A system of practical medicine. By American authors. Vol. 3

by Unknown

It is not necessary to give any detailed discussion of the other symptoms of acute catarrhal pneumonia as occurring in adults—the atypical remittent type of fever; the rapid pulse and breathing; the digestive symptoms, anorexia, thirst, occasional nausea, and a comparatively frequent tendency to diarrhoea; the nervous restlessness and depression, with delirium supervening, at first slight, later more active, and toward the close of fatal cases of such violence as to require restraint, alternately with deepening stupor from exhaustion and defective aëration of the blood. Albuminuria may be present in a slight degree toward the close of severe cases. When death occurs in these acute cases it usually does so from the tenth to the sixteenth day. In children it may occur suddenly during or after a violent paroxysm of cough, or an attack of convulsions may be the immediate cause of death. More commonly death is preceded by evidences of increasing intensity of interference with the aëration of the blood, and with deepening stupor and nervous disturbances such as have been described. 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. When recovery is to follow, the disease declines gradually and irregularly, slight recurrences of fever and renewed catarrhal irritation being observed from time to time. These exacerbations may not rarely be traced to atmospheric influences or to trifling indiscretions on the part of the patient. The pain declines gradually; and the pulse-rate also falls, but even after the temperature has become normal some degree of rapidity of the pulse is apt to remain for a considerable time. The physical signs gradually disappear: the respirations, like the pulse, remain somewhat rapid, or at least are for some time readily accelerated; and there is apt to be some cough remaining, with gradually decreasing muco-purulent expectoration. The digestive functions are also apt to be left in an enfeebled condition, and the recovery of full nutrition and health is often slow. A peculiar sensitiveness of the general system is frequently noted after this disease, so that morbid processes, especially of catarrhal type, are readily excited.

As would be expected, catarrhal pneumonia frequently presents much less violent symptoms and runs a much less acute course than above described, so that it may be said to assume a subacute or chronic form.

In children this may occur as the result of an acute attack, the severe symptoms gradually subsiding, and passing into a less violent but persistent type. In other cases the disease assumes this form from the beginning, and such instances are more commonly noted after ordinary bronchitis of moderate severity or after whooping cough. In adults this form also is less common than in children. It is met with as an intercurrent affection in certain cases of phthisis; and not rarely the exacerbations of that disease are due to the development of centres of catarrhal pneumonia which too often become later the seat of an extension of the tuberculous process. It occurs in this form also in the old and cachectic, and doubtless proves the undetected source of death in many cases where the end is preceded by irregular pains and by some signs of hypostatic infiltration of the lungs. In a feeble and exhausted state of the system at all ages it is liable to be induced. At times this is brought about by a series of recurring slight catarrhal attacks, gradually deepening into a subacute process of catarrhal pneumonia; while in other cases a more powerful disturbing cause will in such states of system directly induce this type of the disease. It develops insidiously. There is little or no pain. The fever is highly irregular; the maxima usually occur in the evening and reach 102° or 103°, but there may be such marked remissions as to make the case closely simulate one of intermittent malarial fever complicated with bronchitis, and I have known such an error to be made in repeated instances. In some cases, especially in the old and feeble, there may be very little fever, at least until the disease is more fully developed. The dyspnoea is not urgent; the pulse is not extremely rapid; and cough may actually seem diminished if the disease has originated in the course of severe bronchitis. The physical signs develop slowly, but may eventually appear over considerable areas of lung-tissue. In this way with an irregular fluctuating pyrexia, presenting from time to time marked exacerbations, with an equally varying amount of cough and muco-purulent expectoration, and with marked and progressive debility and emaciation, these forms of catarrhal pneumonia pursue a course extending over many weeks or months. Complete recovery is still possible, after a tedious convalescence. Commonly, however, some permanent lesion of the lungs, as emphysema, dilatation of the bronchial tubes, or circumscribed induration of the lung, will remain as sequels. In a large proportion of cases a fatal result finally follows, more commonly from the passage of the morbid process into pulmonary phthisis usually associated with true tuberculosis; while in some cases acute miliary tuberculosis supervenes and proves rapidly fatal. Undoubtedly, however, cases of chronic catarrhal pneumonia may continue purely as such, with recurring exacerbations at irregular intervals from the development of new centres of disease, until death is finally induced by exhaustion.

COMPLICATIONS AND SEQUELS.—It is needless to repeat what has been said as to the essential connection between catarrhal pneumonia and bronchitis, so that the latter is to be regarded as an invariable symptom and attendant rather than as a complication. As might be expected also, catarrhal laryngitis of varying degrees of severity is of comparatively common occurrence. Especially in cases occurring in connection with measles, where the upper respiratory tract is already inflamed, the increased intensity of the laryngitis may induce so much swelling as to cause some mechanical obstruction to respiration which will arouse fears of pseudo-membranous formation, and which, during the spasms of cough and dyspnoea which are apt to occur occasionally, will closely simulate true croup. Pleurisy rarely appears in such a high degree as to constitute a serious complication. When the areas affected are superficial, there is apt to be circumscribed plastic exudation on the corresponding portions of the pleura. Less frequently quite extensive plastic pleurisy occurs, with layers of exudation sufficiently thick to modify the physical signs; and in still more rare instances does fibro-serous effusion occur. I have noted the occurrence of purulent pleurisy, as has Jürgensen; and in two cases it was found to be associated with subpleural purulent foci, one at least of which had ruptured. In the other cases the purulent character of the pleurisy was presumably due to the constitutional dyscrasia. Allusion has already been made to the occurrence of emphysema and bronchiectasis in connection with catarrhal pneumonia, especially of the subacute and chronic varieties. The observations of Delafield on the tendency of the catarrhal inflammatory process to extend laterally through the bronchial wall into the peribronchial zones of lung-tissue are of special interest in their bearing on the liability to dilatation of the bronchial tubes and to deep-seated circumscribed indurations of lung-tissue as sequels of catarrhal pneumonia.

Gangrene of the lung I have known to occur as a complication in one case of extraordinary severity, but in which recovery ultimately followed a very tedious process of reparation. It was attended with recurring attacks of hæmoptysis. The case occurred in a young man of twenty-four years of age: the lesions existed chiefly over the right back, though there were smaller centres elsewhere; and the spot of gangrene and from which the hemorrhages occurred was near the right root. He was four months in bed; his convalescence extended over a year; evidences of induration at the above spot lasted five years; and now, eight years after the attack, he is in vigorous health, though still with slight cough.

Pneumothorax may occur as a sequel in protracted cases in consequence of the rupture of a subpleural abscess. I have elsewhere reported cases of this, and Steffen has also reported two instances.

Tuberculosis occurs in various ways in connection with catarrhal pneumonia. There may be a development of acute general miliary tuberculosis, owing to the depressing and irritating effect of the disease upon a constitution strongly predisposed to tuberculosis. Or tuberculous pulmonary phthisis may ensue, either directly as a complication or as a sequel to ulcerative changes of inflammatory nature in the lung. Finally, those who have passed through an attack of catarrhal pneumonia are usually left with such vulnerability of system that any predisposition to phthisis or to tuberculosis is very apt to be readily called into activity. It seems highly important to note this close and complicated connection between catarrhal pneumonia, in its various types and even in its mild and circumscribed form, and subsequent organic disease.

Further evidence of the profound disturbance of nutrition often effected by an attack of this disease may be found in the occasional development of marked rachitis, and in the much more frequent establishment of subsequent anæmia and debility, which prove obstinate and are associated with a high degree of susceptibility of the system to morbid influences, and which are doubtless, in some instances at least, dependent upon impaired primary assimilation due to lesions of the intestinal canal, which existed as complications of the original attack of catarrhal pneumonia. It has been mentioned that gastro-intestinal irritation is often present, both in the acute and in the more chronic forms, and this may reach such a high degree as to justify the name of a complication. It has seemed to be especially in these cases, or in those where, owing to the subsequent vulnerability of the system, gastro-intestinal catarrh occurs as a sequel, that the serious impairment of nutrition above mentioned is most likely to ensue.

Lastly, allusion must be made to the frequency with which severe nervous symptoms appear, especially during the later stage of the attack. As has been seen, convulsions are not rare in children, while at all ages active delirium and extreme restlessness, often requiring restraint, are of frequent occurrence. These cannot be attributed, as a rule, to uræmic intoxication, but are to be referred to the high systemic irritation, the great nervous exhaustion, and the marked interference with respiration and aëration of the blood. It is probable also that circumscribed areas of lepto-meningitis, or even of tuberculous meningitis, are of occasional occurrence in these cases.

DIAGNOSIS.—The direct recognition of catarrhal pneumonia in its acute stage is not always free from difficulty, while both in the acute and chronic forms there are certain conditions with which care must be used not to confound it.