Pneuma

“ 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. ”

“ Chronic Interstitial Pneumonia.—Synonyms.—Cirrhosis of the lungs; Fibroid Pneumonia.
Definition.—A chronic inflammation of the lungs, in which the normal air cells are replaced by fibrous or connective tissue, followed by induration and atrophy of the lung.
Pathology.—The disease is nearly always confined to one lung, though, in very rare cases, both lungs may be involved, while localized areas are the rule. The affected lung becomes atrophied and in extreme cases, may be no larger than the closed hand. As a result of the shrinkage of the lung tissue, the heart undergoes hypertrophy. ”

“ If its relation to pneumonicula be the same in its cure, that I have supposed it to be in its cause, then I am persuaded, that the same excess in blood-letting is indicated in it, above what is necessary in phrenitis, that has been practised in pneumonicula, above what is necessary in the cure of an acute inflammation of the lungs. The continuance, and, in some instances, the increase of the appetite in the internal dropsy of the brain, would seem to favour this opinion no less in this disease, than in the inflammatory state of pulmonary consumption. ”

“ But this office of the pulmonary veins, namely, the ransference of air from the lungs of the heart, is held of such importance, that Hieronymus Fabricius of Aquapendente, contends that the lungs were made for the sake of this vessel, and that it constitutes the principal element in their structure. But I should like to be informed why, if the pulmonary vein were destined for the conveyance of air, it has the structure of a blood—vessel here. Nature had rather need of annular tubes, such as those of the bronchi in order that they might always remain open, and not be liable to collapse ”

“ 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 ”

“ The two lungs must, therefore, be alternately affected as to their capacity according as the heart occupies space on either side of the thorax. In expiration, the heart, E, is more uncovered by the shelving edges of the lungs than in inspiration. In pneumothorax of either of the pleural sacs the air compresses the lung, pushes the heart from its normal position, and the space which the air occupies in the pleura yields a clear hollow sound on percussion, whilst, by the ear or stethoscope applied to a corresponding part of the thoracic walls, we discover the absence of the respiratory murmur. ”

“ The Lungs.—The lungs are completely distended, almost entirely overlapping the heart, and pressing close to the ribs. They are spongy to the feel, and when cut into, a considerable quantity of bloody froth escapes. The froth found in the lungs is the result of the powerful attempts to breathe, and cannot be produced by artificial means. It adheres not to the sides of the bronchial tubes, as does the exudation of bronchitis or pneumonia. The distension of the lungs is due partly to an actual hyperæmia, and partly to inhaled fluid. ”

“ The symptoms in the dogs were all alike, dyspnea, increasing as the inflammation increased, until the accessory muscles of respiration were called into play. The stethoscope showed that air had great difficulty in entering the bronchi and air vesicles, and showed also the tumultuous beating of the heart in pumping blood through the lung. It was impossible to take the temperatures. Post-mortem examinations showed the lungs dark, congested and solid in some places. ”

“ 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. ”

“ In pneumonia the difficulty of breathing consists in its painfulness; in asthma, in the persistent torpor of the respiratory organs. The patient feels as if the expansion apparatus of his chest were utterly paralyzed, the inhaled breath seems to come to the gate of the lungs and no farther ”

“ The blood coming from the stomach too, is generally in larger quantity than that from the lungs.
In addition to these symptoms, the patient is often affected by an increased sensibility of the lungs, observable on any exposure to cold, change of dress, or going from a warm to a cool apartment. There is a sense of soreness in the lungs attended with a sensation of stricture about the chest. Pain is felt in the side or breast, and the patient lies with difficulty on the side affected. ”

“ The lung follows the heart. The whole mediastinum finds itself altered in its position and in its contents. The depressed diaphragm rises promptly to its old position in the pleural cavity. The liver, spleen, and the rib-wall undergo striking modifications. We do not expect the lung to dilate to its full extent, as after aspirations in simple pleurisies. The lung, indeed, is already impaired in its movement. We admit air in order to secure treatment to these surfaces. When air is admitted into the normal chest, the lung is retracted to about one-half its size. ”

“ The unexpanded lungs are brownish-red, firm in consistence and distinctly lobulated. Air-containing lung floats in water and crepitates, and gives off bubbles when cut beneath the water. Attempts at artificial respiration may draw some air into the lungs. Gas-bubbles may be produced by decomposition. In white pneumonia the lung is pale, grayish-white and airless. The larynx, trachea and bronchi are to be examined for presence of mucus, [Pg 185] amniotic fluid, meconium, foreign substances, etc. ”

“ Later observers have confirmed my original observation, that if the body be opened directly after death the left ventricle will be found firmly contracted, though the right heart and the pulmonary arteries, with their branches, are gorged with dark fluid blood. In my cases the lungs did not present at all the appearance of congestion of their minute capillaries, but when they were cut the blood poured from them abundantly, seemingly from their larger vessels. Not only do the lungs suffer from venous congestion, but the whole body also. ”

“ Embolism of one of the middle or larger branches of the pulmonary artery is also characterized by great embarrassment of respiration, but is not likely to be mistaken for asthma by any one at all familiar with the two affections. The cachectic appearance of the patient, the intense anxiety depicted on his countenance, the evidence of cardiac disease or of some affection of the vessels, the weakened cardiac impulse, the thready and at times irregular pulse, together with evidences of more or less pulmonary oedema, are sufficient to distinguish this form of dyspnoea from that of asthma. ”

“ Percussion shows a lack of resonance over the whole lung, not so flat and definitely circumscribed as in pneumonia but a partial flatness of sound over the whole chest. In pneumonia a limited area of lung is absolutely solidified (hepatized) while the remaining lung is practically normal, whereas in acute congestion often the whole lung is gorged with blood but for some time no part of it is entirely divested of air. ”

“ It bears the same relation to phrenitis, when it arises from indirect causes, which pneumonicula does to pneumony; and it is produced nearly in the same manner as the pulmonary consumption, by debilitating causes which act primarily on the whole system. The peculiar size and texture of the brain seem to invite the inflammation and effusions which follow debility, to that organ in childhood, just as the peculiar structure and situation of the lungs invite the same morbid phænomena to them, after the body has acquired its growth, in youth and middle life. ”

“ In heart disease there is often dyspnoea, or difficult breathing, but this is not of the nature of asthma, or phthisic. The condition of the lungs is readily understood. There being an obstruction to the free passage of the blood through the heart, any excessive muscular exertion, or anything, in fact, which increases the action of the heart, is very apt to produce congestion of the lungs, and then the blood becomes surcharged with carbonic acid, which causes increased efforts to take more air into the lungs. ”

“ The countenance becomes at an early period glazed and ghastly, and the extremities cold and clammy. The breathing is often laborious, owing to the movements of the chest increasing the pain in the stomach,—or because pulmonary inflammation is also at times present,—or because the admission of air into the lungs is impeded by the injury done to the epiglottis and entrance of the larynx. To these symptoms are added occasional fits of suffocation from shreds of thick mucus sticking in the throat, and sometimes croupy respiration, with sense of impending choking. ”

“ On examination of the lungs mucous râles are heard in the larger bronchi, cavities may be found at any part of these organs, and points of lobular pneumonia may be detected.
A very serious complication is an inflammation of the heart muscle. This is shown by a very weak and rapid pulse, great prostration, some filling of the lungs. This complication nearly always terminates in death. Other complications which may be mentioned are inflammation of the kidneys, blood poisoning, congestion of the brain, and inflammation of the tendinous sheaths and the tendons of the legs. ”

“ 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 health the two pleural surfaces of the lungs are always in contact, and they secrete just enough serous fluid to allow the surfaces to glide smoothly upon each other. Inflammation of this membrane is called pleurisy. In this disease the breathing becomes very painful, as the secretion of glairy serum is suspended, and the dry and inflamed surfaces rub harshly upon each other.
The root of the lung, as it is called, is formed by the bronchi, two pulmonary arteries, and two pulmonary veins. The nerves and lymphatic vessels of the lung also enter at the root. ”

“ In disease of the mitral valve, in cardiac dilatation and in simple feebleness of the heart, such as is seen in old age and after debilitating fevers, especially typhoid, there is commonly developed a venous congestion of the bases of the lungs, forming the so-called hypo static congestion of those organs, and to this is frequently added pneumonia. ”

“ The lung, which is at first enlarged, becomes shrunken, dense in texture and solid, any unaffected portions being emphysematous; the bronchi are dilated, the pleura thickened, and the lung substance often deeply pigmented, especially in the case of miners, who are apt to suffer from this disease. The other lung is always greatly enlarged and distended from emphysema; the heart becomes hypertrophied, particularly the right ventricle ”

“ 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. ”

“ 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 ”

“ The emphysema occasions an increase in the shortness of breath from which the person had previously suffered, and later, in consequence of the greater difficulty with which the blood circulates through the emphysematous lungs, the right side of the heart becomes dilated, and from that we have the development of a general dropsy of the subcutaneous tissues, and less and less perfect aeration of the blood. ”