Part 39
The _cough_ is usually dry in the commencement of idiopathic pneumonia, rarely recurring by paroxysms, and is without any particular indication; it is soon, however, accompanied with a slight mucous expectoration, which, after some twenty-four or forty-eight hours, begins to assume certain and peculiar characters of the utmost importance as indicating the existence and the different stages of the disease. On the second or third day the expectoration becomes bloody. Each sputum, spit, or _crachat_ of the French is composed of mucus intimately combined with blood--that is, not simple streaks or striæ of blood, as in catarrh; nor is it pure blood, as in hemoptysis. Each sputum is either of a yellow, or rusty, or even red color, according to the quantity of blood intimately mixed with the mucus. These sputa are at the same time tenacious and viscous, adhering so intimately together as to form a homogeneous transparent whole, readily gliding, however, from the basin in which they are held on sufficient inclination being given to it. At this period or stage of the disease, the sputa adhere strongly to each other, but the mass is not sufficiently viscid to stick to the sides of the vessel. When no further change takes place in the sputa the inflammation rarely passes beyond the first stage of obstruction or engorgement, or swelling. When they attain to a more viscous state, and adhere to the inside of the vessel in which they have been received, the progress of the inflammation to the second stage, or that of hepatization, may be feared. In almost every case where the viscidity of the expectorated matter increases, respiration becomes dull or bronchial, percussion of the chest yields a duller sound than before, and the inflammation has attained its highest degree. The expectoration, after being some time stationary, changes its character. If the complaint is to terminate by resolution, or by death, or to pass into a chronic state, the redness and viscidity gradually diminish, and at last disappear. If the rust color and the viscidity should return, there has been a relapse, which the reappearance of the other symptoms will show. When the inflammation is of the most serious nature, and about to terminate fatally, the expectoration diminishes, and at last ceases. In some cases it only diminishes because it cannot be discharged; it accumulates in the trachea, in the larynx, and in the bronchi, until the patient is destroyed. In some rare cases the matter secreted is spit up nearly to the last, and in others, still more rare, the approach of death in the last stage is characterized by a brown expectoration which cannot be mistaken for either of the others which preceded it. If the pneumonia pass into the chronic state, the expectoration becomes yellowish, or somewhat greenish, and at last is purely catarrhal.
Delirium is not an uncommon symptom when the inflammation of the lung is intense in persons of powerful constitutions, particularly during the exacerbation of fever in the night. It yields with the other symptoms when relief is obtained. When, however, it comes on at a later period of the complaint, or when the accompanying fever is not purely inflammatory, or in persons weakened by exhaustion and privation, it is usually a fatal symptom if continued. When mild, it often occurs after repeated and efficient bleedings, which have subdued, but not entirely removed the disease; and yields to opiates and gentle stimulants, by which the pain is removed, although it sometimes remains in a milder degree than before.
The ear discovers, soon after the commencement of the disease, that the natural murmur cannot be distinctly heard, it having been at first partly obscured, and after a time entirely superseded by a peculiar noise, called a crepitating or crepitous rattle or rhonchus. In its purest state it has been likened to the sound of a lock of hair rubbed close to the ear, or to that made by rumpling a fine piece of parchment; or again, to that which is produced by what under ordinary circumstances is called the crepitation of salt, when scattered in small quantities on red-hot coals. This crepitating rhonchus is heard at first in a small part of the lung, generally at the lower rather than at the upper part; it marks the first stage of the disease. It is not of long continuance; the vesicular murmur is either restored, or the crepitating rhonchus ceases to be heard, in consequence of the second stage to this, or that of hepatization, having commenced; the small air-vesicles are no longer pervious; the sound of the breathing, which is now heard, is that of the air more forcibly driven into the larger bronchial tubes causing _bronchial respiration_, which is no longer a vesicular or crepitating, but a whiffing sound, like that caused by blowing forcibly through a quill, or as if little gusts of air were blown in or blown out. The voice betrays to the ear of the auscultator another sign; it descends into the pervious bronchi, and being conveyed to the ear through the solid lung, gives rise to that peculiarity of voice called _bronchophony_, a correct knowledge of which can only be acquired by repeated observation.
When the inflammation of the lung is confined to a small and deeply-seated spot, auscultation may not at first reveal the evil; or it may possibly be overlooked, through the sound part of the lung becoming more active, and giving forth in consequence a stronger and more puerile breathing, which may mislead the listener.
When the vesicular murmur cannot be heard, when the _rhonchus_ or _crepitating râle_ or sound is not present, and bronchial respiration and bronchophony only can be distinguished, the case is one of great anxiety and danger. The second stage of hepatization is passing into the third, or purulent infiltration, of which auscultation shows no further signs, although the matter secreted may be expectorated, in proof of what has taken place. Pus is thus formed, which it is steadily maintained by some pathologists is not deposited in the form of abscess, but is infiltrated throughout the parenchymatous substance of the lung, finding its way into larger bronchial tubes, or being poured out from some parts of their secreting surface; the accuracy of this statement, however, as a rule, may be doubted, from some dissections having proved the reverse.
302. The effects of inflammation of the pleura are well marked; the first is to diminish, if not to annul, the secretion of the exhalation, or halitus, by which it is lubricated; so that its surfaces can no longer glide without noise upon each other. The patient is often made aware of the difference by some uneasy internal sensation; the auscultator, by a rubbing or creaking sound emitted as the inflamed pleuræ, no longer smooth and polished, rub against each other, and become covered by a thick, effused matter, although not actually separated by a liquid. It is a sound which cannot exist after separation has taken place by the intervention of a fluid, or after adhesions have formed; it is, therefore, an early and transitory sign, is frequently interrupted, and returns, as if by jerks, three or four times repeated in succession. The pleura when inspected, after being attacked by inflammation, shows at first but little sign of derangement on its serous surface. It quickly, however, exhibits numberless small vessels, carrying red blood, which are principally seated in the sub-serous cellular tissue, reddening the membrane more deeply in one part than another. These soon begin to take on a new action, leading to the deposition of coagulable lymph or fibrin, which adheres to the inflamed surfaces. These deposits soon assume the determinate form of very thin layers, constituting what are called false membranes; while a serous or sero-purulent effusion takes place, even to filling the cavity of the chest, and which may or may not be ultimately absorbed. When coagulable lymph is first deposited, and about to form a false membrane, it is soft, of a grayish-white color, and does not possess any appearances of organization. Red points are, after a time, perceived in it, which soon become red lines or streaks, on the surface. This organization of the lymph does not depend on the period which has elapsed from the commencement of the complaint. It is seen in the first day of the disease in some cases; it is altogether absent in others, and depends much on the state and habit of the patient. The lymph is sometimes deposited in small drops or spots; in others, in patches of a greater or less size, varying according to the extent of the inflammation which has produced them. When a false membrane is once fully formed, it becomes itself a secreting surface, and may go on augmenting its thickness to so great a degree as materially to diminish the cavity of the chest. I have seen the pleura with a solid deposit of this kind much more than an inch in thickness. In general, it is found in distinct layers, superimposed one upon the other. Whatever may be their thickness, they commonly admit of being separated from each other. The false membranes thus formed, resembling areolar tissue in their properties, may ultimately become cartilaginous, and even bony. When simple adhesions form between the pleuræ, they become lengthened with time; and, although they impede the motion of the lung at first, and may give rise to some uneasy sensations, they gradually become elongated, and give no further inconvenience. The fluid thrown out is serous; is often mingled with flocculi or lymph, which are seen floating in it; it is therefore more or less turbid, resembling whey. It is often nearly colorless and transparent; when the consequence of injury, it is often tinged with blood, forced out from the capillary vessels of the pleura, or of the false membrane, if not caused by the deposition of the fluid coagulated in the first instance after the receipt of the injury.
The quantity of fluid thus thrown out varies from an ounce to several pints; it gravitates according to the position of the patient, unless, when from old adhesions between the pleuræ, it is confined to particular parts. When the cavity of the pleuræ is free, and the fluid is in quantity, it compresses the lung, and diminishes its size by pressing or squeezing the air out of it; it is thus pressed toward the vertebral column, and so greatly diminished in size and augmented in density as to be useless for the purposes of respiration. While the lung is undergoing this compression to its utmost, the mediastinum also yields, and bulges into the opposite side of the chest, carrying the heart more or less with it; so that when the left side of the thorax is thus affected, the heart is seen and heard to beat on the right. The diaphragm now yields in turn, more on the left than on the right side, from the obstacle to its descent afforded by the liver. The intercostal muscles and ribs resist the internal pressure for a considerable length of time, even for weeks; they at last, however, yield; the ribs may even turn a little outward, while the interspaces in thin persons are said to fill out, so as to render that side of the chest nearly smooth, the size of that side, when measured, being larger than the other, in some instances even by two inches, but this rarely occurs unless the fluid within is purulent, and the disease of long standing.
303. After a time, and particularly in wounds of the chest, the effused fluid becomes purulent, the lung, compressed to a small, flattened surface, adheres to the spine by what was its root, if no adventitious attachments have retained it in a different position; and the pleura has become a thick, yellowish-white, irregular, honey-combed sort of covering for it, as well as completely lining the chest. The serous as well as the purulent effusion are both free from any unpleasant odor; unless a kind of gangrene has taken place, when the latter becomes very offensive, and of a greenish-black color, as well as the substance of the false membranes extending to and sometimes beneath the pleura covering the condensed lung, into which openings have even thus been made.
In some cases the surface of the pleura is covered with small tubercles, some as large as a filbert; in others it appears to have a reticular or honey-combed appearance; and in particular cases, large irregularities or excavations may be observed in it when much thickened, being evidently spots of ulceration, which, if they had proceeded, would have ended by allowing passage to the matter outward, until it formed an external abscess, implicating in all probability one or more of the ribs; thus giving rise to an exfoliation which, by being separated internally, might in time be the cause of further mischief, if not previously covered by a thin layer of false membrane. When chronic pleurisy succeeds to a more acute attack, or they alternate with each other, particularly after penetrating wounds of the chest, several layers seem to be laid down one upon the other. This deposit is never so thick upon the pleura pulmonalis; nevertheless it is thick enough in most instances to prevent the lung from again dilating, the substance of it being generally quite permeable to, although so compressed as to be deprived of, air. It is then flattened, drawn upward toward its root against the mediastinum and spinal column, unless by some previous adhesion such a course has been prevented, and it adheres, as it has been often known to do, to the side of the chest. As that adhesion may occur in more than one spot, so may the effusions or deposits take place between them, constituting circumscribed sacs, and rendering the case more complicated.
304. The changes which take place in the structure of the lung in pneumonia are three in number: 1. Engorgement. 2. Hepatization. 3. Purulent infiltration. The formation of an abscess or vomica, and the occurrence of gangrene, may be omitted, as well as of chronic disorders, in the views about to be taken of the disease from injury.
In the first stage of inflammatory obstruction, or that of engorgement, the lung has assumed externally a livid-red or violet color. It is heavier and firmer than in its healthy state, and the natural feeling of crepitation, although greatly diminished, is not extinct. The lung retains the impression of the finger, and pits on pressure as if it contained a liquid, although air-bubbles can yet be distinguished in it, and its cellular or spongy texture is still to be observed. On cutting into it, a quantity of sanguineous or turbid fluid flows from it, mingled with numerous minute air-bubbles. In some places the color of the incised surface is darker and more compact, showing that some progress has been made toward the stage of hepatization. It nevertheless tears with greater facility than in a healthy state.
In the second stage, or that of the red softening of Andral, the hepatization of Laennec--the latter term being in most common use, from the lung assuming somewhat the appearance of liver in solidity and weight--the lung does not crepitate, no air-bubbles pass out of it, but a thick, bloody fluid exudes on pressure, and it sinks for the most part in water. The color is somewhat less red or violet than in the first stage, and lighter and more varied in color when cut into. The openings of the larger vessels and of the bronchi, when cut across, are observed as white specs; the interlobular tissue is thicker and more marked in lines running in different directions; while many little granular points can be discovered, especially with a glass, apparently of a more solid material than the surrounding parts.
The word solidity, or solidification, is sufficiently explanatory in contradistinction to the naturally pervious and crepitating state of the lung. Andral believed that hepatization arises from an excessive congestion of blood, and not from any deposition of lymph. It is not easy, however, to understand, in the present state of our knowledge, how acute inflammation can go on for three or more days without secretion and deposition being added to congestion. That hepatization, or impermeability to air, may take place in the typhoid pneumonia in twenty-four hours, and that it as suddenly seems to be removed, is hardly conclusive, as it shows merely that a thoroughly well-loaded lung ceases to be permeable to air until a part of the load shall have been displaced.
When the lung, inflamed to the second stage, or that of hepatization, is about to be restored to a state of health, a slight crepitation or crackling begins again to be heard at the end of each inspiration; and as this increases, (the rhonchus crepitans redux of Laennec,) the bronchial respiration and voice gradually, or after a time, diminish, until they entirely disappear; while a mucous râle or rattle commences, the index of that free expectoration by which pneumonia usually terminates.
In the third stage of morbid change, or that of purulent infiltration, the lung is of a lighter color, from the intermixture of a new matter in its substance, although in the first degree it preserves its firmness and granular structure. The new secretion is of an opaque, straw or yellow color, and puriform in its nature. This is discoverable more particularly in spots; but as the disease proceeds, it pervades the whole substance of the lung, which becomes softer and more moist, and is easily broken down by the fingers, the granular structure having disappeared. It is more or less a purulent sort of sponge, in which all of the lung that can be perceived under a strong light may be resolved into small blood-vessels, bronchial tubes, and interlobular septa.
These three degrees or stages of inflammation may be met with in the same lung, for the most part gradually intermingling one with the other. The lower part of the lung being ordinarily first affected, is usually the seat of the purulent infiltration of the third stage; while in the tubercular affection, which ends in phthisis, the disease commonly begins in the upper part.
Resolution or recovery from even this, the last of the morbid changes which have been observed, may take place, although it is less likely to do so after idiopathic than traumatic inflammation, in which the lung was previously healthy, and the constitution unimpaired.
LECTURE XXI.
GENERAL BLOOD-LETTING, ETC.
305. The first and most essential remedy in the treatment of pleuritis and pneumonia from injury is bleeding, which should be resorted to in every case, whenever the febrile excitement is really inflammatory. All old people, under such circumstances, unless in a cachectic state, bear at least one bleeding well; they often bear more; and no fact is more important, in opposition to the opinions commonly entertained on this subject. In young people, who have not been reduced in health and strength by privations and hard service, the bleeding should be repeated until the desired object has been effected; the quantity required to be drawn in inflammation, particularly after _injuries_, is often very great. It may almost become a question, in some cases, whether a patient shall be allowed to die of the disease, or from loss of blood; for convalescence is rapid in proportion as the inflammation is of small extent, and has been early subdued. As the first stage of pneumonia only lasts from twelve hours to three days before it passes into the second, and the second from one day to three before matter begins to be deposited, no time should be lost to prevent these evils taking place, if the patient is to be saved, without incurring a risk, from which few escape with health, even if life be ultimately preserved. Bleeding in inflammation of the pleura, in _young_ and _healthy_ persons, should therefore be effected with an unsparing hand, until an impression has been made on the system--until the pain and the difficulty of breathing have been removed--until the patient can draw a full breath, or faints; and the operation should be repeated, from time to time, every three or four hours, according to the intensity of the recurrence, or the persistence of the essential symptoms. The pulse does not often indicate the extent or severity of the inflammation, although it often expresses the amount of the constitutional irritability of the person. It is sometimes exceedingly illusory as a guide, and is never to be depended upon in the earlier stages of disease, when accompanied by pain and great oppression of breathing. Whenever the pulsations of the heart are proportionally much stronger than those of the arteries, we may bleed without fear, and with the certainty of finding the pulse rise; but if the heart and pulse are both weak, the abstraction of blood will almost always occasion complete prostration of strength, and may be fatal.
306. When many years ago in charge of a regiment of infantry, on the top of the Berry Head, the outermost point of Torbay, the men thus greatly exposed were attacked by pneumonia. According to the practice taught in London, I bled my patients three and four times in the first forty-eight hours. I first drew sixteen ounces, then fourteen, then twelve, then abstracted, as the complaint continued, eight ounces; gave tartar emetic, so as to keep up nausea; then calomel, antimony, and opium, and lost my patients. I examined the bodies of all, and found that they had lived to what is now called the third stage of pneumonia, combined in almost all with pleuritis, with effusion, and the formation of false membranes. The disease was essentially a pleuro-pneumonia, varying in different degrees, as the pleura or the lungs were principally affected; and I saw with regret that the disease had not in any way been arrested; that the means employed had been insufficient. What was to be done? My sixteen ounces of blood were increased to thirty, but it would not do. It was evident that, to succeed, no limit should be placed to the abstraction of blood in the first instance, but the decided incapability of bearing its further loss. Every man was therefore bled, when he came into the hospital, until he fainted, and the bleeding was repeated every four hours, or even oftener, as long as pain or difficulty of breathing remained; under this improved practice all recovered.