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.