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 others35 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.
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 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.