Pulmonary Diseases

The symptoms of an ordinary “cold” accompany the onset of an acute bronchitis. The coryza extends to the tubes, and may also affect the larynx, producing hoarseness, which in many cases is marked. A chill is rare, but there is invariably a sense of oppression, with heaviness and languor and pains in the bones and back. In mild cases there is scarcely any fever, but in severer forms the range is from 101^o to 103^o. The bronchial symptoms set in with a feeling of tightness and rawness beneath the sternum and a sensation of oppression in the chest. The cough is rough at first, cutting and sore, and often of a ringing character. It comes on in paroxysms which rack and distress the patient extremely.

During severe spells the pain may be very intense beneath the sternum and along the attachments of the diaphragm. At first the cough is dry, but in a few days the secretion becomes muco-purulent and abundant, and finally purulent. With the loosening of the cough great relief is a experienced. The sputum is made up largely of pus-cells, with a variable number of the large round alveolar cells, many of which contain carbon grains, while others have undergone the myelin degeneration. The respiratory movements are not greatly increased in frequency unless the fever is high. There are instances, however, in which the breathing is rapid and when the smaller tubes are involved there is dyspnea. On palpation the bronchial fremitus may often be felt. On auscultation in the early stage, piping sibilant rales are everywhere to be heard. They are very changeable, and appear and disappear with coughing. With the relaxation of the bronchial membranes and the greater abundance of the secretion, the rales change and become mucous and bubbling in quality.

The course of the disease depends on the conditions under which it develops. In healthy adults, by the end of a week the fever subsides and the cough loosens. In another week or ten days convalescence is fully established. In young children the chief risk is in the extension of the process downward. In measles and whooping-cough, the ordinary bronchial catarrh is very apt to descend to the finer tubes, which become dilated and plugged with muco-pus, inducing areas of collapse, and finally broncho-pneumonia. This extension is indicated by changes in physical signs. Usually at the base the rales are subcrepitant and numerous and there may be areas of defective resonance and of feeble or distant tubular breathing. In the aged and debilitated there are similar dangers if the process extends from the larger to the smaller tubes. In old age the bronchial mucosa is less capable of expelling the mucus, which is more apt to sag to the dependent parts and induce dilatation of the tubes with extension of the inflammation to the contiguous air-cells.

Osler, W. (1892). The Principles and Practice of Medicine. New York: D. Appleton & Company. Pg. 490.

Entered by: Ayushi Chintakayala, 6/11/2020

All who are affected with the disease are liable to sudden and violent paroxysms of dyspnea, or to slighter derangement of the respiration; at the same time there are no decided signs of bronchial inflammation. If the respiration be examined, the inspiratory sound is feeble, but at first there is generally no rhonchus; the wheezing, which is occasionally heard at a distance from the patient, is produced almost exclusively in the larynx. The rhonchi and other signs of bronchial irritation are heard if the attack is accidentally complicated with acute bronchitis. If the spasmodic difficulty of breathing continues for a certain time, a few hours, for example, there is always more or less rhonchus to be heard in the chest. This is at first the sonorous or sibilant rhonchus, both in inspiration and expiration; not fixed in any portion of the chest, but diffuse.

Almost as soon as they appear, some trace of mucous rhonchus may also be heard, generally at the base of the lungs; sometimes, however, there is little or no liquid in the chest, and the sounds are limited to the sonorous and sibilant rhonchi. When there is much liquid secretion there is a sub-crepitant rhonchus heard at the same time with the mucous — that is, the liquid is secreted in the smaller tubes, which of course produces this sound. Some of these rhonchi are always produced in every paroxysm of asthma, being caused by the swelling of the mucous membrane, which of course gives rise to a dry sound , the moist rhonchi occurring only when there is some liquid secreted. The cough in cases of asthma is also to a certain extent peculiar. It is always spasmodic, sometimes violent, and may generally be known by its peculiar intonation. It varies very much in different attacks of the disease, and in different individuals, and is often so slight as to be evidently due to an effort made by the patient to free his chest from the difficulty of respiration.

There is sometimes a certain amount of expectoration in nervous asthma, but not always. Upon examination, the matter expectorated is found to consist merely of a thin, glairy mucus. The pulse and circulation are sometimes totally unaffected; but if the difficulty of respiration be extreme, there is generally an increase in frequency of the pulse, though not a decided fever. Paroxysms of true asthma terminate by a gradual decline, or, as in the variety termed asthmatic bronchitis, the attack is not relieved until a free secretion of glairy liquid from the bronchial membrane takes place; in either case the disorder is singularly apt to return in a short time upon a renewal of its exciting causes.

Gerhard, W. W. (1860). The Diagnosis, Pathology, and Treatment of the Diseases of the Chest. United Kingdom: J.B. Lippincott.

Entered by: Bernardo Galvan, 6/16/2020

The discharge is small or at most moderate, and the blood is frothy, and sometimes clotted, particularly towards the end of the attack. Those profuse hemorrhages, which are vulgarly called vomitings of blood, arise almost always from pulmonary apoplexy. On this account, the smallness of the discharge, in any case, may be considered as affording a strong probability that the hemoptysis is the result of simple exhalation. The absence of the stethoscopic signs of pulmonary apoplexy, adds greatly to the certainty of our diagnosis. In the bronchial hemorrhage, the chest is perfectly sonorous.

There exists no crepitous rhonchus; but only  a mucous rhonchus with unequal bubbles, which are usually larger than those of catarrh, and seem to be formed by more liquid materials, and to burst more frequently. The rhonchus is more or less abundant according to the quantity of blood effused. When the hemorrhage is slight, there is no general disturbance of the constitution perceptible; even the pulse continues natural.  When the hemoptysis is more considerable, it is attended by a distinct febrile state; the pulse becomes more frequent, and exhibits a vibratory character, independent of either its force or frequency.

Laennec, R.T.H. (1838). A Treatise on the Disease of the Chest, and on Mediate Auscultation. Wood & Company. Pg. 141–142.

Entered by: Ayushi Chintakayala, 7/10/2020

Congenital –

This occurs in still-born and weak infants, due to weakness of the muscles, obstruction of the trachea and bronchi, or syphilis. The lungs are unexpanded and solid if the condition is total; if partial there are areas containing air.

 

Acquired – Active or Passive:

Atelectasis / Active Collapse (Massive Collapse) – occurs after operations, especially on the abdomen, injuries to the chest, trunk and pelvis, gunshot wounds of the chest (not necessarily on the injured side) and after some acute infections […]. […] The collapse may involve one lobe (usually a lower one), a portion of a lobe, or the whole lung.

The symptoms appear usually within 24 hours of the operation or injury, buy may be delayed for some days. The onset is sudden with severe dyspnea, cyanosis, and prostration. There may be pain, usually in the lower thorax. There is a cough which depends somewhat on associated bronchitis or pneumonia. There is usually fever with increase in the pulse and respiration rate. In milder attacks the symptoms may not be marked. The chest shows decreased expansion on the affected side, to which the heart is displaced, and increased movement on the sound side. The costal movement is absent or reversed on the affected side. Vocal fremitus is variable, usually increased; the percussion note is dull or flat; the breath-sounds are usually bronchial or tubular but may be distant; rales are not constant but are numerous as the lung expands. The voice-sounds are usually exaggerated. The X-ray shows a dense shadow over the affected area with diaphragm high and immobile and the heart displaced. Bronchitis, pneumonia, or pleurisy may follow and naturally influence the signs.

Relaxation or Passive Atelectasis / Passive Collapse – pressure form without, as from pleural effusion, pneumothorax, or obstruction of a bronchus is responsible.

[…] may be general or local and in mild forms is very common. Pleural effusion, pneumothorax, pressure of an aneurism or a foreign body in a bronchus may cause collapse of a large area. Dorsal decubitus and abdominal distention cause collapse at the bases. Small areas of collapse occur with severe bronchitis, bronchopneumonia, etc. The symptoms are so mixed with those of the causal condition that a definite description is not possible. Tympany may be marked, as above a pleural effusion. In the cases due to outside pressure, as aneurism, or a foreign body the vocal fremitus and breath sounds are decreased and the percussion note is dull. With incomplete collapse, dullness and many crackling rales are found. The course depends on the causal condition; a collapsed lung may expand again after a long period of collapse but there is always danger of fibroid change.

Osler, W. & McCrae T. (1892/1925). The Principles and Practice of Medicine: Designed for the Use of Practitioners and Students of Medicine (10th ed). New York: D. Appleton & Company. Pg. 659 – 660. New York: D. Appleton and Company.

Created by: Taha Jilani, 07/01/2021

Entered by: Rachel Johnson, 08/29/2021

When the whole of one lung is affected, percussion sometimes elicits a duller sound than normal owing no doubt to the compression of the pulmonary substance […] pectoriloquy more or less perfect is perceived; together with a large mucous rhonchus, […]. The bronchial respiration becomes cavernous over the site of the greatest dilatations; and in those nearest the surface of the lungs, the cough and rattle assume also the cavernous character. In the same points, the voice, respiration, and cough, frequently yield the veiled puff, that is, a sensation as if a thin veil or wet membrane was only interposed between the column of air and the ear, and vibrated at each breath. Sometimes all these phenomena disappear for a time particularly if existing in the lower parts of the lungs, owing to the accumulation of sputa, and re-appear after a copious expectoration or a change of posture.

When the dilatation exists only in one point, the signs just mentioned are confined to that point, […]. If the dilatation is moderate and nearly equal in several of the bronchi, there will be diffused bronchophony in place of pectoriloquy. When the dilatation is extensive, bronchophony and bronchial respiration exist over the whole space affected, and perfect pectoriloquy in some points only. In cases even of the most extensive dilatation, the symptoms rarely indicate the severity of the disease. Most commonly there is neither fever (at least continued fever) nor emaciation […]. Even the respiration is not impeded, except under the influence of quick and rapidly renewed movements. […] When the dilatation is very extensive, it is extremely copious. It is always mucous, but occasionally resembles the secretion in the last stage of the acute catarrh, and sometimes it is quite piriform. It is generally without smell, but occasionally has the odor of pus […]. 

Laennec, R.T.H. (1838). A Treatise on the Disease of the Chest, and on Mediate Auscultation. Wood & Company. Pg. 133-135.

Entered by: Ayushi Chintakayala, 7/8/2020

When the whole of one lung is affected, percussion sometimes elicits a duller sound than normal owing no doubt to the compression of the pulmonary substance […] pectoriloquy more or less perfect is perceived; together with a large mucous rhonchus, […] The bronchial respiration becomes cavernous over the site of the greatest dilatations; and in those nearest the surface of the lungs, the cough and rattle assume also the cavernous character. In the same points, the voice, respiration, and cough, frequently yield the veiled puff, that is, a sensation as if a thin veil or wet membrane was only interposed between the column of air and the ear, and vibrated at each breath. Sometimes all these phenomena disappear for a time particularly if existing in the lower parts of the lungs, owing to the accumulation of sputa, and re-appear after a copious expectoration or a change of posture. When the dilatation exists only in one point, the signs just mentioned are confined to that point, […]. If the dilatation is moderate and nearly equal in several of the bronchi, there will be diffused bronchophony in place of pectoriloquy. When the dilatation is extensive, bronchophony and bronchial respiration exist over the whole space affected, and perfect pectoriloquy in some points only. In cases even of the most extensive dilatation, the symptoms rarely indicate the severity of the disease. Most commonly there is neither fever (at least continued fever) nor emaciation […]. Even the respiration is not impeded, except under the influence of quick and rapidly renewed movements. […] When the dilatation is very extensive, it is extremely copious. It is always mucous, but occasionally resembles the secretion in the last stage of the acute catarrh, and sometimes it is quite piriform. It is generally without smell, but occasionally has the odor of pus […]. 

Laennec, R.T.H. (1838). A Treatise on the Disease of the Chest, and on Mediate Auscultation. Wood & Company. Pg. 118–119.

Entered by: Ayushi Chintakayala, 7/8/2020

Results from trauma to or disease of the vessels of the chest wall, pleura, lung and mediastinum. It is a common sequence of wounds of the chest by bullets, shrapnel, or bayonet. […] The blood usually comes from the lung. The amount varies from a few ounces to several pints. When withdraw, the blood forms a scanty clot because much of the fibrin has been deposited on the pleura. The fluid is not all blood but mixed with serous exudate with many leucocytes, endothelial and eosinophile cells. […] The lower lobe is often collapsed. […] Shock, cough, dyspnea, and hemoptysis are present in majority of cases. Slight fever is frequent and the pulse is quickened. If not infected, the progress is uneventful. The cough lessens, slight fever persists, but with moderate exudates the absorption is rapid. A slight icteric tinge of the skin may be present. With massive hemorrhage, as from an aneurism, there is collapse and sudden death. The signs vary with amount of fluid. With a massive exudate there is a flat or Skodaic note on percussion, absence of fremitus, and distant or feeble tubular breathing. […] A phenomenon, not seen in ordinary effusion, is the early flattening and immobility of the side, which with high level of diaphragm speaks for massive collapse of the lung, with displacement of the heart to the affected side. […] Contralateral collapse of the unaffected lung occurs not infrequently, indicated by flatness at the opposite base with tubular breathing and increased fremitus.

Osler, W. & McCrae T. (1892/1925). The Principles and Practice of Medicine. (10th ed, pp. 678-679). New York: D. Appleton & Company.

Created by: Taha Jilani, 06/08/2021

Entered by: Rachel Johnson, 07/12/2021

Transudation of simple non-inflammatory fluid into the pleural cavities, and occurs as a secondary process in many affections. The fluid is pale yellow with a specific gravity below 1.1015; it does not clot; the cells are scanty and the amount of albumin is small. It occurs with cardiac disease, in acute or chronic nephritis, in severe anemia, from pressure due to new growth and obstruction of azygos veins. It occurs more often on the right side and if on both sides, there is more fluid on the right side. In renal disease hydrothorax is almost always bilateral, but in heart affections the right side is more commonly involved. The physical signs are those of pleural effusion, but with exudation is rarely excessive. In kidney and heart disease, even when there is no general dropsy, the occurrence of dyspnea should at once direct attention to the pleura. In chronic myocardial disease the effusion is usually on the right side, and may recur for months. The greater frequency of the dextral effusion has been attributed to compression of the azygos vein, but compression of the pulmonary veins by the dilated right auricle seems more probable.

Osler, W. & McCrae T. (1892/1925). The Principles and Practice of Medicine. (10th ed, pp. 678). New York: D. Appleton & Company.

Created by: Taha Jilani, 06/08/2021

Entered by: Rachel Johnson, 07/12/2021

It begins with chills and shivers. Thirst, heat, discomfort, and the other symptoms of fever follow. A few hours later, the patient is seized with a violent stabbing pain in the side, which spreads towards the shoulder blades, the spine, or the front of the chest. The cough is frequent and afflicting. The matter spit up is at first scanty and thin. As the disease advances it becomes more copious, more concocted, and more mixed with bloody particles. As the cough, the spitting of blood, and the pain increase, and as the expectoration becomes freer, the fever abates. The bowels are sometimes loose, sometimes confined.

Sydenham, T. (1850). The Works of Thomas Sydenham, M.D. Volume II. London: Sydenham Society. Pg. 243.

Entered by: Sonia Y. Khan, 6/26/2020

But in a great affection, such as inflammation [of the lungs], there is a sense of suffocation, loss of speech and of breathing, and a speedy death. This is what we call Peripneumonia, being an inflammation of the lungs, with acute fever, when they are attended with heaviness of the chest, freedom from pain, provided the lungs alone are inflamed; for they are naturally insensible, being of loose texture [...]. But if any of the membranes, by which it is connected with the chest, be inflamed, pain also is present; respiration bad, and hot; they wish to get up into an erect posture, as being the easiest of all postures for the respiration. Ruddy in countenance, but especially the cheeks; the white of the eyes very bright and fatty; the point of the nose flat; the veins in the temples and neck distended; loss of appetite; pulse, at first, large, empty, very frequent, as if forcibly accelerated; heat indeed, externally, feeble, and more humid than natural, but, internally, dry, and very hot, by means of which the breath is hot; there is thirst, dryness of the tongue, desire of cold air, aberration of mind; cough mostly dry, but if anything be brought up it is a frothy phlegm, or slightly tinged with bile, or with a very florid tinge of blood.

The blood-stained is of all others the worst. But if the disease tend to a fatal termination, there is insomnolency; sleep brief, heavy, of a comatose nature; vain fancies; they are in a doting state of mind, but not violently delirious; they have no knowledge of their present sufferings [...]. The extremities cold; the nails livid, and curved; the pulse small, very frequent, and failing, in which case death is near at hand, for they die mostly on the seventh day. But if the disease abate and take a favourable turn, there is a copious hemorrhage from the nose, a discharge from the bowels of much bilious and frothy matters, such as might seem to be expelled from the lungs to the lower belly, provided it readily brings off much in a liquid state. Sometimes there is a determination to the urine. But they recover the most speedily in whose cases all these occur together. In certain cases much pus is formed in the lungs, or there is a metastasis from the side, if a greater symptom of convalescence be at hand. But if, indeed, the matter be translated from the side to the intestine or bladder, the patients immediately recover from the peripneumony; but they have a chronic abscess in the side, which, however, gets better. But if the matter burst upon the lungs, some have thereby been suffocated, from the copious effusion and inability to bring it up.

Aretaeus and Adams. (1856). The Extant Works of Aretaeus the Cappadocian. London: Sydenham Society. Pg. 261.

Entered by: Sonia Y. Khan, 6/18/2020

Impeded respiration, slight cough with more or less of a watery expectoration, are the only signs by which we can be led to suspect its existence. In some cases, there is scarcely any perceptible expectoration; in others it is copious, colorless, frothy, and of a consistence and appearance resembling whit of egg dissolved in equal parts of water. […] In cases where the edema is complicated with partial spots of pulmonic inflammation, amid the mass of expectoration just described there are found some sputa of a tawny, greenish or light rusty color, but still less transparent. […] Both lungs are either equally affected at the same time, or if one is smore so than the other, there appears to be still a sufficient quantity or air retained in it to prevent its yielding the dull sound. […] the respiration is much feebler than might be expected, from the great dilatation of the thorax; and there is, at the same time, a slight crepitation, as in the first degree of peripneumony, more like a rhonchus […].  

Laennec, R.T.H. (1838). A Treatise on the Disease of the Chest, and on Mediate Auscultation. Wood & Company. Pg. 189.

Entered by: Ayushi Chintakayala, 3/1/2021

If the embolus is sufficiently large enough to occlude the main branch of the pulmonary artery sudden death may occur. If a medium-sized, but still large branch is the seat of the obstruction there will be cough, haemoptysis, mental anxiety, intense dyspnea, syncope, and perhaps coma and convulsions. If the smallest branches are involved there may be no recognizable symptoms; or there may be moderate dyspnoea, cough, and slight haemoptysis; or the expectoration, especially at the onset, may consist of a small quantity of nearly pure blood or gelatinous bloody mucus, the blood subsequently disappearing.

It is not, at first certainly, the rusty sputum of a pneumonia. Cough and haemoptysis occurring during the course of chronic cardiac disease is very suggestive of embolism. If the infarction is large and, as is usually the case, occupies the lower lobe, there will be near the base circumscribed dullness, increased fremitus and voice sounds, broncho-vesicular or bronchial breathing, and moist rales. There may be pleural friction accompanied by transient pain.

Butler, G. R. (1902). The Diagnostics of internal medicine: a clinical treatise upon the recognised principles of medical diagnosis. New York: Appleton. Pg. 843.

Entered by: Erin Choi, 6/17/2020

The diagnostic local symptoms of vesicular, lobar emphysema, relate to respiration and cough. A moderate degree and extent of the affection occasion want of breath on exercise, the breathing being without habitual embarrassment; the patient is unable to run, or walk rapidly, and especially to ascend stairs, without the respiration becoming labored. If the affection be considerable, the patient has labored breathing when at rest. The labor is especially manifest in expiration; this act is prolonged, the inspiratory act being shortened and quickened. A greater amount of the lesion involves much suffering from dyspnea; the cervical veins are enlarged; the prolabia and face are cyanotic; the patient is unable to lie down; there is oedema of the limbs, and there may be anasarca or general dropsy. The latter symptoms denote dilation of the right ventricle and auricle. Cough and expectoration are usually symptoms. […] The cough is often spasmodic, consisting of a series of short expiratory efforts, resembling in this respect a paroxysm of whooping cough. During the cough the face becomes deeply congested, the veins of the neck are swollen, and lividity is sometimes marked, these symptoms denoting distension of the right auricle. The expectoration varies in quantity and in other characters as in different cases of chronic bronchitis without emphysema. […] The physical diagnosis in cases of moderate emphysema is based on positive and negative evidence furnished by percussion and auscultation. The resonance on percussion over the upper lobes of both lungs is vesiculo- tympanic, as compared with the resonance over the lower lobes. In other words, the intensity is greater, the pitch is higher, the vesicular and tympanic quality being combined. […] The respiratory murmur, especially over the upper lobes, is weakened. […] The inspiratory sound is shortened, and in a certain proportion of cases, the expiratory sound is prolonged. The prolonged expiratory sound is low in pitch and blowing in quality.

Flint, A. (1879). Clinical medicine: a systematic treatise on the diagnosis and treatment of diseases ; designed for the use of students and practitioners of medicine. London: Churchill. Pg.129-130.

Entered by: Erin Choi, 6/11/2020

These are - a pain, at first slight, or a simple feeling of irritation at the bottom of the trachea, experienced momentarily, and sometimes only when the patient sings, cries, or raises the voice in speaking. This state may continue a long time […] ten years, without any other apparent alteration in her health. […] After a time, the pain becomes constant, even when the patient is silent; and even then it is found that the voice is not always perceptibly altered in its character. Cough soon supervenes, attended by a colorless, ropy, pituitous expectoration, intermixed with opaque puriform particles. When this becomes abundant, a rhonchus, perceptible by the naked ear, is heard in the trachea; and when not so heard, I have found it very distinct by means of the stethoscope. The instrument detected it at the same time in various parts of the lungs […] owing probably to the accumulation of phlegm in the smaller bronchi, since the respiration became good after expectoration. These symptoms are soon accompanied by extreme dyspnea, the patient being obliged to remain in the sitting posture night and day, and when he awakes after an imperfect sleep he is apt to be seized with a suffocated cough, as if some foreign body had got into the trachea; and this continues until after the expectoration of a certain quantity of mucus. At this stage, emaciation, which had hitherto been slow in its progress, makes rapid advances, and sometimes produces extreme extenuation; and the patient at last dies with all the symptoms of the suffocative catarrh.

Very great efforts of voice, acute cries, violent forcing of the head backwards, have sometimes appeared to be the occasional cause of the ulcers of the trachea. Cutaneous complaints and syphilis would seem also to predispose to them. Although sometimes met with in phthisical cases, they are found more commonly in subjects whose lungs are entirely sound.

We must, however, except those cases where ulceration […] is occasioned by the rupture of softened tubercles situated in one of the cervical or bronchial glands […] being entirely analogous to those fistulous openings produced by the discharge of a tubercle, abscess, or gangrenous eschar of the lungs […]. Ulcers of the kind have a great tendency to cicatrization, and are found after a certain time, smooth, polished, and without any appearance of spreading.

Laennec, R.T.H. (1838). A Treatise on the Disease of the Chest, and on Mediate Auscultation. Wood & Company. Pg. 147–148.

Entered by: Ayushi Chintakayla, 7/10/2020