CROUPOUS PNEUMONIA. 179 



or there is but a short remission, after which the disease grows vrorse 

 again, and continues into the second week. The pneumonic infiltration 

 continues to spread, the temperature remains high, and is sometimes 

 higher than ever. Signs of extreme prostration now set it, due in part 

 to the elevation of the temperature, partially also to exhaustion pro- 

 duced by continuous and excessive calorification, and to the profuseness 

 of the exudation, which I have repeatedly estimated at three pounds 

 after comparison of the weights of the diseased and healthy lung. The 

 fever, formerly of "inflammatory" type, now assumes an asthenic, 

 " nervous " (typhoid) character. The pulse grows extremely frequent, 

 small, and soft ; the tongue becomes dry and incrusted ; all the senses 

 are blunted ; the patient not unfrequently voids his urine and faeces in 

 voluntarily, in the bed ; some patients lie in a stupor from which they 

 can scarcely be roused ; others, again, are wildly delirious, so that it is 

 scarcely possible to restrain them in bed. In many such cases, especially 

 if the patient have not been depleted by blood-letting, a change for 

 the better may still take place toward the end of the second week, 

 and 'again the transition from a condition apparently desperate, to one 

 of almost complete convalescence, may then occur in the course of a few 

 hours. 



The crisis at the end of the first week fails to occur also, when the 

 stage of hepatization passes on into that of purulent infiltration, and 

 the fever continues into the second week with equal or even aggravated 

 intensity. Here, too, the pulse is usually small, and the mouth is dry 

 and sticky. The patients are somnolent, or else delirious ; the tempera- 

 ture, especially in the. evening, is greatly elevated, and sometimes there 

 are slight chills. The sputa, which are generally profuse, contain great 

 quantities of cells in a state of fatty degeneration. It is clear that aus- 

 cultation and percussion alone can distinguish an extension of the pro- 

 cess of hepatization from the transition into purulent infiltration. 



When the pneumonia attacks aged persons, or subjects of depraved 

 constitution, adynamic symptoms may arise, even though the malady be 

 not of unusual duration and although purulent infiltration have not 

 occurred. Indeed, so promptly do they sometimes develop, so immedi- 

 ately do they appear after the chill, and the first onset of the fever, that 

 the signs of pulmonary disorder are entirely eclipsed by those of grave 

 asthenic fever. As we have stated already, many patients of this kind 

 have no cough and no characteristic sputa y nor do they complain 

 either of dyspnoea or of pain. The frequency of respiration is often 

 ascribed to the fever, and patients sometimes die with the diagnosis of a 

 " typhoid influenza," a catarrhal fever, or a " typhoid gastric fever," 

 whose autopsy reveals extensive pneumonic infiltration ; the physician 

 having been deceived by external appearances, which really bear greatej 



