonia.

Since the intervals between the individual attacks of pneumonia may be several days, we then have the picture of recurrent pneumonia, of which we gave examples in our lecture.*

F., twenty three years of age, of robust appearance, was taken ill on December 8, 1889, with a chill and all the typical signs of influenza. Fever disappeared after two days, but the bronchial manifestations continued. On December 25 pain in the left side, high fever, without chill and dyspnea. In the right upper lobe (dorsal) and in the left lower lobe there were evident signs of engorgement (crepitation, subbronchial breathing, bronchophony). The infiltration in the dorsal portion of the right upper lobe was soon complete (dulness, bronchial breathing). On January 3 critical fall of temperature and all the signs of resolution. On January 4 and January 5 complete apyrexia. The dulness had disappeared; moist, moderately large bronchial rales were heard. On January 6 the temperature again rose, with a rigor, up to 40.5° C. The dorsal part of the right upper lobe was completely infiltrated anew. In place of the previous rales of resolution, bronchial breathing with complete dulness again appeared.- This pneumonia ended by crisis upon the eighth day (January 14). But the purulent expectoration mixed with blood persisted for some time. Here we have the duration of a pneumonia recurrens of twenty one days, including the period of intermission.

J. F., aged twenty one, was taken ill upon the twenty fourth of December, 1889, with typical influenza. Upon the twenty sixth of December apyrexia with complete euphoria. On the twenty eighth of December rigor, dyspnea, and at once purulent bloody sputum with yellow froth and much serum. In the right middle lobe and in the left lower lobe crepitations and relative dulness. Temperature, 39.8° to 40.6° C. Upon the thirtieth, complete apyrexia, but continuation of expectoration and dyspnea. Upon the thirty first, relatively comfortable. Upon the first of January, without a chill, a rise in the temperature to 40.3° C; increased dyspnea; now a pneumonic area in the left upper lobe (at the apex and the surrounding areas) can be demonstrated. From the first to the third of January, high continued fever. Upon the fourth of January'complete apyrexia; upon the fifth of January, rigor and a new area of inflammation in the supraspinal region of the left upper lobe was noticed. Upon the ninth of January critical fall of temperature; euphoria. The purulent sputum continued for two to three weeks longer. Recovery. We have here, in the period of thirteen days, three distinct attacks of pneumonia.

* Loc. ext., p. 48.

Influenza pneumonia occasionally shows a recurring character in the sense that the inflammatory process frequently changes its position at short intervals. Admitting that this occurrence is more characteristic of the catarrhal form, nevertheless it must be noted that such cases of pneumonia fugax are, as has been proved by autopsy, not infrequently of a fibrinous or cellular fibrinous nature, and they also sometimes terminate, after several recurrences, as a lobar croupous pneumonia.

Clinically, these successional pneumonias run an irregular course, both as regards the condition of the patients, who are better one day, worse the next, and also as regards the temperature, which is subject to steep ascents and as sudden falls. Teissier very rightly remarks: "Ces poussees se reproduisent souvent avec une persistance desesperante, si bien, qu'en croit en avoir fini un jour de facon a pouvoir predire une issue favorable, et le lendemain se produit une poussee nouvelle qui met les jours des malades en danger ou amene la mort d'une facon rapide."

We have still to call attention to some important acute affections of the lung which resemble pneumonia; first of all, those cases in which, either at the beginning or at the height of the attack of influenza, severe dyspnea and cyanosis with either high or only moderate temperature set in. On auscultation one finds, either scattered all over or limited to one side or lobe, marked crepitus without dulness. Expectoration may be absent, or there may be spumous or sanguino lent spumous sputum in large quantities, occasionally even pure bloody sputum, as if from an infarct. Such patients may die after a few days with the symptoms of marked cardiac asthenia and tachycardia. At the autopsy one finds neither a croupous nor a bronchopneumonia, but an enormous hyperemia of the lungs. Teissier and others call these acute, frequently fatal cases of hyperemia of the lung (we have already called attention to these under Acute Diffuse Capillary Bronchitis, compare p. 605) "congestion, pulmonarire, simple," or, on account of the hemoptysis occurring in such cases, as "congestion haBmoptoique " (Heryng). In accordance with an opinion especially in favor in France and England, Teissier, Althaus, and others consider this enormous hyperemia of the lungs to be due to a paresis of the pulmonary vasomotor nerves by the toxins of influenza.