Pleuro-pneumonia

“ The struggle for breath in the first stage of pneumonia is frequently alarming to witness. The relative frequency of pulse and respiration is more modified in pneumonia. The stitch-like, cutting pain in pleurisy is characteristic and very circumscribed, whereas in pneumonia, unless the pleura is involved, there is little or nothing beyond a dull soreness. ”

“ In pleurisy the pulse is firm, small, tense, and wiry; in pneumonia it is full and bounding. The amount of chlorides in the urine is not altered in pleurisy, but in pneumonia they are diminished or absent. The pulse-respiration ratio is not affected in pleurisy, while in pneumonia it may fall as low as 2:1. There are no critical days in pleurisy, while in pneumonia crisis occurs about the fifth or seventh day. In pleurisy with effusion there may be bulging of the intercostal spaces, and the heart may be displaced; these phenomena never occur in pneumonia. ”

“ 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 ”

“ 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 two layers in health touch each other, but are separated when there is fluid in the cavity. The inner layer covers the lungs and drops into the grooves of the lungs. You can thus readily understand how easy it is for the pleura to be attacked. Also when the lung is inflamed we have what we call pleura-pneumonia. Pleurisy is a very painful disease. It hurts to move, breathe, or cough. The patient holds his chest when he coughs. The fluid that forms is poured out from the inflamed membrane, sometimes it is so great in quantity it must be drawn off,—tapped ”

“ 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. ”

“ There is no relationship between the amount of lung-tissue involved and the intensity of the symptoms; high fever, delirium or convulsions, and rapid heart-failure are often as well marked when a post-mortem reveals only one lobe to be involved as when a double pneumonia exists. ”

“ 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. ”

“ In chronic wasting diseases, in feeble, weak individuals, or in those already suffering from cardiac disease, weakness of the pulse is a very marked symptom.
I cannot regard a feeble pulse in pneumonia as due to the pulmonary hepatization, for it is not that pneumonia which is most extensive that is accompanied by the greatest heart-flagging. Heart-failure may exist before, or just as, consolidation is beginning. In many pulmonary affections the obstruction to the pulmonary circulation is greater than in pneumonia, and yet there is no heart-failure. ”

“ 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. ”

“ 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. ”

“ There are symptoms of extreme prostration from its onset. After well-marked pneumonic symptoms have been present for a few days, the patient passes into a condition of extreme prostration.
There is little or no expectoration, no dyspnoea, no pain, no cough. Sordes collect on the teeth and gums; the tongue becomes thickly coated with black crusts; the pulse becomes small, feeble, and rapid, and there is a tendency to the formation of bed-sores; and then occur stupor, somnolence, and a continuous low muttering delirium. This form of pneumonia is met with most frequently in the aged. ”

“ It is oftener confined to the right side.
Treatment.—The instructions in regard to the general management of bronchitis and pneumonia must be adhered to in the treatment of pleurisy. Comfortable quarters, pure air, warm clothing to the body and bandages to the legs, a plentiful supply of pure cold water, the laxative feed, etc., in this case are equally necessary and efficacious. The hot applications applied to the chest, as directed in the treatment of pneumonia, are very beneficial in pleurisy, and should be kept up while the symptoms show the animal to be in pain. ”

“ In Pneumonia, the symptoms differ from Pleurisy, yet the difference manifests itself in this, that in Pleurisy there is more pain, and in Pneumonia more difficult breathing. Pneumonia is often a consequence of a cold, bronchitis, or the termination of some disease of the air-passages, and may begin with symptoms of a cold—rough coat, want of appetite, low spirits, etc. In other cases, it begins with a shivering chill; the legs, ears and skin are cold; the coat is rough; the nose pale and dry; quick pulse, which afterwards becomes frequent and full ”

“ THE HEART IN PNEUMONIA As pneumonia heads the list of the causes of death in this country, and as the heart fails so quickly, sometimes almost in the beginning in pneumonia, a special discussion of the management of the heart in this disease is justifiable.
Acute lobar pneumonia may kill a patient in twenty-four or forty- eight hours; lie may live for a week and die of heart failure or toxemia, or he may live for several weeks and die of cardiac weakness. If he has double pneumonia be may die almost of suffocation. ”

“ As the migrating object is usually infected, its passage through the diaphragm always produces a localised patch of diaphragmatic pleurisy. Although possible, it is only rarely that the pleural sac becomes generally infected, or that rapidly fatal septic pleurisy is set up. Usually the localised pleurisy causes the base of the lung to become adherent to the anterior surface of the diaphragm. The foreign body continuing its movements, passes into the lung, and there sets up pneumonia. ”

“ Infectious pneumonia is a specific inflammation of the lungs, accompanied with interstitial edema and inflammation of the tissues of these organs and a constitutional disturbance and fever. It causes a profound sedation of the nervous system, which may be so great as to cause death. It is sometimes attended with pleurisy, inflammation of the heart or septic complications, which also prove fatal. ”

“ 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. ”

“ In old age the stages rapidly merge into each other, and suppuration of the [p. 313] lung may occur within thirty-six or forty-eight hours from the onset of the pneumonia, while it is not at all infrequent for complete red hepatization to occur within the first six or eight hours.
The changes in the pleura over a pneumonic lung are quite characteristic. An uneven, thin, downy-looking layer of plastic lymph is spread over the pleural surface, which presents a fine arborescent vascularity. At times this plastic layer may partially conceal the liver-brown color of the pneumonic lung. ”

“ The shortness of breath on exertion is due in great part to the anæmia, and progressively increases with the advance of the disease. The free action of the diaphragm is hampered by the enlarged spleen. There may be cough from bronchitis, and toward the end signs of oedema at the bases of the lungs. Pneumonia is not uncommon as a final complication. ”

“ The serious acute congestion of the lung in sthenic pneumonia in a full-blooded, sturdy person with high tension pulse may be relieved by cardiac sedatives, vasodilators, brisk purging, or by the relaxing effect of antipyretics. Venesection is often the best treatment. ”

“ The respiratory murmur may be lessened in certain morbid conditions, such as emphysema and congestion of the lung, and may completely disappear in pneumonia or broncho-pneumonia, a fact which is even of greater significance. ”

“ 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. ”

“ Deteriorated conditions of the blood, anaemia, chlorosis—such as occurs so commonly in young women—is prone to make the outlook in pneumonia more serious. Pneumonia of the upper lobes of the lungs is more apt to be followed by complications, and is therefore more serious than pneumonia of the lower lobes. Secondary pneumonia—that is, inflammation of the lungs which develops as a complication of some other disease—is much more unfavourable than primary pneumonia which develops in the midst of health. The amount of lung involved is of course a serious factor in the prognosis. ”

“ It seems to me that the resemblance of pneumonia to the acute general diseases is to be found for the most part in its nervous phenomena, and that the complications which render pneumonia dangerous are those which interfere directly with the muscular power of the heart or diminish its nerve-supply. ”

“ Young and vigorous subjects suffer most, but almost always recover soonest.
4. The weak pulse, want of reaction, non-disappearance of the pneumonic consolidation, or its appearance during the progress of exhaustive diseases, are the unfavourable signs of pneumonia.
5. Continued exercise or work after the attack; low diet, large blood-lettings; depressants, such as tartar emetic and sedatives; expectorants, such as squills and ipecacuanha; mercury and violent purgatives, are opposed to the restorative treatment of the disease, and when not fatal, tend to prolong its duration. ”

“ But modern research has demonstrated that there is no relation whatever between the symptoms and the morbid state of the lung, which it is the object of the well-informed physician to remove. It would be easy to show that there are many cases where all the symptoms of a pneumonia have been present, but 264where a post-mortem examination has proved that there was no inflammation of the lung; and that a still larger number of instances might be cited where fatal pneumonia has occurred without any of its symptoms having existed during life. ”

“ 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. ”

“ Hypostatic congestion of the lungs is accompanied by copious, watery, blood-stained expectoration. In pneumonia the sputa, though bloody, are rarely watery. Pneumonia occurs anywhere in the lung, and has well-marked rational symptoms; hypostatic congestion occurs in the most dependent portion of the lung, disappears when the patient sits up, is accompanied by no rational symptoms except dyspnoea and expectoration, and usually can be traced to a long-continued recumbent posture in those who are suffering from extensive blood-changes. ”