with Evening Exacerbations, reaching nearly the highest pyrexia of the
second stage: Recovery.]
Just before the final fall the fever may be greater than at any time
preceding.[34] When the decline in temperature is gradual (lysis), the
normal temperature is usually reached by the ninth day, but it may be
delayed until the twelfth or fourteenth day. A very slow or protracted
lowering of the temperature is attended by a coincident slow
disappearance of the physical signs of consolidation. There is no
explanation for this, except that it is met with oftenest in the weak,
debilitated, and dissipated where venesection has been practised or a
depressing plan of treatment has been resorted to.
[Footnote 34: See Fig. 33, where a temperature of nearly 105° F. is
followed on the evening of the fifth day by the final fall.]
A high temperature persisting after the tenth day indicates purulent
infiltration (see Fig. 38).
Pneumonia involving the apex of the lung is usually marked by a higher
average range of temperature than when it is confined to the lower
lobes. Statistics show that the fifth and seventh days are the days of
crisis in the majority of uncomplicated pneumonias. Of 867 cases
terminating by crisis, in 677 the crisis occurred before the eighth
day. Neither the height of the temperature-range nor the amount of lung
involved affects the critical day.
In the form of pneumonia sometimes called bilious--a form that prevails
in miasmatic regions--the temperature is markedly paroxysmal.
In children the temperature rises very rapidly, sometimes reaching 106°
F. within the first twelve hours. The highest recorded temperature in
the pneumonia of children, with recovery, is 106°-107° F. The average
temperature {326} of pneumonia at this period of life is 104° F., the
range being higher than in adult pneumonia.
In children the day of crisis is oftener the seventh than the fifth
day. The fall of temperature during the crisis is somewhat remarkable;
it often falls two and a half degrees below the normal, and this
exceedingly low temperature may be maintained for two or three days,
and yet the child recover.
The accompanying charts show ordinary temperature-curves from children
with pneumonia (see Figs. 35, 36).
[Illustration: FIG. 35. A Typical Case of Lobar Pneumonia in a Child:
Recovery.]
[Illustration: FIG. 36. A Case of Lobar Pneumonia in a Boy ten years
old, in which thermometrical observations were made every four hours:
Crisis on the sixth day.]
In old age it is often difficult to determine the exact day of the
invasion of pneumonia except by the temperature. The rectal temperature
rises to 103° or 104° F., or even higher, on the first days, and
continues at about the initial point for three or four days, with daily
morning and evening oscillations of a degree or a degree and a half.
The temperature-rise does not begin for several hours after the initial
chill, if a chill occur (see Fig. 37).
[Illustration: FIG. 37. A Typical Case of Senile Lobar Pneumonia:
Recovery.]
Relapse in pneumonia is a rare event; it is quite phenomenal for it to
occur four days after the crisis. The temperature suddenly rises, but
usually returns to normal in three or four days.
Pulse.--The pulse in pneumonia varies with the type and extent, as well
as with the stage, of the disease. In an ordinary mild case the
pulse-rate is usually between 90 and 120 per minute. When the
pulse-rate for any length of time is above 120, the case must be
regarded as an exceedingly grave one.
{327} The pulse at the onset of croupous pneumonia is usually full and
soft. As the disease progresses it becomes small and feeble. In severe
cases, and when the nervous system is markedly implicated, it is rapid,
and may be 130 to 140, or even 160, at the onset of the disease. In
such cases it will also be small and feeble.
A high temperature is usually accompanied by a rapid pulse, and a low
temperature by a moderately frequent, full pulse. At the day of crisis,
when the temperature falls, the pulse will fall; and this occurs in the
severe as well as in the mild cases.
Subsequent to the third or fourth day in severe cases the pulse, in
addition to its frequency and feebleness, may exhibit dicrotism, or it
may be jerky, very compressible, and intermittent. Sometimes just
before death the pulse becomes markedly slow. The feebleness of the
pulse is ascribed by some to cardiac depression, the result of the high
temperature; by others it is claimed that the afflux of blood to the
left ventricle obstructs, and causes a deficiency in, the aortic
circulation. In other words, hepatization is adduced as a cause of the
feeble pulse. In chronic wasting diseases, in feeble, weak individuals,
or in those already suffering from cardiac disease, weakness of the
pulse is a very marked symptom.
I cannot regard a feeble pulse in pneumonia as due to the pulmonary
hepatization, for it is not that pneumonia which is most extensive that
is accompanied by the greatest heart-flagging. Heart-failure may exist
before, or just as, consolidation is beginning. In many pulmonary
affections the obstruction to the pulmonary circulation is greater than
in pneumonia, and yet there is no heart-failure. The pneumonia with the
highest temperature-range is not necessarily the pneumonia in which
heart-failure is most marked {328} or earliest to develop. There are
many diseases in which there is a much higher range of temperature and
yet no evidence of heart-failure occurs.
If a prolonged high temperature is the cause of feeble heart-power by
the parenchymatous changes which it induces in its muscular fibres,
such a high fever is not met with in pneumonia, and the heart is rarely
found at post-mortem to exhibit such changes. May not the
heart-failure, as indicated by a rapid, feeble, and intermittent pulse
in pneumonia, be due to the presence in the blood of a morbific agent
(as in certain infectious diseases) which so affects the nerve-centres
which supply the heart that its contractile power is diminished and its
rhythm disturbed? The pulse early shows commencing heart-failure by
each cardiac pulsation producing a variable filling of the arteries
with blood; hence the beats first vary in force, then waves occur, then
true intermissions. I have been able to detect this heart-insufficiency
by these variations of the pulse within twenty-four hours after the
onset of a pneumonia, and occasionally during the initiatory chill.
In children the pulse-rate is greatly increased; it may reach 200 in a
minute. It is very small, unequal and irregular, but never
intermittent.
In senile pneumonia the pulse is not a reliable indication. The pulse
may be only 50, and yet this would be a rapid pulse for the particular
case in which it occurs.
In old age, both in health and in disease, the pulse has a fictitious
hardness on account of arterial changes. The pulse may not be
intermittent or irregular, yet the heart may be very irregular and
intermittent in its action. Again, the pulse may be feeble and
intermittent and the heart be acting regularly.
Remittence of the pulse is quite common in senile pneumonia independent
of cardiac changes. The action of cold upon the surface in the aged is
very quickly indicated by the radial pulse lessening its volume and
strength, so that if the pulse at the wrist is taken it should be from
the arm which has been covered. To avoid error, the pulse in senile
pneumonia must be counted at the heart.
The surface of the body may be pungently hot and dry until the crisis
is reached, or it may be bathed in perspiration from the onset of the
disease. A moist surface has been regarded as a very favorable sign,
but when in the height of the disease the parched skin becomes moist
and the patient is not relieved, it is an unfavorable rather than a
favorable symptom, and is met with more often in fatal cases than in
those that recover.
In most cases of croupous pneumonia the expression of the countenance
is characteristic. It is one of anxiety, and over the malar bones is a
mahogany flush--not, as in typhus fever, diffused, but well defined and
circumscribed, so that it is sometimes called the pneumonic spot. While
the cheeks exhibit a spot of this dusky hue, the rest of the face may
have an earthy pallor. Bouillard states that the pneumonic flush on the
cheek is most marked when the pneumonia has its seat at the apex of the
lung. Some authorities state that the cheek flushes most or solely on
the affected side, while others[35] have shown that the cheek on the
side opposite to that affected is the one that is usually flushed. In
this connection it is interesting to mention the case of Jaccoud, who,
suffering from an attack of pneumonia himself, noticed for twenty-four
hours preceding the pneumonia signs a flush and a burning sensation in
the cheek opposite to the side affected. Usually one cheek is more
flushed than the other, and this is undoubtedly due to disturbance of
the vaso-motor system.
[Footnote 35: Barthez and Rilliet.]
When the impediment to the circulation is excessive, or when vaso-motor
disturbance is marked, the lips become cyanosed. At the time of crisis
the face becomes paler.
In about one-half the cases pneumonia is attended by an herpetic {329}
eruption upon the lips, nose, cheeks, or eyelids. It rarely appears
before the second or third day. It may not appear until the crisis is
reached. Herpes occurs with varying frequency in different years, but
is more commonly met in pneumonia than in any other febrile state. One
winter nearly every case of pneumonia in Bellevue Hospital was
accompanied by herpes labialis. When sweating exists and involves the
entire body, it is very frequently accompanied by sudamina, which are
either abundant or sparse, and seem to have a critical significance.
In children, while the surface of the body is hot and dry the
extremities are cool. The pneumonic flush instead of having a mahogany
tint assumes a bluish-white tint. Cyanosis of the extremities is more
frequent than in adults, and herpes labialis more common. All the
cutaneous symptoms are exaggerated in children.
In old age the pneumonic flush is often the first objective sign of
pneumonia. The eyelids alone are cyanotic. If the face is dusky at
first, it subsequently assumes a sallow hue, and the surface-heat,
which is greatest in the morning, is succeeded by a cold, clammy
perspiration.
Cerebral Symptoms.--The cerebral symptoms in the early stage of
pneumonia are not very significant. Headache is usually present at the
onset, and may continue throughout the disease. It usually steadily
diminishes after the third day. If it is severe in the evening, there
will be slight delirium at night--so slight as often to escape notice.
Delirium and convulsions rarely occur except in debilitated subjects
and in persons of enervating habits. It is most frequently met with in
alcoholic subjects, and then it assumes the character of delirium
tremens. It is an active, busy, restless delirium: the patient is
constantly talking, but seldom in a coherent manner. Sometimes, in
those who are not alcoholic subjects, the delirium may assume an active
and violent character. Whenever active delirium is present, it is
important to make careful and diligent search into the previous habits
of the patient.
Pneumonia of the apex is more apt to be accompanied by severe cerebral
symptoms than when it has its seat at the base.
Delirium may pass into coma. When delirium and headache are marked
symptoms, muscular tremors (subsultus tendinum) are very apt to occur,
with insomnia and frightful hallucinations. Indeed, these cerebral
symptoms are often so prominent in alcoholic pneumonia, and occur so
early, that the pneumonia may be wholly masked, and will only be
discovered by the temperature-range and by a careful physical
exploration of the chest.
When delirium is present in feeble patients, it assumes a low muttering
typhoid type, and a state of stupor is soon reached.
Among the rare nervous symptoms met with in pneumonia may be mentioned
photophobia, disturbances of vision, and deafness.
In children the cerebral symptoms are more prominent than in adults,
and they do not seem to be influenced by the extent of lung involved.
Stupor and restlessness on the one hand, or headache, delirium, and
convulsions on the other, may usher in pneumonia in children without
any prodromata.
Sometimes children pass rapidly into a semi-comatose condition which
has not been preceded by delirium or convulsions. Convulsions are as
common in children as they are rare in adults, and occur with greatest
frequency and severity during dentition. The convulsions may be general
and resemble those of epilepsy (pneumonie éclamptique of Barthez and
Rilliet), or they may attack single muscles or groups of muscles, the
child occasionally passing into a tetanic or opisthotonic condition.
If convulsions do not occur until late they are quickly followed by a
deep and fatal coma. A very rare occurrence is partial paralysis of the
muscles which were involved during the convulsive period. Such
paralysis is often {330} permanent. Again, the cerebral symptoms may
closely resemble those which attend cerebro-spinal meningitis--viz.
headache, constipation, great prostration, delirium, convulsions,
opisthotonos, and strabismus. As in meningitis, there is a peculiar
cry, and all the symptoms may point directly to the brain. These
symptoms are most likely to be present in the pneumonia of the apex in
children from five to seven years of age.[36]
[Footnote 36: This form is the pneumonie méninges of Barthez and
Rilliet.]
In senile pneumonia headache may persist throughout the entire attack;
it is usually accompanied by delirium of a mild type, especially when
the apex of the lung is involved. These patients are very loquacious
and have a constant desire to get out of bed.
Alimentary Tract.--The symptoms referable to the digestive apparatus
are neither diagnostic nor important. Nausea and vomiting are not
infrequent, and in about 15 per cent. of all cases are among the
initial symptoms. Gastric symptoms, when severe and persistent, greatly
endanger life. There is no characteristic appearance of the tongue: it
may be normal throughout, or covered with a creamy-white fur, which
becomes dry and brown as the disease advances. In severe cases and
toward the end of the disease the lips and tongue become brown, dry,
and cracked, and sordes collect on the teeth. Anorexia is marked at the
onset, and the thirst is intense. When convalescence commences the
tongue becomes clean and the appetite returns. Occasionally there is a
catarrh of the oral mucous membrane. Diarrhoea may occur as one of the
initial symptoms. It is most apt to be present when there are nausea
and vomiting. As a rule, the bowels are constipated and the stools dry.
In young children nausea and vomiting are more common, and in 50 per
cent. of the cases usher in the disease. They usually cease on the
second day, although they may persist until the crisis occurs.
Excessive and violent diarrhoea may precede a fatal termination.
In senile croupous pneumonia the tongue early becomes dry, shrivelled,
and covered with a thick brown coating, and is protruded with
difficulty. Although these patients do not complain of thirst, they
take with avidity fluids that are placed to their lips. As the period
of crisis is reached critical diarrhoea is of frequent occurrence.
Loss of strength occurs earlier and is more marked in pneumonia than in
any other acute disease except typhus fever. Pneumonia patients become
very weak within the first five days. The recovery of strength during
convalescence is rapid.
Urine.--The urine at the onset of pneumonia is scanty, high-colored,
and of high specific gravity. The amount of urea excreted is twice or
three times more than the normal. The excess of urea increases until
the crisis, and then suddenly diminishes with the fall in temperature,
often below the normal standard.[37]
[Footnote 37: The daily amount of urea normally excreted is subject to
great variations: it ranges between 355 and 460 grains. Parkes gives
the result of 25 different observations: the lowest estimate was 286.1
gr. and the highest 688.4 gr.]
Uric acid is also increased, and follows the same course as that of the
urea. The inorganic salts of the urine, especially the sodium chloride,
are diminished, and during the height of the pneumonia may be wholly
absent. Much has been written concerning this diminution, which is by
no means peculiar to pneumonia, but in no other acute disease is its
diminution so constant and marked a symptom. Sodium chloride is
probably retained in the system, for when the salt has been
administered in large quantities none has appeared in the urine. The
reappearance of the chlorides in the urine marks the approach of
convalescence, and when the crisis occurs they appear in excess,
following an opposite course to the urea and uric acid.
Although these last two ingredients are in very rare cases retained,
the {331} same as the chlorides, to appear when the crisis occurs,
their retention is usually accompanied by a critical diarrhoea, which
is followed by a prolonged convalescence. The diarrhoea is undoubtedly
due to the irritation caused by the urea.
Parkes[38] states that sulphuric acid is increased and phosphoric acid
is diminished, but Huss affirms that both acids are diminished. With
the increase of the urea and uric acid, and diminution of chlorides,
biliary pigment will appear in the urine, and occasionally the biliary
acids.
[Footnote 38: _On the Urine._]
Slight albuminuria is an ordinary phenomenon of pneumonia, and, though
usually met with in the second stage, it may appear at any time. This
symptom is present in 35 per cent. of all cases. Its presence is a
point of resemblance between pneumonia and other acute blood diseases.
The more severe the pneumonia, the more marked is the albuminuria. Some
have ascribed its presence to passive hyperæmia the result of the
pulmonary obstruction. This is questionable, except in those rare cases
where venous engorgement is indicated by cyanosis, enlargement of the
liver, jugular pulsation, etc.
In children the amount of urine corresponds to the quantity of fluid
taken.
Critical Phenomena.--At the end of the first week, during which all the
symptoms have increased in severity, the continued fall of temperature
tells us that convalescence is established. As the temperature falls,
profuse (critical) sweating occurs. Both of these phenomena may occur
to such an extent that for hours the condition of the patient is one of
collapse.
In rare cases death has occurred in the midst of these symptoms. The
respirations and pulse-rate are diminished in frequency, the pulse
being small and frequently exhibiting dicrotism. The cough becomes
loose, the dyspnoea abates, the flush disappears from the cheek, the
sputum is more copious, and is expectorated with less difficulty; it
loses the rusty color from metamorphosis of its hæmoglobin, diminishes
in viscosity, and no longer adheres to the side of the vessel, but
becomes more opaque, of a creamy consistency, and resembles that of
simple bronchial catarrh. When resolution is retarded, the
creamy-yellow tint may give place to an almost black hue, on account of
the excessive amount of pigment present. As convalescence advances, the
sputa become scantier, more mucous, watery, transparent and colorless.
At the time of crisis the intense thirst diminishes, the appetite
returns, pain in the side subsides, and the patient passes into a
quiet, natural sleep, to waken fully convalescent, suffering only from
extreme exhaustion.
Epistaxis, hæmaturia, and hemorrhage from the bowels sometimes occur at
the critical period, and may be regarded either as accidents or as the
result of the defervescence. After the crisis the amount of urea in the
urine (which during the height of the disease was augmented) falls to
normal or nearly to normal. Sodium chloride appears in the urine as
soon as the crisis occurs.
The critical phenomena in children are the same as in adults, and
frequently the fall in temperature is so great that for hours after the
crisis they lie half unconscious, with a cold surface covered with a
colliquative sweat. With the critical sweat there is often a catarrhal
flow from the nose. When children have been extremely restless or
delirious the crisis is marked by the patient passing into quiet sleep.
In old age, when recovery occurs, it is generally by crisis, and a
critical diarrhoea is much more frequent than a critical sweat.
In adults and in children the recovery of strength and flesh is rapid;
in the aged the period of convalescence is very prolonged, and often
does not begin (when the pneumonia is of the asthenic--typhoid--type)
until the fourteenth or fifteenth day; still, complete recovery may be
reached.
Symptoms indicating Danger.--When croupous pneumonia is to terminate
fatally, dyspnoea is greatly increased; the patient suddenly sinks; the
pulse {332} becomes extremely small, rapid, irregular, intermittent,
and dicrotic. Large moist râles are heard over the larger bronchi and
trachea, while the auscultatory signs of pulmonary oedema become more
and more apparent. The sputa become frothy, liquid, and blood-stained,
or are entirely suppressed. The respirations become more and more
hurried, the face is sunken and livid, the extremities are cold, and
the superficial capillary circulation is more and more interfered with,
as is indicated by the cyanosis. The body is bathed in a profuse cold
perspiration. The fatal issue is usually preceded by coma.
The temperature may steadily rise up to the time of death, or death may
occur in the defervescence. In alcoholic pneumonia death is preceded by
cerebral symptoms, such as somnolence, numbness of the limbs, a sense
of formication, and slight convulsive attacks.
In children death is often preceded by convulsions or coma. If the
disease is protracted, death may be preceded by extreme exhaustion and
collapse. Cyanosis and extreme rapidity of the pulse are usually
present in children just before the fatal issue.
Senile pneumonia may end fatally within a few hours after its onset in
a most unexpected manner. The aged patient walks apathetically about,
totters to the bed, lies down, and dies. If the pneumonia has existed
for a number of days, the signs of a fatal termination are sallowness
of the face, a cold clammy skin, expansion of the alæ nasi, and a
sudden rise or fall of the temperature. The inspirations become mere
gasps, and, following the apathy, the patient gradually lapses into
complete coma.
Symptoms which attend the Termination of Pneumonia in Abscess.--Acute
pneumonia terminates in abscess in from 1 to 2 per cent. of all the
cases. It is therefore a rare termination. It is most frequent in
debilitated, weak subjects and in those who have received a depressing
plan of treatment. The expectoration is exceedingly copious and fetid,
and the sputa are yellowish or yellowish-gray in color, consisting
almost wholly of purulent matter. Pigment is usually found in the
expectorated masses, and when shreds of pulmonary tissue are present
the diagnosis is established. The fever assumes a hectic type and is
accompanied by rigors and sweats.
After these symptoms have continued for a time, the patient grows
weaker and emaciated, and death results from exhaustion, from asphyxia
(when a large bronchus is plugged with pus), or from the discharge of
the abscess into a neighboring cavity.
DaCosta states that "pulmonary pneumonic abscesses are at the base of
the lung;" Fox locates them "at the apex;" Green, "on the upper lobe;"
I have found them in both situations.