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.
The physical evidences of a lung-cavity are the most reliable signs of pneumonic abscess. Abscess is a very rare termination of croupous pneumonia in children. In old age the formation of abscesses is never evinced by any well-marked symptoms. The finding of elastic fibres in the sputa with the physical signs of a cavity are the only diagnostic signs.
Symptoms which attend the Termination of Pneumonia in Gangrene.—Gangrene as a termination of pneumonia has been found in about 14 per cent. of cases.39 This must be regarded as an exceptionally high percentage. Its occurrence is usually accompanied by symptoms of sudden collapse. The pulse becomes rapid, feeble, and intermittent, the face is pale and of a deathly hue, and there is a profuse expectoration of blackish-green masses containing shreds of decomposed and decomposing lung-substance of an exceedingly fetid odor. The breath is fetid and the whole body emits a cadaverous smell. The rapidly-increasing prostration is sometimes accompanied by hemorrhage.
39 In 28 out of 200 cases (Guy's Hospital Reports, Sec. vii., 1848).
The sickening and indescribable odor of pulmonary gangrene is most perceptible after an attack of coughing. Gangrene has its most frequent site in the lower lobes of the lung, and it is here that a careful search must be made for the rather ill-defined physical signs which attend its development. In old age, when a pneumonia is to terminate in a gangrene, typhoid symptoms appear very early, and death occurs with symptoms of the profoundest collapse within five days from the initial chill.
Symptoms which attend the Termination of Pneumonia in Purulent Infiltration.—The symptoms of purulent infiltration differ but slightly from those of the third stage of pneumonia. When resolution does not take place at the period of crisis, and the temperature remains high, accompanied by symptoms of prostration and profuse putrid expectoration, with none of the physical signs of resolution, purulent infiltration is to be suspected. Death may result from exhaustion, or recovery take place after a prolonged convalescence (see Fig. 38).
| FIG. 38. |
| Croupous Pneumonia in the Adult, terminating in Purulent Infiltration: Death on fourteenth day. |
Mild delirium is a frequent symptom during the stage of purulent infiltration. The sputa contain a large number of cells in various stages of fatty degeneration. The temperature has regular evening exacerbations, and often ranges higher than during any preceding period of the disease. The tongue becomes brown and dry, sordes collect upon the teeth, and the patient passes into a typhoid state.