Pneumoconiosis

“ 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. ”

“ 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. ”

“ 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. ”

“ 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. ”

“ The most frequent seat of pneumonia is the base or lower lobes, but occasionally the apices are the only parts affected. The right lung is the most often attacked. Pneumonia may extend to the entire lung or it may affect both lungs. The death rate of acute lobar pneumonia in the chief London hospitals is 20%. With an organism so prevalent as the pneumococcus it follows that alcoholism, diabetes and other general diseases and intoxications must render the body liable to an attack. Males are more commonly attacked than females, and a previous attack seems to give a special liability to another. ”

“ 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. ”

“ 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 ”

“ In pneumonia, as in typhoid fever, so-called walking cases always have a serious prognosis. They occur in very strong patients who resist, not the invasion of the disease, but its {152} weakening influence, and keep on their feet for several days, despite the presence of symptoms that require them to be in bed. When a patient walks into a doctor's office in the third or fourth day of a pneumonia with most of one lung consolidated, exhaustion of the heart and of the nervous system, under these unfavourable conditions, will usually have made his resistive vitality very low. ”

“ From Chronic Pneumonia.—Mediastinal growth invading the lung from its root has been mistaken for chronic pneumonia. Walsh lays stress on the following signs as distinguishing tumor: 1. A tendency to increase instead of diminution of bulk of the affected side. 2. Implication of the mediastinum, with dyspnoea out of proportion to the extent of consolidation. 3. Different characters of respiration in the two diseases. To these may be added pressure symptoms in general in cases of tumor, with displacement of the heart toward the side unaffected by the pulmonary process. ”

“ An anthracotic lung has, therefore, less chance of recovery from pneumonia than a lung which has not undergone changes from the deposit of carbon.
Dr. William Charles White, from a study of the relation of the mortality from tuberculosis and pneumonia to the smoke content of the air, shows that, in Pittsburgh, pneumonia increases with the density of smoke irrespective of the density of the population or of poverty. Tuberculosis, on the other hand, he shows to he independent of the smoke density, following, as it does everywhere, the line of overcrowding and poverty. ”

“ 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 cases of death from uncomplicated pneumonia a very variable extent of lung is involved. In some cases this result may be ascribed to the weakness of the individual and especially of the heart, but in others the virulence of the micro-organisms and the toxins which they have produced is probably the more correct explanation. The improvement in a patient suffering from pneumonia usually commences suddenly, with a rapid fall in the temperature. ”

“ 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. ”

“ Pneumonia is commonly unilateral, and can occur in any part of the lung, while pulmonary oedema is bilateral, and usually occurs in the most dependent portion of the lung. In pneumonia we have the crepitant, dry râle, while in pulmonary oedema we have subcrepitant râles, larger and more liquid than those in pneumonia. Bronchial breathing and bronchophony occur in pneumonia, and are absent in pulmonary oedema. Percussion dulness is more marked in pneumonia than in pulmonary oedema, and the diseases with which the latter condition is apt to arise will aid us very much in the diagnosis. ”

“ The quantity may equal that from the most typical bronchial or broncho-pulmonary hæmoptysis in phthisis; usually it is not copious. Fever is not an ordinary accompaniment, but may develop in consequence of increased structural lesion, as from pneumonic infiltration around a large infarction. It has not then the typical range of ordinary pneumonia, seldom going beyond 100 or 101. The physical signs exclusive of the primary cardiac lesion are those pointing to limited infiltration of lung-tissue about the middle or lower region of the lung. ”

“ When the summit of the lung is involved, the dyspnoea is always greater than when the pneumonia is at the base. In pneumonia of the apex in children the dyspnoea is so great that the nostrils are widely dilated, the mouth is open, and its corners are drawn downward and outward. In senile pneumonia, even when the respirations are 70 per minute, patients do not complain of difficulty in breathing.
When persons over seventy who have been asthmatic or are the subjects of chronic bronchitis develop a pneumonia, they often suffer less from dyspnoea than before the pneumonic attack. ”

“ All forms of broncho-pneumonia depend on the invasion of the lung by micro-organisms. No one organism has however been constantly found which can be said to be specific, as in lobar pneumonia; the influenza bacillus, micrococcus catarrhalis, pneumococcus, Friedländer's bacillus and various staphylococci having been found. ”

“ 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. ”

“ Double pneumonia is not often recovered from, and pneumonia of an entire lung is more dangerous than when only a single lobe is involved. In pneumonia at the apex in infancy and old age the prognosis is unfavorable. The more feeble the patient at the time of the attack, the less are his chances of recovery. ”

“ Exceptional cases are those in which the interstitial pneumonia is the result purely of the local action of inhaled irritating particles (vide PNEUMONOKONIOSIS) . In these cases the tuberculous characteristics may be wanting. In cases of fibroid phthisis both lungs are often affected. But the affection is apt to be confined to, or much more extensive in, one lung, so that during life it either is, or appears to be, unilateral. Exceptionally, both lungs are extensively affected. It may originate in and be limited to a lower lobe. ”

“ 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. ”

“ 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. ”

“ It is an extremely fatal affection in both the very young and old. Young persons who have suffered from it are not infrequently attacked by pulmonary tuberculosis subsequently. It must be admitted that we are even less certain of its bacteriology than we are of that of lobar pneumonia. In some cases Frankel's pneumococcus is found, and in others various other micro-organisms. Many of the latter are doubtless saprophytic, and are not the essential cause of the disease, but it is not probable that any one particular form of organism accounts for all forms of broncho-pneumonia. ”

“ If it is less intense over the affected portion of the lung, it is exaggerated over the unaffected portion. These changes are apt to pass unrecognized unless auscultation is practised frequently and early in the disease. As soon as the engorgement is well marked and exudation takes place into the air-cells, fine crackling sounds are heard at the end of inspiration. These sounds are called crepitant râles, and are regarded as the characteristic sign of the first stage of pneumonia. ”

“ 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. ”

“ Section of the vagi certainly produces hepatization of the lungs, but it is not the hepatization of croupous pneumonia. Its distinctive microscopical characteristics are always wanting in the part of the lung consolidated by such experiments. A strong argument of those who adhere to the local theory of pneumonia is, that cold occupies a prominent place in its production. As exposure to cold and to draughts is a common experience, it is easy to ascribe the origin of any disease to cold. ”