Bronchopneumonia

“ One of the most remarkable phenomena is the rapidity with which the lung tissue clears up, and its freedom from alteration or from infiltration into the connective tissue as frequently takes place after broncho-pneumonia. When resolution does not take place, death may occur from extension of the disease and subsequent toxaemia, from circulatory failure, from the formation of one or more abscesses or more rarely from gangrene of the lung or from the complication mentioned below. Chronic interstitial pneumonia is infrequent, following on the acute variety. ”

“ Unlike many acute diseases, pneumonia does not render a person less liable to future attacks; on the contrary, those who have been once attacked must be looked upon as more prone to be affected again. Acute pneumonia usually attacks the whole or greater part of one lobe 'of one lung, but more than one lobe may be affected, or both lungs may be involved. The disease produces a solid and airless condition of the affected part owing to a fibrinous exudation taking place into the aircells and smaller bronchial passages. ”

“ If the disease proceeds favorably, at the end of five, seven, or ten days the temperature, breathing, and pulse become normal suddenly, and the patient rapidly emerges from a state of danger and distress to one of comfort and safety. The sudden onset of pneumonia with chill, agonizing pain in side, rapid breathing, and often delirium with later bloody or rusty-colored, gelatinous expectoration, will then usually serve to distinguish it from bronchitis, but not always. ”

“ Labored breathing, which is at once hurried, deep, and without intermission, is seen in severe laryngitis, croup, capillary bronchitis, and pneumonia, in all cases alike from the difficulty experienced in introducing into the lungs the requisite amount of air. It is especially marked in double pneumonia, pleuro-pneumonia, complicated with effusion in the chest, and in old standing broken wind with dilatation of the right heart. ”

“ It not unfrequently happened that persons, who had passed through the different stages of the disease, and were advancing rapidly to convalescence, were suddenly seized with an affection of the chest, pleurisy, bronchitis or pneumonia, and speedily carried off by the violence of the inflammation. The skin, exquisitely sensible in its denuded state to atmospherical vicissitudes, transmits with great promptness the morbid impression to the lungs, already prone to take on disease, in consequence of the active part they are compelled to play during the eruptive fever. ”

“ The temperature is the best guide in such cases; if it is above normal (983/5° F.) the patient should stay indoors. In infants, young children, enfeebled or elderly people, bronchitis may be a serious matter, and may be followed by pneumonia by extension of the inflammation from the small bronchial tubes into the air sacs of the lungs, and infection with the pneumonia germ. The principal signs of severe attacks of bronchitis are rapid breathing, fever, and rapid pulse.
The normal rate of breathing in adults is seventeen a minute, that is, seventeen inbreaths and seventeen outbreaths. ”

“ When the practitioner is first consulted he often finds only indications of the crisis period of a localised pneumonia at the base of the affected lung. The symptoms include fever, accelerated breathing, moaning, loss of appetite, cough without discharge, dulness over the base of the lung on percussion, disappearance of the respiratory murmur in the dull area, souffle opposite the inferior bronchi, and normal or juvenile respiration towards the front, i.e., in the anterior lobe, and sometimes in the cardiac lobe. ”

“ Bronchitis is always developed out of previous catarrh, though there is a wide difference between the duration of the preliminary stage and the occurrence of serious symptoms in different cases; while it may be laid down as a general rule that the severity and danger of an attack are in proportion to the rapidity of its onset. An attack of pneumonia, or inflammation of the lung-substance sets in, as a rule, more suddenly, with fever, a temperature of 103° to 105°, general distress, headache, not unfrequently delirium ”

“ Of course the only exact way of learning the nature of a chest trouble is thorough, careful examination by a physician, for cough, fever, rapid breathing and rapid pulse occur in many other diseases besides bronchitis, particularly pneumonia.
Pneumonia begins suddenly, often with a severe chill, headache, and general pains like grippe. In a few hours cough begins, short and dry, with violent, stabbing pain in one side of the chest, generally near the nipple. The breathing is rapid, with expanding nostrils, the face is anxious and often flushed. ”

“ The relation between such lung diseases as bronchitis and pneumonia and the unwholesome condition of the air of our dwellings has not been sufficiently recognized by the medical profession and the public. One of the most common causes of an attack of bronchitis is a Budden exposure of the bronchial mucous membrane to extreme conditions of air. A man who breathes for some hours the hot and dry vitiated air of an unventilated room is prone to be thus affected on passing out into cold, damp night air. ”

“ In pneumonia or inflammation of the lung-substance the process is different. A portion of one or other lung, sometimes of both, becomes overfilled with blood, or congested, and though the air-tubes themselves are not the special seat of the congestion, yet the air-cells are pressed on by the surrounding swollen substance, and the entrance of air into them is impeded. If the mischief goes further the substance becomes solid and impervious to air, and lastly it becomes softened, its structure destroyed, and infiltrated with matter ”

“ So serious are the disturbances of the circulation all over the body by these spasmodic suffocation-fits, that rupture of small blood-vessels may occur in the eyes, the brain, in the lungs, and on the surface of the skin. The heart becomes distended, and if originally weakened may be seriously dilated or overstrained; the lungs become congested and inflamed, and any of the [Pg 265] numerous accidental germs which may be present will set up a broncho-pneumonia, which is the commonest cause of death in this disease, as in measles. ”

“ It is a widely accepted statement, in textbooks of Pathology at least, that the stage of red hepatization in pneumonia follows the period of engorgement and precedes the grey form. This interpretation is open to question concerning the lesions that are encountered in influenza, as well as in those that are seen after gas inhalation. Unquestionably, in the stage of engorgement the lung has a red appearance, enhanced by the acellular, serofibrinous exudate in the alveoli through which the greatly congested vessels are seen. ”

“ This symptomless interval is followed sooner or later by ever increasing cough and expectoration of sputum, finally by bronchiectasis and pulmonary abscess, chronic sepsis, and invalidism.
Pathology.—If the foreign body completely obstructs a main bronchus, preventing both aeration and drainage, such rapid destruction of lung tissue follows that extensive pathologic changes may result in a few months, or even in a few weeks, in the case of irritating foreign bodies such as peanut kernels and soft rubber. Very minute, inorganic foreign bodies may become encysted as in anthracosis. ”

“ This work indicates, not only the possible importance the species may play, but also points to the rôle of the infecting organism which, when sufficiently virulent, incites a characteristic reaction even when inoculated in a minimal quantity into the trachea as distinct from the bronchioles or lung tissue.
Pneumonia unassociated with a simultaneous or preliminary incapacitation of the mechanism of the upper respiratory tract, differs from the pulmonary lesions encountered after measles, gas poisoning, influenza, etc., and those experimentally produced by intrabronchial insufflations. ”

“ They are dependent upon the fact that the pneumonic process has a very striking tendency to undergo organization, a process which involves not only the exudate in the alveoli, but also that within the bronchioles. The organizing process may be present in both these portions of the lung or may be confined to the bronchiole alone, and lead to a progressive interference with the ingress and egress of alveolar air, so that atelectasis and emphysema become permanent, and in turn lead to narrowing of the vascular bed, ultimately producing right-sided cardiac decompensation. ”

“ But another case occurs, the invalid complains precisely of the same symptoms: he has cough, expectoration, wheezing in the chest, and difficulty in breathing—he gradually falls away in flesh, and the hectic fever increases. Palliatives are resorted to, as in the former case, not to cure, which is considered impossible, but simply to alleviate his suffering—he also dies. On inspection, the lungs are found generally sound; no tubercles are discovered; but there is found to be an ulcerated spot of more or less extent in the bronchial membrane. ”

“ Foreign bodies, such as feed accidentally getting into the lungs by way of the windpipe, as well as the inhalation of irritating gases and smoke, ofttimes produce fatal attacks of inflammation of the lung and bronchial tubes. Pneumonia is frequently seen in connection with other diseases, such as influenza, purpura hemorrhagica, strangles, glanders, etc. Pneumonia and pleurisy are most common during cold, damp weather, and especially during the prevalence of the cold north or northeasterly winds. Wounds puncturing the thoracic cavity may cause pneumonia. ”

“ The alveolar as well as the bronchiolar wall is thickened by a homogeneous material in which cell-body and exudate cannot be differentiated. This acute necrosis, as has been mentioned, is encountered in gas poisoning but is unusual in other known types of respiratory infection. Doubtless, it is a precursor to the more destructive lesions commonly found in later stages of the disease—abscesses which extend through the bronchiolar walls (Fig. XXXI) , necrotizing areas of pneumonia in which huge clumps of bacteria are found (Fig. XXXII) , and true gangrene (Figs. XXXIII, XXXIV, XXXV) . ”

“ In other cases of pneumonia we get a certain amount of serous effusion into the pleura; and sometimes, especially in children, the pneumonia is followed by the development of an empyema. Pleurisy with effusion is also frequently a complication of valvular heart disease and dilatation of the heart, and in such cases is often associated with the formation of superficial pulmonary infarcts. It is also seen in many other diseases of the lungs. For instance, in chronic pulmonary phthisis pleuritic adhesion's over various parts of the lungs are the rule ”

“ When death occurs it is usually directly due to heart failure; in some cases it is caused by asphyxia, owing to the great amount of exudation into the lung tissue, rendering its further function impossible.
Complications.—The pulmonary complications of infectious pneumonia are secondary inflammatory or necrotic changes in the lungs themselves. Suppuration at times takes place in the bronchi and may extend to the lung tissue. In this case mucous râles develop which are most distinctly heard over the trachea and on the sides of the chest directly behind the shoulders. ”

“ Inhaling cold air after sitting in a close atmosphere, will induce an attack of bronchial inflammation, or thickening of the air-tubes, in persons of all classes and conditions. Persons who are liable to frequent attacks of bronchitis, are apt to imagine that their lungs are affected, since it prevents a free use of the voice in singing or speaking audibly. I will repeat that this complaint generally terminates with a loss of tone in the lung substance, caused by the failure of the tubes to supply them with oxygen or air ”

“ When pulmonary lesions are extensive, the bronchial mucosa is not only softened, opaque and covered with a serous, or muco-purulent discharge, but deeply congested and petechiated. When the chest is opened there is usually an effusion, pale straw, red or bloody and more abundant than in contagious pneumonia. False membranes may exist and show a blackish tint from extravasated blood. The lung fails to collapse and shows on the surface and throughout its substance petechiæ and small black infarctions. ”

“ If the patient is breathing from twenty-five to thirty-five times per minute, the respiration being confined to one lung as indicated by the lack of expansion in the other, and if he lies so as to take the strain off the lung that does not expand, it is almost sure that the patient has pneumonia. In case the lung is fixed rigidly by the muscles and the opposite lung forced to do all the work, then the patient has pleurisy. ”

“ The degree of cardiac failure present is to be ascribed rather to nervous exhaustion than, as in many cases of croupous pneumonia, to the action of hyperpyrexia on the muscle of the heart. The extreme interference with respiration in catarrhal pneumonia is readily accounted for, not only by the extent of lung-tissue actually involved in the process, but by the associated bronchitis with swelling of the mucous membrane, by the accumulated bronchial secretions, and by the frequent complication with collapse. ”

“ After removal, the lung retains its shape, but is more flaccid than the consolidated lung of lobar pneumonia. It cuts with very little resistance and immediately a large amount of a syrupy, pink fluid escapes and obscures the entire area. With the fluid scraped away, the variations in the consistency of the lung become visible. The pale areas around the borders and chiefly at the apex in which the air sacs are discernible with the naked eye, sink slightly below the remainder of the surface, and the pleural edge inverts. ”