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Pneumonia – Pathology and Diagnostics with Therapeutic Hints

The eminent Dr. C.G. Raue discusses pneumonia and gives therapeutic hints.

Catarrhal pneumonia never originates primarily in the alveoli, unless it be brought on by an irritant, such as chlorine, for instance, when an inflammation may arise in the alveoli and the bronchi simultaneously; otherwise it is always a secondary morbid process to bronchitis, which compare. For this reason it has received the name of Bronchopneumonia; and as the inflammatory process presents itself at first in isolated nodules, from the size of a pea to that of a hazel-nut within the collapsed portions of the lung tissue which still contains isolated portions accessible to air, it has also been named Lobular pneumonia. This morbid process may diffuse all over the lungs in the form of isolated infiltrations, and usually progresses from behind and below, forwards and upwards.

According to all observations its most frequent occurrence is found in the first three years of life, and those of old age, and as indirect causes we may set down all disturbances that favor the development of bronchial catarrh — such as, measles, whooping-cough, diphtheria, influenza, rotheln, sometimes typhus, variola and scarlatina; also foreign bodies in the bronchi and inhalation of gases.

It presents no regular type of fever; the physical diagnosis is of great difficulty. We must mainly rely on the presence of a capillary bronchitis; on the consolidation of the lung, beginning at its base, arising slowly, at first without any prominent signs and mostly bilateral; on the retraction of the lower ribs seen during inspiration; on the indefinite limitation of the disease, the absence of all critical periods and the fluctuations which occur in general and local symptoms.

THERAPEUTIC HINTS — Compare Bronchitis and Croupous Pneumonia.

Serous pneumonia, see Oedema of the lungs.

Pneumonia from embolism happens only in otherwise diseased persons. The emboli are formed either from clots which have originated in the cavities of the right side of the heart, or in the veins of the systemic circulation. In the first place there is disease of the heart, and in the latter their sources are either large external wounds, venous thrombi of the uterus in puerperal women, or bed sores, ulcerations and suppurations of various kinds. When these plugs are non-infectious. They produce mere hemorrhagic infarction. When they are of an infectious nature, they result in embolic or metastatic abscesses, which may perforate into the bronchi, or into the pleural cavity, or even break through the chest walls. Simple infarctions are often accompanied with an effusion into the pleural sac, and are much oftener found in the right lung than in the left.

Croupous pneumonia, is that form which is commonly meant by the term “pneumonia,” and consists of an acute inflammation of the alveoli and bronchioles in which a fibrinous exudation is poured out upon the free surface of the mucous membrane, and there coagulates. It attacks in preference the inferior lobes of the lungs, especially on the right side; very rarely both lungs at the same time. It very rarely pervades one whole lung, being much oftener confined to limited portions, which may even be too small to be detected by percussion. It is also of rare occurrence that the inflammation remains confined to a central portion of a lobe only, (central pneumonia) but generally spreads to the surface of the lobe which joins the pleura.

In aged persons and cachectic individuals the posterior parts of the lungs are most frequently attacked. When normally progressing, pneumonia offers three distinct stages for consideration:

1. The inflammatory stage or hyperemia of the capillaries in the lung tissue with exudation of coagulable lymph.

2. Hepatization, or infiltration of the lung tissue with coagulable lymph.

3. Its resolution, or purulent infiltration.

The characteristic signs of these different stages are as follows:

First stage : As a general thing the disease sets in with a violent chill, often attended with vomiting and followed by an intense fever, with a temperature of 104 to 105 in the evening and from 0.9° to 2.7° less in the morning; the pulse rises to 100 or 110 and the respiration to 40 or 50 per minute. In other cases the disease sets in with several light chills or chilliness, or the chill is entirely absent and the scene opens with convulsions and complete loss of consciousness. The skin is at first very dry, but becomes moist usually about the third day, though only temporarily. The face is purplish-red, and frequently only on that side which corresponds to the diseased side of the lungs. The lips become covered with hidroa, (fever blisters) arid also very often only on the affected side, or, at least, more marked on that side. The alae nasi make corresponding movements with respiration. The voice of the patient is low and he speaks in broken sentences.

Cough is, in almost all cases, present, although in some less marked than in others. The patient generally tries to suppress it, on account of the pain which it gives. At first it is dry, but after a time it yields a tough, jelly-like, viscid sputum, difficult to expectorate, and adhering to the lips, from which it has to be wiped off; it soon changes to the characteristic color of rust, from an admixture of blood.

When the patient complains during the coughing spells of stitching pain in the chest, it is more or less a sign that the pleura participates in the morbid process; when he complains of dull, heavy pains, they probably originate in the bronchial tubes. In consequence of the disturbed circulation through the lungs, the blood being either not sufficiently oxygenized, or being prevented from or retarded in its return from the brain, different brain symptoms originate, such as delirium, stupor, etc., so that the case may take the appearance of typhoid fever, from which it is easily distinguished by the hidroa on the lips, which are scarcely ever found in typhoid fever.

In rare cases we observe jaundice combining with pneumonia. In such cases the liver appears enlarged on account of the engorgement which is brought about by the impeded circulation. As the hepatic veins cross the gall-ducts the latter become compressed and the gall retained. In other cases it seems that pneumonia is complicated with a parenchymatous inflammation of the liver, or a catarrh of the duodenum, causing in either case, icterus.

The urine is scanty and concentrated, and deposits, on cooling, a sediment of brick-dust urates. The bowels are usually constipated. The Physical Signs at this stage are the following :

Inspection discovers decreased mobility of the diseased side of the thorax. In cases where both the lower lobes are engorged, the patient moves only the upper part of the thorax in breathing, whilst the abdomen remains quiet on account of the impossibility to retract the diaphragm.

Palpation shows an increased vocal fremitus, unless the bronchial tubes should be stopped up by mucus. The impulse of the heart is also increased, but felt in its normal position. Percussion yields generally a short, tympanitic sound over the parts involved, as long as they still contain air. Auscultation reveals the crepitant sound which, according to Wintrich, arises in consequence of the sticking together of the walls of the air-cells, and their separation by inspiration.

Second stage, hepatization. The above-mentioned symptoms — fever heat, dyspnea, cough, pain, and brain symptoms continue. The thorax appears, on inspection, still less movable during respiration ; the vocal fremitus is strong, provided there does not intervene a pleuritic effusion between the hepatized lung and the thoracic wall. Percussion gives forth a dull sound, and the resistance of the thoracic walls to the percussing finger is increased, provided the hepatized portion of the lung have the thickness of about one inch, and a superficial extent of several inches. A central location of the hepatization alters the percussion sound very little, on account of the intervening portion of lung containing air.

Auscultation yields neither the natural vesicular breathing, nor the crepitant sound of the first stage, but bronchial breathing, bronchophony, and even pectoriloquy, provided the bronchial tubes, which are contained in the hepatized portion of the lung, be not stopped by mucus, blood-coagula, etc. There are also heard all sorts of rattling noises, if mucus exists in the bronchial tubes.

Third stage, resolution. This sets in sometimes with a sudden relaxation of all the violent symptoms — the temperature falls in from 12 to 36 hours to the normal, and at times even below the normal; the congested, even purplish face becomes pale, the skin moist, the dyspnoea ceases, the sputa become copious, frothy, yellowish, easily expectorated; the urine increases and becomes natural again.

On inspection, we observe that the thoracic walls regain their natural mobility; the percussion sound again becomes tympanitic, and by means of auscultation we observe the bronchial breathing and bronchophony becoming weaker; the crepitation sound reappears, until, at length, the natural vesicular respiration is re-established. This is the regular progress of simple pneumonia, lasting, on an average, from fourteen to twenty-five days, of which two, three, or five days are consumed by its first development, five to eight days by exudation progressing to perfect hepatization, and seven to fourteen days by the resorption of the exudation and convalescence.

But, to the first invasion of inflammation, new invasions often follow, so that it is not uncommon to find in one lung all three stages united. Or, the adjoining portion of the healthy lung becomes oedematous, that is, infiltrated by a serous exudation, in which case the dyspnoea increases to suffocation. There is, at the same time, a frothy expectoration and fine rattling noises in the lung not affected with croupous pneumonia. The impossibility of breathing, on account of the serous infiltration, causes an accumulation of carbon in the blood, and, in consequence, death by suffocation.

Or, the disease takes an asthenic form when the symptoms of the central nervous system assume great prominence from the beginning, so that the whole process might be mistaken for meningitis or typhus; still the infiltration of the lung progresses slowly, and in severe cases is often attended with pleuritis, jaundice, albuminuria, and considerable enlargement of the spleen. This form is also called Typhoid pneumonia.

Or, the morbid process combines with diseases of the heart, such as endocarditis, pericarditis, or valvular affections, all of which lessen a favorable prognosis considerably. Or, abscesses form in the third stage of the disease, which, if small, or deeply seated, offer no phiysical signs, and may discharge and heal. When large, and forming large cavities, we may hear pectoriloquy, and, in some cases, metallic tinkling. Or, the hepatization changes into tubercular infiltration, which is especially the case when the seat of inflammation is in the upper regions of the lungs. In such cases the fever does not leave altogether, but shows some aggravation every night; cough, dyspnoea and the dull percussion sound of hepatization continue, while auscultation reveals bronchial breathing and bronchophony.

Or, the inflammation assumes a chronic form, and the hepatized lung becomes indurated or cirrhosed, the interstitial tissue growing tense and rendering the air-cells impervious to air. The patient is almost free from fever, but recovers very slowly in strength, and we observe, for a long time, the dull percussion sound and the bronchial breathing; whilst, the thorax, in these places, gradually sinks in.

Or, the whole morbid process ends in gangrene, which happens very seldom, and which may be diagnosticated by the sudden general collapse and the cadaverous smell of the breath and expectoration, which is dark blackish and copious.

The mean or average time which it takes for pneumonia to run its course, if it is not interfered with by medicines, is, as above stated, twenty-five days. But this average may, by judicious treatment, be considerably shortened; for pneumonia can be arrested in each of its stages. The most interesting data in this respect have been brought forth by Dr. Eidherr, of Vienna, who has collected all cases of pneumonia out of a large hospital practice, which had been recorded there for ten years. From these data it appears that under the application of the sixth decimal attenuation of the appropriate remedies the average came down to nineteen, under the application of the fifteenth potency to fourteen, and under the application of the thirtieth potency to eleven days.

The Diagnosis must be based on the above detailed physical signs; but one of the most constant and characteristic signs is the great frequency of respirations compared with the pulse, which in very severe cases may approach that of the pulse, usually, however, amounts to one respiration for two or three beats of the heart, while in health the ratio is about 2 to 9, that is 1 respiration to 4 pulsations.

The most fatal days of pneumonia are those between the fifth and eighth days.

Therapeutic Hints:

Sulphur, according to Eidherr, when exudation sets in, that is, when auscultation reveals the crepitation sound.

lodium or Kali hydr., according to Kafka, at the beginning, when the disease localizes itself.

Bromium, in extensive hepatization of the lower lobes.

Phosphorus in capillary bronchitis or or catarrhal pneumonia.

Tartar emet, in pleuro-pneumonia.

Schussler recommends Ferrum phos. for the first, Kali mur. for the second, and Calcarea sulph. for the third stage.

All this is very well, but will not suffice for all cases; we will still have to consider the following:

Aconite, first stage, high fever; must lie quietly upon the back; cannot lie on the right side, by stitching pains in the left. “Raising is difficult, the expectoration being tenacious, falling in a round lump and of a dark cherry-red color.” (C. Pearson.)

Arnica, traumatic cases.

Arsenicum , great anxiety and restlessness with tossing about; great thirst, but drinking little at a time; burning and heat in the chest; pale face; cold extremities; prostration.

Baptisia, “If I could only get my body together; it seems to be in pieces, all scattered about, and I want to get it together.” Typhoid form.

Belladonna, nervousness, delirium, threatening convulsions; drowsiness; inability to go to sleep; starting in sleep. Face flushed, eyes congested; congestion towards the brain. Dry, tickling cough, worse in the night.

Bryonia, expiration shorter than inspiration; inclination to lie perfectly still; the slightest motion increases all the symptoms; great thirst, wanting large draughts of water; desire for acid drinks; or little or no thirst with dryness of the mouth. Better on lying on the painful side; sometimes the reverse. “Expectoration falling in round, jelly-like lumps, and of a yellow or soft brick shade.” (C. Pearson.)

Capsicum, “when coughing, the air from the lungs causes a strange, offensive taste in the mouth, and a badly smelling breath rushes out of the mouth.” (A. R. Wright.)

Carbo veg, third stage; cough by spells, or no cough; hippocratic face, eyes half open, nose pinched and cold, lips blue, pupils insensible, no complaining or crying; pulse small, quick, difficult to count; body emaciated and marbled; feet and hands blue and cold; abdomen distended with gas; respiration frequent and superficial; breath cold — a perfect picture of collapse.

Chelidonium, right side; bilious symptoms; pain under right shoulder-blade; great and quite irregular palpitation of the heart.

Cuprum, after a previous catarrh in the chest or in the bowels; sudden attacks of dyspnoea to suffocation; face earthy, dirty, bluish, seldom red; roof of mouth always red; sweat not profuse, sometimes sour-smelling, without relief; diarrhoea.

Ferrum met, no ailments previous to the chill, dyspnoea increases slowly, face pale, and in adults it becomes collapsed, hippocratic or expressionless, stiff and stupid; the roof of the mouth always white; skin neither cold nor burning hot; pulse neither full nor hard; stool consistent, brown.

Ferrum Phos, the expectoration is clear blood.

Gelsemium, after a sudden check of perspiration with pain under the scapula of both sides. (A. E. Small.)

Kali carb, cough worse towards 3 o’clock a.m., almost choking; pain in lower part of chest with dull percussion sound; pulse small and somewhat irregular ; face pale, skin and stool dry.

Kali hydr, after shaking chill, fell in a deep sleep, out of which he could not be roused; snoring loudly with closed eyes, injected conjunctiva, hot head, dry tongue, bluish lips, sunken lower jaw, bluish finger nails; irregular and intermitting pulse; lies upon his back; the extremities, when raised, fall back as if paralyzed; has not voided urine nor asked for any drink. Both upper portions of the lungs hepatized. (Kafka.)

Lachesis, great dyspnoea, worse in the afternoon or after sleep, left side, badly-smelling stools, even if formed.

Lycopodium, circumscribed redness of the cheeks; lips and tongue ulcerated, red and dry ; fan-like motion of the alae nasi; cannot bear to be covered; sweat without relief; cross on getting awake. “The patient raises a whole mouthful of mucus at a time, of a light rusty color, stringy and easily separated.” (Pearson.)

Merc sol, right side, bilious symptoms, jaundice, diarrhoea.

Nitrum, annoying feeling of heaviness in the chest, as though some great load were pressing the thorax together; can drink only in little sips for want of breath, dyspnoea to suffocation.

Nitr. ac, in protracted cases, in weak, cachectic individuals, where there is a sudden abatement of pain, and yet an increase of the pulse in smallness and quickness.

Opium, Mr. H. F., aged 40 years, of a phlegmatic temperament; double pneumonia. At times feels as though he were not in his house, which he expresses by saying: “I wish I could be in the house with my family.” Although in a desperate condition, he is not much alarmed and wants to sit up a great part of the time, because the bed feels too hot. His whole body, except the lower extremities, perspire profusely, the sweat is very hot. The perspiring parts are covered by a heavy crop of sudamina. He gropes with his hands above the bed as though he were hunting something.

About the author

C.G.Raue

C.G.Raue

Dr. C.G. Raue, M.D., studied with Constantine Hering in Philadelphia. He received his medical degree in1850 and practiced in both Trenton N.J. and Philadelphia Pa. He also served as Professor of Pathology and Diagnosis at the Homoeopathic College of Pennsylvania.

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