26 The Lancet, vol. ii., 1878, p. 701, Couldrey.
In the great majority of cases croupous pneumonia is ushered in by a distinct chill. Huss and Grisolle found a chill in 80 per cent. of their cases; Fismer and Louis in about 77 per cent. of theirs; and Lebert in over 92 per cent. of his. In 84 out of 100 cases admitted to my ward in Bellevue Hospital, a distinct chill marked the invasion of the disease.
Generally, the patient retires in his usual health, to be seized with a severe chill during the night. The chill lasts from half an hour to two or three hours. Its abruptness and severity are almost characteristic of the pneumonia.
In children, headache, nausea, vomiting, delirium, and convulsions may take the place of the chill; its onset then closely resembles that of the exanthemata, indicating the action of some irritating poison upon the nerve-centres. When these symptoms are not present there will be more or less anorexia, thirst, and a tendency to stupor. The child will awake in the middle of the night with a burning skin, a bounding pulse, flushed face, and hacking cough. When there are convulsions, followed by a loss of consciousness, the pneumonia is usually at the apex of the lung.27
27 Rilliet and Barthez.
If an old person is seized with a severe chill during the night, it is almost a certain indication that pneumonia is developing. Although the chill of invasion is of less frequent occurrence, it is more significant than in adult life. A protracted fit of shivering and pain in the side are the two diagnostic symptoms of acute sthenic senile pneumonia. They occur in about 50 per cent. of all cases, and from statistics taken from the Salpêtrière it seems that in March and April these two symptoms are almost always present.
In the other half of the cases of senile pneumonia the onset is marked by a frequent, irregular respiration, slight rise in temperature, short hacking cough, and signs of great exhaustion. Nausea, vomiting, diarrhoea, and collapse or a semi-comatose condition may usher in a senile croupous pneumonia.
Durand and Fardel give the following statistics of the mode of advent in 35 cases of senile pneumonia: 7 began with distinct rigors; 8 with rigors and pain in the side; 6 with rigors and vomiting; 8 with pain in side alone; and 6 with vomiting only. When a chill is the initial symptom, either in childhood, adult life, or at the senile period, it is rarely repeated.
In adults, following the chill there is usually pain underneath the nipple of the affected side; sometimes the earliest symptoms following the chill are headache, vomiting, and diarrhoea, dyspnoea, a hacking cough, and pain that simulates that of lumbago. Within twenty-four hours after the invasion the aspect of the patient becomes characteristic: there is a rapid rise in temperature, attended with great prostration; the pain in the side is aggravated by coughing and deep inspirations; and the respiratory movements are accelerated. The countenance assumes a dull or anxious expression, with a tendency to lividity; the pulse is accelerated, full, and soft; there is complete anorexia and great thirst; speech is difficult, and often there is great restlessness. The urine becomes scanty and high-colored, the bowels are constipated, and the tongue is dry and covered with a white coating.
These symptoms either increase in severity or are attended by exacerbations and remissions until the day of crisis, which usually occurs between the third and the ninth day; when, if recovery is to take place, there is a sudden remission of all the pneumonic symptoms; the temperature falls abruptly; the surface becomes moist; the flush of the countenance disappears; the pulse and respiration become normal; and the patient rapidly passes on to complete convalescence.