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 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.