CHAPTER IV DISEASES OF THE RESPIRATORY TRACT (Part 1)

CHAPTER IV DISEASES OF THE RESPIRATORY TRACT (Continued) The Lungs The lungs consist of air-cells at the termination of the small bronchi. On cross-section, as in the illustration, Fig. 25. — Section of lung: a, Cross-sertion of small bronchus; b, alveolus; c, alveolar wall lined with fiat epithelium; d, top wall of alveolus entirely cut across ; e, section into infundibulum, showing several alveoli opening into it (Leroy). they resemble a bunch of grapes. The alveoli or air-cells have resilient walls permitting them to expand and to contract. 75 76 DISEASES OF CHILDREN FOR NURSES In the thin walls of the air-cells are minute capillary vessels which are so arranged that the oxygen from the inspired air contained in the alveoli is readily absorbed by the blood in the capillaries; at the same time the carbon dioxid (C02), which is the product of the waste of the body, is thrown off from the blood into the air-cells and exhaled. This process purines the blood, changes venous Larynx Right auricle- Coronary artery Fie 26.— Relation of lungs to other thoracic organs (Ingals). blood into arterial, and is the sole function of the lungs. Between the groups of air-cells there is a supporting structure of connective tissue. The air vesicles are lined with mucous membrane. The lungs are divided into lobes: the left lung into two, the superior and inferior, and the right into three lobes, the superior, the middle, and the inferior. DISEASES OF THE RESPIRATORY TRACT "J 7 The lungs are covered by the pleura. The respirations during childhood vary. In the newborn they are from 30 to 50 per minute, in the first year 28 to 30, at five years 22 to 25, at fourteen years 20, in adult life 18 per minute. The thin chest walls in childhood give less protection to the lungs than those of an adult, consequently children are more affected by exposure. A distended stomach may embarrass the respiration of a child, owing to the high position of the diaphragm. Acute congestion may give rise to as severe symptoms as pneumonia, due to the small, undeveloped air-cells. CONGESTION OF THE LUNGS Congestion of the lungs may be active, passive, or hypostatic. Active congestion is due to an increase in the flow of blood from the heart to the lungs. The arteries become engorged and the function of the lungs is restricted. Active congestion of the lungs is seen in conditions which produce an overactivity of the heart, such as high altitudes, excitement, and cardiac hypertrophy. In inflammatory diseases of the lungs there is an associated active conges- tion. The first stage of croupous pneumonia consists in this type of congestion. Passive congestion is caused by some obstruction to the How of blood from the lungs to the heart. It is most often caused by heart disease; under such conditions the heart is so damaged that it is unable to pump the blood with the normal force and maintain the necessary speed, the current thus becomes dammed back in the great vessels of the lungs. 78 DISEASES OE CHILDREN FOR NURSES Hypostatic congestion is seen in diseases which require the patients to remain for long periods upon their backs. Such protracted illnesses always weaken the heart, so that it docs not have the power to force the blood column through the arteries at the normal speed and pressure. This allows the blood current to become sluggish, and in the dependent portions of the lungs there is a congestion due to an engorgement of the vessels. The reason for changing the position of a patient in bed at frequent intervals is to overcome this tendency to hypo- static congestion. Symptoms of congestion consist of cough, dyspnea, slightly accelerated respirations, and fever. Treatment consists in the application of some form of counterirritation to draw the blood from the congested lungs to the surface. Dry cups, mustard paste, amber oil, camphorated oil, and antiphlogistin may be used. An oiled-silk or a cotton-batting jacket at times is worn in addition. PNEUMONIA This term is applied to inflammation of the lungs. The main divisions of pneumonia are bronchopneumonia, croupous pneumonia, pleuropneumonia, hypostatic pneu- monia, and chronic bronchopneumonia. Bronchopneumonia is also termed lobular pneumonia, meaning that several lobes of the lungs are involved. The pneumonic areas are small, they do not occupy a whole lobe, and are scattered through several lobes of the lungs. It is also termed catarrhal pneumonia. Croupous pneumonia is also termed lobar pneumonia, meaning that the pneumonic consolidation usually in- volves the entire lobe of a lung or at least a part of one. DISEASES OF THE RESPIRATORY TRACT 79 It is sharply circumscribed and there are no scattered areas through the other lobes, as in bronchopneumonia. More than one lobe may be involved, the disease spreading through the additional lobe or lobes in the same manner. The term pneumonia 0} the apex is used when the apices of the lungs are involved. A rare form of croupous pneumonia is double pneumonia, in which both lungs are affected, but not necessarily the whole of each. A massive pneumonia is an inflammation not only of the air vesicles, but also of the bronchi and other lung structures. A creeping or migratory pneumonia affects successively different lobes of the lungs. Epidemic pneumonia involves large numbers of children and seems to be con- tagious. The contagiousness of bronchopneumonia cannot be determined without more complete data than at present existing. There seems to be no doubt, from clinical observations alone, that the secondary forms, especially those that complicate measles and diphtheria, are some- times communicated in this way. This is probably not often true of primary cases except in hospitals for infants, where the rapid development of case after case in the same ward cannot be explained upon any other hypothesis (Holt). Croupous pneumonia is not contagious. Under two years of age bronchopneumonia is more frequently seen than croupous pneumonia. The propor- tion is 75 per cent, bronchopneumonia and 25 per cent, croupous pneumonia. The reason for this is found when the structure of the lungs is studied. Before two years of age the lungs are undeveloped and their structure is mostly bronchial in character. As the child grows the air vesicles become more and more developed and the struc- 80 DISEASES OE CHILDREN EOR NURSES ture of the lungs more vesicular in type. Bronchopneu- monia is an inflammation of the terminal bronchi; croupous pneumonia is an inflammation of the air vesicles; pneu- monia is a common disease at all ages. Therefore, before the air vesicles have developed the pneumonia attacks the predominating structures, the capillary bronchi, giving rise to bronchopneumonia; and later when the air vesicles become the principal part of the lungs the pneumonia attacks them, giving rise to croupous pneumonia. Prognosis. — In childhood croupous pneumonia is rarely a fatal disease, while bronchopneumonia causes more deaths among infants than any other disease excepting infantile diarrhea. In the adult croupous pneumonia is one of the most treacherous and fatal diseases that exists, the mortality ranging from 20 per cent to 40 per cent, or one in every four or five dying, while bronchopneumonia is rarely met with as a primary condition. The high mortality of croupous pneumonia in the adult is principally caused by heart failure occurring during the course of the disease. The great vascularity of the lungs (the whole amount of blood in the body passes through the minute capillaries of the lungs once in about twenty- two seconds (Vierordt) ) renders it necessary that there should be no obstruction. Normally, the lungs can be likened to a sponge. It is easy, under such circumstances, for the heart to pump the blood column through the unresisting tissues. In pneumonia, however, the structure of the lungs becomes like liver. This vastly increases the obstruction and the strain upon the heart. In children the heart is strong and vigorous and it is able to cope with the extra strain, while an adult's heart has not the same inherent strength after years of work. In addition an DISEASES OF THE RESPIRATORY TRACT 8 1 adult has probably "put on flesh," every ounce of which means extra work for the heart (this is the reason that a thin person can withstand an attack of pneumonia better than a stout one). The ferocity of the disease itself seems to be worse in an adult than it is in a child, owing usually to lowered vitality from overwork and exposure. These reasons explain the difference in the mortality of croupous pneumonia in adults and in children. Pleuropneumonia is much more frequent in childhood than in adult life. Acute Bronchopneumonia. — Under two years of age most cases of primary pneumonia are bronchial in type. After two years of age the great majority of cases of pneumonia which follow measles, diphtheria, pertussis, and influenza are of this variety. The mortality of bronchopneumonia in children stands second only to gastro-intestinal diseases. It varies greatly, but about 40 per cent, of the cases die. This is due to the weak resisting powers of the undeveloped infant and also to the fact that when bronchopneumonia is a secondary condition it complicates such diseases as pertussis, scarlet fever, diphtheria, and influenza. These already have so weak- ened the child's constitution that when pneumonia sets in the child is physically unable to cope with the added infection. Bronchopneumonia is not often seen among the better classes as a primary condition. It is a disease due to exposure and poor hygienic surroundings. Primary cases are usually due to the pncumococcus and secondary cases to what is termed a mixed injection. This mixed infection may be due to the bacilli causing the disease of which the pneumonia is a complication, such as the bacillus of 82 DISEASES OF CHILD A' EX FOX XL'FSES influenza and the pneumococcus, or it may be due to the presence of the streptococcus and staphylococcus (pus organisms). The latter is the usual cause. Bronchopneumonia generally begins in the larger bronchi, gradually working into the smaller tubes and finally involving the air vesicles. It is easier to under- stand bronchopneumonia if it is considered as a bronchitis of the terminal bronchial tubes and adjacent air vesicles. As in bronchitis, there is an inflammation of the small bronchial tubes with congestion and swelling of the mucous membrane, an over-secretion of mucus, and a shedding of the lining epithelial cells. This exudate fills the small air-cells adjacent to the inflamed bronchial tube, producing a pneumonic consolidation. The presence of the mixed infection causes this consolidation, composed of debris, to break down and suppurate, and thus pin-point abscesses are formed in the pneumonic area. These areas are scattered; as the disease extends from the bronchioles, only' the air vesicles adjacent to the inflamed tubes are involved. The most frequent location of the disease is in the lower lobes, posteriorly, of both lungs. The healthy portions of the lungs are distended to accomplish their added task and hence a condition of hypertrophic com- pensatory emphysema co-exists. There are no definite stages, as in croupous pneumonia. Symptoms. — The clinical picture of bronchopneumonia is an exceedingly varied one: there is no typical course. The symptoms most frequently seen are as follows: The symptoms of bronchitis, if present, become slowly or rapidly worse and merge into those of pneumonia. More often in primary bronchopneumonia the onset is sudden, the child is seized with vomiting and high fever, DISEASES OF THE RESPIRATORY TRACT 83 cough, accelerated respiration, prostration, and cyanosis. The temperature is remittent in type. It is high, but has wide daily fluctuations of from four to five degrees. This high temperature continues for a week or two and then falls by lysis. Lysis is a gradual fall of the temperature to normal, taking from two days to a week to reach this point. In contrast to this, crisis is a sudden drop from an exceedingly high temperature to normal within twenty- four hours. p R T. in. e z in e 3 m. e s to e 6 m.e 7 7;i. c fn. e. 9 m. e. M.e m e /5 no 70 108 i\ ,", IbO bS /or 1 > », 1 150 60 10 b / ' ' \7" i M 5S IDS > ' ,", ,', 130 SO /O'f 1 ; A i\ 1 , 120 45 103 J_ 1 \ v i\ V \ 1 1 1 I/O <*o IOZ / \ V /\ , / A •/ \ , \ 100 35 101 J \l V \ A 1/ A ,\ « 9o 30 100 V v , A /\ f v,/ V 80 zs 9? V V \ 70 20 98 V < 60 15 97 Fig. 27. — Chart of the temperature (- Child -) and respirations (- : year old (Kerr). -1 in bronchopneumonia. Just before death the temperature often reaches 107 ° F. and 109 ° F. The respirations average from sixty to eighty per minute, often they are one hundred per minute, and occasionally a hundred and twenty. There is great short- ness of breath (dyspnea), the child struggles for each breath, the chest is retracted at the base, and the other symptoms of dyspnea are present. The respiratory action is more affected than the heart action, and if the child succumbs it is usually by respiratory failure, the symptoms of which arc very rapid, superficial breathing, sometimes 84 DISEASES OF CHILDREN FOR NURSES a hundred to a minute, blueness of the lips and finger-nails, and often a bluish hue to the body. The pulse averages from one hundred and fifty to two hundred per minute. When very rapid it is often irregular. The character of the pulse is more important than the rapidity. At first it is full and strong, but later it becomes weak, thready, compressible, and intermittent. Cough is always present and very persistent, more so than in croupous pneumonia. A good, strong cough is not an unfavorable symptom, as it shows that the reflex irritability of the bronchial tubes is still present. When this is lost the mucus is not removed, the lungs fill up, and respiratory failure threatens. Suppression of cough is, therefore, a bad sign. There is no expectoration before four years of age, the mucus is either swallowed or re-inspired. During severe paroxysms of coughing, if the child be turned on its face or inverted, much of the mucus will run out of the mouth. A blueness (cyanosis) of the skin and mucous membrane is found in severe cases. It is due to a sudden congestion of a portion of the lungs not previously affected. Even when present only at lips and finger-tips, the patient should be very carefully watched, and if further symptoms of respiratory failure develop, they should receive prompt treatment (see pages 94 and 363). Prostration is progressive; at first it may be moderate, but in the final stages there may be symptoms which are known as the typhoid state. These are delirium, picking at the bed-clothes (carphalogia), twitching of the tendons (subsultus tendinum) rare in childhood, and ;y, brown, fissured tongue. Gastro-intestinal Symptoms. — Often there are from four DISEASES OF THE RESPIRATORY TRACT 85 to six green stools a day, containing mucus and undigested food, due to the weakened digestion from the fever and induced by feeding improper food. This same condition may cause vomiting. Vomiting and diarrhea add much to the danger of the attack, and when the result is in doubt, may turn the scales against the patient. In summer this complication is more frequent and more severe. Disten- tion of stomach and intestines from gas may cause attacks of cyanosis, which condition should be relieved as soon as possible. The rectal tube may be employed with care. The urine is scanty. Complications. — Pleurisy is nearly always present. Pur- ulent meningitis sometimes complicates acute broncho- pneumonia, but the most frequent complications are referable to the gastro-intestinal tract. Croupous pneumonia is an acute, infectious, inflam- matory disease of the lungs characterized by a high fever and ending by crisis in from five to nine days. Seventy- five per cent of the cases of croupous pneumonia are caused by the diplococcus pneumoniae The term lobar pneumonia is generally used for. this form of pneumonia, so-called on account of its tendency to involve a whole lobe of the lung in contradistinction to bronchopneumonia, which is sometimes called lobular pneumonia. Croupous pneumonia is one of the oldest recognized diseases; it was described fairly accurately by Hippocrates in 460 P>. C. In childhood pneumonia follows, in a general way, the character of an attack in the adult. In speaking of bronchopneumonia it was said that it was the pneumonia of early infancy. This is true until children arc about 86 DISEASES OF CHILDREN FOR NURSES two years of age, after which they are usually attacked by croupous pneumonia. This disease has a tendency to attack children that were previously healthy; it is especially prevalent in the spring of the year,, Epidemics are not frequent among children, and the disease is rarely fatal. In the order of frequency the disease attacks the following portions of the lungs: left base, right apex, right base, left apex. The complications of pneumonia are pleurisy, endo- carditis, meningitis, and neuritis. Children rarely have complications, the one most often seen being empyema, which is probably on account of the proneness of children to have severe pleurisy associated with croupous pneumonia. The temperature is generally higher, the pulse more rapid, the duration shorter, and the cerebral symptoms more frequent in children than in adults, otherwise, as has been mentioned before, the disease is the same. The cause of croupous pneumonia is usually exposure. The disease occurs more frequently in males than in females. It is usually primary, occasionally it will com- plicate some form of infectious disease. There are four distinct stages in croupous pneumonia: The stage of congestion