In adults delirium is an unfavorable symptom, except when it occurs at the onset of the pneumonia. When delirium occurs late in one who is the subject of chronic alcoholismus, it generally indicates a fatal termination. Convulsions in children with great jactitation, and in old age subsultus tendinum and a tendency to coma, are unfavorable signs. Great exhaustion and signs of prostration, accompanied by a sunken, pallid countenance and cold, clammy perspiration, are always attended with danger. In children bronchial breathing after the seventh day, numerous subcrepitant râles, copious and persistent diarrhoea, and swelling of the veins of the hands, are unfavorable.
In old age a sudden rise or fall in temperature, apathy, somnolence, and a sallow countenance, are all symptoms indicative of great danger. Any complication renders the prognosis unfavorable, and the occurrence of pulmonary oedema or congestion in the unaffected parts of the lung is to be regarded as a forerunner of death.
Purulent infiltration, the formation of an abscess, and the development of gangrene are all attended with danger. Recovery from gangrene is very rare.
Death does not result from heart-clot, for the conditions which favor the forming of the clot precede its formation. The fibrin factors in pneumonia are increased—often 400 per cent. more than normal. The heart is so enfeebled that the right ventricle cannot empty itself; the columnæ carneæ and the chordæ tendineæ whip up the residual blood (already prepared for clotting). Heart-clot, it is well known, is the rule when the death struggle is prolonged and the cardiac contractions gradually become weaker and weaker. Such heart-failure is always the beginning of death.
In seeking for the causes of death in pneumonia, observers have taken the results of their post-mortems as a standard of their observations. One finds oedema of the lungs at the majority of his autopsies, another finds a clot in the heart in most of his fatal cases; hence the conclusion is reached that pulmonary oedema and heart-clot are causes of death in pneumonia. But it must be remembered that in every disease there is a great difference between the cause and the mode of death. If, as a result of the failure of heart-power during the last hours of life, pulmonary congestion and oedema are developed and clots are found in the heart-cavities, it ought not to be assumed that these conditions are the cause of death. Jürgensen states that in fatal cases of pneumonia oedema of the lungs is always present, and heart-clots are frequently met with.
Death may occur, then, from heart-insufficiency, from some of the complicating diseases (cardiac especially), or from asphyxia. In some cases death seems to come from the overwhelming of the system with a poison which acts primarily and principally upon the nervous system. In a few cases fatal collapse has followed an apparently regular, well-marked crisis.
TREATMENT.—The treatment of croupous pneumonia involves not only many unsettled questions in modern therapeutics, but it embraces a history of the therapeutics of inflammation. An heroic, antiphlogistic plan of one period gave place to the rational plan of another, and that in turn to the expectant plan of a later period, while to-day an antiseptic method finds many advocates.
Regarding it as a general disease with characteristic local lesions, and not a local inflammation with constitutional symptoms, its treatment must vary with the constitutional condition of the patient and the type of the disease. When uncomplicated and occurring at certain periods and in certain conditions of life, it will terminate spontaneously in recovery. But when certain complications exist and certain conditions are present, and at certain ages, it is almost necessarily fatal. Any plan of treatment in such a disease, if resorted to indiscriminately, must needs be unreliable and unsatisfactory.
Although there is no doubt that a large percentage of cases of croupous pneumonia will recover without treatment, there is also little doubt but that well-directed therapeutical efforts can save lives and render convalescence less tedious. If it is remembered in the treatment of pneumonia that the pneumonic lung no more requires treatment than do the intestinal ulcers in typhoid fever, and that we are to be governed by the patient's general condition, and not by the physical changes in the lung as indicated by the physical signs, it is evident that all those measures which have been employed for the arrest of a local inflammatory process have no place in our therapeutics. It is for this reason that venesection, which at one time had its stronghold in the treatment of pneumonia, has now fallen into disuse. A summary of the arguments against its practice seems to be conclusive, and the numerous discussions that have so often distracted the most careful and truthful observers are well expressed in the following terms:49 1st. That indiscriminate bleeding immensely increases the mortality of the disease. 2d. That it is specially fatal in old people and in young children, in patients of exhausted constitutions, and in those suffering from chronic diseases, and particularly from Bright's disease. 3d. That it is absolutely unnecessary in the majority of cases of young adults and also young children. 4th. That in the majority of cases it has no influence whatever either in cutting short the disease, in lessening its duration, or in diminishing the pyrexia, but that occasionally these results appear to follow from its use when practised early. 5th. That in the majority of cases it hinders the critical fall of temperature and delays convalescence. 6th. That in the majority of cases, as shown especially by Bennett's and Didel's data, recovery is equally if not more rapid when it is not practised as when it is resorted to. 7th. That in a few cases a moderate venesection may be necessary in the early stages to avert immediate danger of death from asphyxia.
49 Wilson Fox, Reynolds's System of Medicine.