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 Handbook of
PULMONARY AND CRITICAL
CARE MEDICINE
 Handbook of
PULMONARY AND CRITICAL
CARE MEDICINE
Second Edition

Editor-in-Chief
SK Jindal MD FAMS FNCCP FICS FCCP
Emeritus Professor (Pulmonary Medicine)
Postgraduate Institute of Medical Education and Research
Chandigarh, India
Medical Director
Jindal Clinics, Chandigarh

Foreword
Randeep Guleria

JAYPEE BROTHERS MEDICAL PUBLISHERS

The Health Sciences Publisher
New Delhi | London | Panama
 Jaypee Brothers Medical Publishers (P) Ltd

Headquarters
Jaypee Brothers Medical Publishers (P) Ltd
4838/24, Ansari Road, Daryaganj
New Delhi 110 002, India
Phone: +91-11-43574357
Fax: +91-11-43574314
Email: [email protected]

Overseas Offices
J.P. Medical Ltd Jaypee-Highlights Medical Publishers Inc
83 Victoria Street, London City of Knowledge, Bld. 235, 2nd Floor
SW1H 0HW (UK) Clayton, Panama City, Panama
Phone: +44 20 3170 8910 Phone: +1 507-301-0496
Fax: +44 (0)20 3008 6180 Fax: +1 507-301-0499
Email: [email protected] Email: [email protected]
Jaypee Brothers Medical Publishers (P) Ltd
Bhotahity, Kathmandu, Nepal
Phone: +977-9741283608
Email: [email protected]
Website: www.jaypeebrothers.com
Website: www.jaypeedigital.com
© 2019, Jaypee Brothers Medical Publishers
The views and opinions expressed in this book are solely those of the original contributor(s)/
author(s) and do not necessarily represent those of editor(s) of the book.
All rights reserved. No part of this publication may be reproduced, stored or transmitted in any
form or by any means, electronic, mechanical, photocopying, recording or otherwise, without
the prior permission in writing of the publishers.
All brand names and product names used in this book are trade names, service marks,
trademarks or registered trademarks of their respective owners. The publisher is not associated
with any product or vendor mentioned in this book.
Medical knowledge and practice change constantly. This book is designed to provide accurate,
authoritative information about the subject matter in question. However, readers are advised
to check the most current information available on procedures included and check information
from the manufacturer of each product to be administered, to verify the recommended dose,
formula, method and duration of administration, adverse effects and contraindications. It is the
responsibility of the practitioner to take all appropriate safety precautions. Neither the publisher
nor the author(s)/editor(s) assume any liability for any injury and/or damage to persons or property
arising from or related to use of material in this book.
This book is sold on the understanding that the publisher is not engaged in providing
professional medical services. If such advice or services are required, the services of a
competent medical professional should be sought.
Every effort has been made where necessary to contact holders of copyright to obtain
permission to reproduce copyright material. If any have been inadvertently overlooked, the
publisher will be pleased to make the necessary arrangements at the first opportunity. The
CD/DVD-ROM (if any) provided in the sealed envelope with this book is complimentary and
free of cost. Not meant for sale.
Inquiries for bulk sales may be solicited at: [email protected]
Handbook of Pulmonary and Critical Care Medicine
First Edition: 2012
Second Edition: 2019
ISBN 978-93-5270-615-0
 Dedicated to
The memories of my parents who made a doctor out of me, Dr SK Malik who
handed over the reins to me and Dr Dheeraj Gupta, a trusted colleague and friend
who tirelessly helped in shaping this specialty.
 Contributors

AG Ghoshal MD DNB FCCP Ajmal Khan MD DM

Director Assistant Professor
National Allergy Asthma Bronchitis Institute Department of Pulmonary Medicine
Kolkata, West Bengal, India Sanjay Gandhi Postgraduate Institute
of Medical Education and Research
AK Janmeja MD Lucknow, Uttar Pradesh, India
Former Professor and Head
Department of Pulmonary Medicine Alladi Mohan MD
Government Medical College Chief
Chandigarh, India Division of Pulmonary, Critical Care and
Sleep Medicine
AN Aggarwal MD DM Professor and Head
Professor and Head Department of Medicine
Department of Pulmonary Medicine Sri Venkateswara Institute of Medical
Postgraduate Institute of Medical Sciences
Education and Research Tirupati, Andhra Pradesh, India
Chandigarh, India
Amanjit Bal MD DNB MAMS
Abha Chandra MD Additional Professor
Professor and Head Department of Histopathology
Department of Cardiothoracic and Postgraduate Institute of Medical
Vascular Surgery Education and Research
Sri Venkateswara Institute of Medical Chandigarh, India
Sciences
Tirupati, Andhra Pradesh, India Arjun Srinivasan MD DM
Pulomonary and Critical Care Medicine
Abinash Singh Paul MD DM Kovai Medical Center and Hospital (KMCH)
Consultant Pulmonologist Specialty Hospital
Life Line Hospital Chennai, Tamil Nadu, India
Dubai, UAE
Arun S Shet MD
Aditya Jindal DNB DM FCCP Department of Medical Oncology
Consultant Interventional Pulmonology St John’s National Academy of Health
and Intensivist Sciences
Jindal Clinics, Chandigarh, India Bengaluru, Karnataka, India
Ajay Handa MD DNB DM FCCP FAPS Arunabh Talwar MD FCCP
Senior Advisor (Medicine and Pulmonary Department of Pulmonary
Medicine) Critical Care and Sleep Medicine
Professor of Internal Medicine North Shore University Hospital
Rajiv Gandhi University of Health Manhasset, New York
Sciences (RGUHS), Bengaluru Professor of Medicine
Command Hospital Air Force Hofstra North Shore- LIJ School of Medicine
Bengaluru, Karnataka, India New Hyde Park, New York, USA
viii Handbook of Pulmonary and Critical Care Medicine

Arunaloke Chakrabarti MD Bharat Bhushan Sharma MD

Professor and Head Assistant Professor
Department of Medical Microbiology Pulmonary and Allergy Division
Postgraduate Institute of Medical Sawai Man Singh (SMS) Medical College
Educationand and Research Jaipur, Rajasthan, India
Chandigarh, India
Bill Brashier DTCD
Arvind H Kate MD Former Head
Institute of Pulmonology Academic Clinical and Molecular Research
Medical Research and Development Chest Research Foundation
Mumbai, Maharashtra, India Pune, Maharashtra, India

Ashim Das MD
C Ravindran MD DTCD MBA
Professor and Head
Professor
Pulmonary Medicine
Department of Histopathology
DM Wayanad lnstitute of Medical Sciences
Postgraduate Institute of Medical
Calicut, Kerala, India
Education and Research
Chandigarh, India Carmen Luraschi-Monjagatta MD
University of Southern California
Ashok Shah MD Keck School of Medicine of USC
Former Director Professor Los Angeles, California, USA
Department of Pulmonary Medicine,
Vallabhbhai Patel Chest Institute Chandramani Panjabi MD
New Delhi, India Head, Respiratory Medicine
Mata Chanan Devi Hospital
Atul C Mehta MBBS FACP FCCP New Delhi, India
Department of Pulmonary Medicine
Charles Feldman MB BCh PhD DSc
Cleveland Clinic
Department of Internal Medicine
Cleveland, Ohio, USA
University of the Witwatersrand Medical
B Vijayalakshmi Devi MD School
Additional Professor Parktown, Johannesburg, South Africa
Department of Radiodiagnosis Charles Peng MD
Sri Venkateswara Institute of Medical Pulmonary, Critical Care and Sleep
Sciences Medicine Fellow
Tirupati, Andhra Pradesh, India Pulmonary Hypertension Center
Icahn School of Medicine at Mount Sinai
Baishakhi Ghosh MD
Mount Sinai Beth Israel
Research Student
New York City, New York, USA
Chest Research Foundation, Pune
Research Scholar D Behera MD FCCP
Symbiosis International University Professor
Pune, Maharashtra, India Department of Pulmonary Medicine
Postgraduate Institute of Medical
Balamugesh T MD DM FCCP Education and Research
Professor Chandigarh, India
Department of Pulmonary Medicine
Christian Medical College D Robert McCaffree
Vellore, Tamil Nadu, India MD MSHA Master FCCP
Regents’ Professor of Medicine Pulmonary
Basil Varkey MD FRCP FCCP Disease and Critical Care Section
Professor Emeritus of Medicine University of Oklahoma
Medical College of Wisconsin Health Science Center
Milwaukee, Wisconsin, USA Oklahoma City, Oklahoma, USA
 Contributors ix
Daniel E Banks MD MS G Gaude MD
Professor Professor and Head
Department of Medicine Department of Pulmonary Medicine
Uniformed Services University of Health Jawaharlal Nehru Medical College
Sciences Belgaum, Karnataka, India
Bethesda, Maryland, USA GA D’Souza MD
Professor and Head
David Honeybourne MD
Department of Pulmonary Medicine
Consultant Physician and Clinical Director St John’s Medical College
Honorary Clinical Reader in Respiratory Bengaluru, Karnataka, India
Medicine and Biological Sciences
Department of Respiratory Medicine GC Khilnani MD
Birmingham Heartlands Hospital Professor
Birmingham, UK Department of Pulmonary, Critical care
and Sleep Medicine
Deepak Aggarwal MD All India Institute of Medical Sciences
Assistant Professor New Delhi, India
Department of Pulmonary Medicine
Gaurav Prakash MD DM
Government Medical College Associate Professor
Chandigarh, India Bone Marrow Transplantation
Devasahayam J Christopher Department of Internal Medicine
MD FCCP FRCP Postgraduate Institute of Medical
Professor and Head Education and Research
Chandigarh, India
Department of Respiratory Medicine
Christian Medical College Gautam Ahluwalia MD FAPS FICP FIACM
Vellore, Tamil Nadu, India Professor
Department of Medicine
Dheeraj Gupta MD DM Dayanand Medical College and Hospital
Former Professor Ludhiana, Punjab, India
Department of Pulmonary Medicine
Postgraduate Institute of Medical Girish Raju MD
Department of Medical Oncology
Education and Research
St John’s National Academy of Health
Chandigarh, India Sciences
Dhruva Chaudhry MD DM Bengaluru, Karnataka, India
Professor and Head Gwen Skloot MD
Department of Pulmonary and Critical Associate Professor of Medicine
Care Medicine Ichan School of Medicine at Mount Sinai
Pt Bhagwat Dayal Sharma Postgraduate New York City, New York, USA
Institute of Medical Sciences
Gyanendra Agrawal MD DM
Rohtak, Haryana, India Consultant Pulmonologist
Dilip V Maydeo MD Jaypee Group of Hospitals
Noida, Uttar Pradesh, India
Professor of TB and Respiratory Diseases
KJ Somaiya Medical College H Shigemitsu MD FCCP
Mumbai, Maharashtra, India Professor of Medicine
Chief, Division of Pulmonary and Critical
Dinkar Bhasin MD Care Medicine
Deaprtment of Medicine Fellowship Program Director
All India Institute of Medical Sciences University of Nevada, School of Medicine
New Delhi, India Las Vegas, Nevada, USA
x Handbook of Pulmonary and Critical Care Medicine

Harakh V Dedhia MBBS Kalpalatha K Guntupalli

Former Professor of Medicine MD FCCP FCCM MACP
Section of Pulmonary and Critical Care Professor of Medicine
Medicine Chief, Pulmonary, Critical Care and Sleep
West Virginia University School of Medicine Medicine
Morgantown, West Virginia, USA Baylor College of Medicine
Houston, Texas, USA
Inderpaul Singh Sehgal MD DM
Assistant Professor Karakontaki F MD
Department of Pulmonary Medicine Sismanoglio General Hospital
Postgraduate Institute of Medical Athens, Greece
Education and Research
Karan Madan MD DM
Chandigarh, India Assistant Professor
Indu Verma PhD Department of Pulmonary, Critical Care
Professor and Sleep Medicine
Department of Biochemistry All India Institute of Medical Sciences
Postgraduate Institute of Medical New Delhi, India
Education and Research Kripesh Ranjan Sarmah MD MNAMS
Chandigarh, India Assistant Professor
Javid Ahmad Malik MD DM FCCP Department of Pulmonary Medicine
Additional Professor and Head Guwahati Medical College
Department of Pulmonary Medicine Guwahati, Assam, India
SKIMS Medical College Krishna K Singh PhD
Srinagar, Jammu and Kashmir, India Senior Technical Team Lead
Jaydeep Odhwani Siemens Healthcare Diagnostics
BJ Medical College Tarrytown, New York, USA
Ahmedabad, Gujarat, India Kumar Utsav MD
Jean I Keddissi MD
BJ Medical College
Ahmedabad, Gujarat, India
Professor of Medicine
Pulmonary Disease and Critical Care Lakhbir K Dhaliwal MD
Section Former Professor and Head
University of Oklahoma Health Science Department of Obstetrics and
Center Gynecology
Oklahoma City, Oklahoma, USA Postgraduate Institute of Medical
Education and Research
Jeba S Jenifer MD Dip Pal Med
Chandigarh
Associate Professor
Palliative Care Unit Lakshmi Mudambi MD
Christian Medical College Pulmonary-Critical Care Medicine
Vellore, Tamil Nadu, India Baylor College of Medicine
Houston, Texas, USA
Jyothi E MD DTCD
Assistant Professor Liesel D’silva MD DETRD
Department of Pulmonary Medicine Senior Medical Advisor
Government Medical College Specialist in Respiratory Medicine
Kozhikode, Kerala, India Mumbai, Maharashtra, India
 Contributors xi
Liziamma George MD FCCP Navneet Singh MD DM FACP FCCP FICS
Associate Professor of Clinical Medicine Additional Professor
Weill Medical College Department of Pulmonary Medicine
Director, Medical Intensive Care Unit Postgraduate Institute of Medical
New York Methodist Hospital Education and Research
Brooklyn, New York, USA Chandigarh, India
Madhur Kalyan MSc Ngozi Orjioke MD
Senior Research Fellow
University of Southern California
Department of Biochemistry
School of Medicine
Postgraduate Institute of Medical
Los Angeles, California, USA
Education and Research
Chandigarh, India Nikhil C Sarangdhar MBBS
Malay Sarkar MD Assistant Professor
Professor Department of TB and Respiratory Diseases
Department of Pulmonary Medicine KJ Somaiya Medical College
Indira Gandhi Medical College Mumbai, Maharashtra, India
Shimla, Himachal Pradesh, India
Nikhil Gupta MD
Mamta Kalra PhD Assistant Professor
Senior Scientist Immatics US Inc Department of Medicine
Houston, Texas, USA Era’s Lucknow Medical College
Manabu Nonaka MD Lucknow, Uttar Pradesh, India
Nippon Medical School Nusrat Shafiq MD DM
Tokyo, Japan Additional Professor
Mark Astiz MD Department of Pharmacology
Weil Medical College, New York Postgraduate Institute of Medical
Methodist Hospital Education and Research
Brooklyn, New York, USA Chandigarh, India

Miyuki Hayashi MD Om P Sharma MD

Nippon Medical School Former Professor of Medicine
Tokyo, Japan Keck School of Medicine
Division of Pulmonary and Critical Care
Monica Barne MBBS
Medicine
Chest Research Foundation
Pune, Maharashtra, India University of Southern California
Los Angeles, California, USA
N Goel MD
Assistant Professor P Baruwa MD
Department of Pulmonary Medicine Senior Consultant
Vallabhbhai Patel Chest Institute Tuberculosis and Respiratory Medicine
University of Delhi Gauhati, Assam, India
New Delhi, India
PR Mohapatra MD
Nagarjuna V Maturu MD DM Professor and Head
Pulmonologist and Somnologist Department of Pulmonary Medicine
Yashoda Hospitals All India Institute of Medical Sciences
Hyderabad, Telangana, India Bhubaneswar, Odisha, India
xii Handbook of Pulmonary and Critical Care Medicine

PS Shankar MD FRCP FAMS DSc DLitt Pralay Sarkar MD DM

Emeritus Professor of Medicine Assistant Professor
Rajiv Gandhi University of Health Department of Pulmonary and Critical
Sciences, Bengaluru Care Medicine
SMV Medical College, Puducherry Baylor College of Medicine
KBN Institute of Medical Sciences Houston, Texas, USA
Kalaburagi, Karnataka, India Prashant Chhajed MD DNB
Director of Pulmonology and Center for
PS Tampi MD DM
Sleep Disorders
Consultant
Fortis Hiranandani Hospital
Bombay Hospital and Medical Research
Mumbai, Maharashtra, India
Centre
Mumbai, Maharashtra, India Preyas Vaidya MD
Institute of Pulmonolgy
Pankaj Malhotra MD MAMS Medical Research and Development
Professor Mumbai, Maharashtra, India
Department of Internal Medicine
Postgraduate Institute of Medical Preeti Verma MD
Education and Research Department of Obstetrics and Gynecology
Chandigarh, India Chandigarh, India

Parameswaran Nair MD PhD R Caroli MD

Professor of Medicine Consultant Pulmonologist
Division of Respirology Fortis Hospital
McMaster University Noida, Uttar Pradesh, India
Hamilton, Ontario, Canada Rachael A Evans MB ChB MRCP (UK) PhD
Division of Respiratory Medicine
Peter J Barnes FRS FMedSci
West Park Healthcare Centre
Margaret Turner-Warwick Professor of
University of Toronto
Medicine
Toronto, Ontario, Canada
Head of Respiratory Medicine
Imperial College London Raja Dhar MD MRCP MSc
Airway Disease Section Consultant Pulmonary and Critical Care
National Heart and Lung Institute Medicine
London, UK Fortis Hospital
Kolkata, West Bengal, India
Polychronopoulos V MD PhD FCCP
Director Rajendra Prasad
MD DTCD FAMS FCCP FNCCP
3rd Chest Department
Head
Sismanoglio General Hospital
Department of Pulmonary Medicine
Athens, Greece Era’s Lucknow Medical College
Prahlad Rai Gupta MD DM Lucknow, Uttar Pradesh, India
Former Professor Rajesh N Solanki MD FNCCP
Department of Pulmonary Medicine Professor, Head, Unit II
Sawai Man Singh (SMS) Medical College Department of Pulmonary Medicine
Jaipur, Rajasthan, India BJ Medical College
(Consultant, Shalby Hospital, Jaipur) Ahmedabad, Gujarat, India
 Contributors xiii
Rama Murthy Sakamuri PhD Ruby Pawankar MD PhD
Post-Doctoral Fellow Professor of Rhinology and Allergy
Department of Pathology Department of Otolaryngology
New York University Langone Medical Nippon Medical School
Centre Tokyo, Japan
New York City, New York, USA
Ruchi Bansal MD
Richa Gupta MD Department of Medicine
Assistant Professor Divison of Pulmonary, Critical Care and
Department of Pulmonary Medicine Sleep Medicine
Christian Medical College and Hospital New York Methodist Hospital
Vellore, Tamil Nadu, India Brooklyn, New York, USA

Ritesh Agarwal MD DM
S Kashyap MD
Professor Professor and Head
Department of Pulmonary Medicine
Department of Pulmonary Medicine
Director
Postgraduate Institute of Medical
Kalpana Chawla Government Medical
Education and Research
College
Chandigarh, India
Karnal, Haryana, India
Roger S Goldstein SK Jindal
MB ChB FRCP FCRP FCCP
MD FAMS FNCCP FICS FCCP
Department of Respiratory Medicine Emeritus Professor (Pulmonary Medicine)
West Park Healthcare Centre Postgraduate Institute of Medical
Toronto, Ontario, Canada Education and Research
Chandigarh
Romica Latawa PhD
Medical Director
Department of Biochemistry
Jindal Clinics, Chandigarh, India
Postgraduate Institute of Medical
Education and Research Sahajal Dhooria MD DM
Chandigarh, India Assistant Professor
Department of Pulmonary Medicine
Ronald Anderson PhD
Postgraduate Institute of Medical
Division of Pulmonology Education and Research
Department of Internal Medicine Chandigarh, India
University of the Witwatersrand
Johannesburg, South Africa Samir Malhotra MD
Professor
Roxana Sulica MD Department of Pharmacology
Director Postgraduate Institute of Medical
Pulmonary Hypertension Program Education and Research
Assistant Professor of Medicine Chandigarh, India
Icahn School of Medicine at Mount Sinai
Mount Sinai Beth Israel Sanjay Jain MD
New York City, New York, USA Professor
Department of Internal Medicine
Rubal Patel MD Postgraduate Institute of Medical
Tift Regional Medical Center Education and Research
Tifton, Georgia, USA Chandigarh, India
xiv Handbook of Pulmonary and Critical Care Medicine

Sanjeev Mehta MD Suman Laal PhD

Consultant Associate Professor
Lilavati Hospital, Bhartiya Arogya Nidhi Department of Pathology
Hospital Bandra (West) New York University
Mumbai, Maharashtra, India Langone Medical Centre
Veterans Affairs New York Harbor
Sean E Hesselbacher MD Healthcare System
Baylor College of Medicine New York City, New York, USA
Ben Taub General Hospital
Houston, Texas, USA Sundeep Salvi MD DNB PhD FCCP
Director
Shingo Yamanishi Chest Research Foundation
Nippon Medical School Pune, Maharashtra, India
Tokyo, Japan
Surendra K Sharma MD PhD
Shu Hashimoto MD PhD Ex-Professor and Head
Nihon University Department of Medicine
Tokyo, Japan All India Institute of Medical Sciences
New Delhi, India
Sidney S Braman MD FCCP
Professor of Medicine Uma Devraj MD
Associate Professor
Ichan School of Medicine at Mount Sinai
Department of Pulmonary Medicine
New York City, New York, USA
St John’s Medical College
Sneha Limaye MBBS Bengaluru, Karnataka, India
Research Fellow Umesh Jindal MD
Chest Research Foundation Senior Consultant and Director
Pune, Maharashtra, India Jindal IVF and Sant Memorial Nursing Home
Chandigarh, India
Srinivas Rajagopala MD DM
Assistant Professor of Chest Diseases VK Jindal PhD
Department of Medicine Honorary Professor of Physics
St John’s Medical College and Hospital Advanced Centre for Physics
Bengaluru, Karnataka, India Panjab University
Chandigarh, India
Stagaki E MD
Consultant VK Vijayan MD PhD DSc FAMS
3rd Chest Department Advisor to Director-General
Sismanoglio General Hospital Indian Council of Medical Research (ICMR)
Bhopal Memorial Hospital and Research
Athens, Greece
Centre and National Institute for Research
Stuti Agarwal PhD in Environmental Health
Senior Research Fellow Bhopal, Madhya Pradesh, India
Department of Biochemistry VR Pattabhi Raman MD
Postgraduate Institute of Medical Consultant Pulmonologist
Education and Research Kovai Medical Center and Hospital
Chandigarh, India Coimbatore, Tamil Nadu, India
Subhash Varma MD Vijay Hadda MD
Professor and Head Assistant Professor
Department of Internal Medicine Department of Pulmonary, Critical Care
Postgraduate Institute of Medical and Sleep Medicine
Education and Research All India Institute of Medical Sciences
Chandigarh, India New Delhi, India
 Contributors xv
Vikram Jaggi MD DNB William J Martin Jr MD
Medical Director Associate Director
Asthma Chest Allergy Centres
National Institute for Environmental
New Delhi, India
Health Sciences
Virendra Singh MD Director
Consultant Pulmonary Physician
Office of Translational Research
Asthma Bhawan
Jaipur, Rajasthan, India National Institutes of Health
North Carolina, USA
Vishwanath Gella MD DM
Senior Consultant Pulmonologist Zeenat Safdar MD FACP FCCP
Continental Hospitals
Hyderabad, Telangana, India Associate Professor of Medicine
Director
Walter G Shakespeare MD
Division of Pulmonary and Critical Care Baylor Pulmonary Hypertension Center
Medicine Pulmonary and Critical Care Medicine
Baylor College of Medicine Baylor College of Medicine
Houston, Texas, USA Houston, Texas, USA
 Foreword

It is indeed a pleasure to write a foreword to this very useful Handbook of

Pulmonary and Critical Care Medicine (2nd edition) by Professor SK Jindal. In my
mind, this is something that is needed not only for students but also for internists
and specialists as well. Pulmonary and critical care medicine is a rapidly changing
field of medicine and one of the fastest growing specialties. For everyone, this
handbook is a ready reckoner and something which we all should have on our
desks. Often a clinical or a busy student needs to have a readily available source
to clarify problems or to help in being sure about the diagnosis or management
strategy. This handbook is ideally suited for such a need. It has a wealth of up-
to-date knowledge which is easy to access. It is concise and very user friendly.
It covers multiple areas including pathophysiology, radiology and clinical
management in an integrated manner and is therefore easy to read and refer to.
Being a teacher for now more than 30 years, I have seen how rapidly and
radically pulmonary and critical care medicine has evolved. From being a
tuberculosis driven specialty, it has become a specialty which has so much
of internal medicine and has evolved with new areas like sleep medicine and
interventional pulmonology, now considered an integral part of “pulmonary
medicine”. Recognizing this, we now have a very active DM program in “pulmonary
medicine” which is one of the most sought after program by postgraduates. Also,
there has been an exponential increase in medical knowledge over the last 20
years. Some feel that this has led to an enormous accumulation of knowledge
and multiple options being available, without a clarity as to what is ideal and
what is best for the patient. It is important for both internists and specialists to
stay in touch with the changing times. This book is therefore essential in today’s
time.
I would like to take this opportunity to congratulate the authors and Professor
SK Jindal for coming out with this excellent handbook and greatly appreciate
the hard work that has been put in writing this book.

Randeep Guleria
MD DM FAMS
Padma Shree and B C Roy Awardee (Eminent Medical Person)
Director and CEO
All India Institute of Medical Sciences
New Delhi, India
 Preface to the Second Edition

‘No bubble is so iridescent or floats longer than that blown by the successful teacher’
William Osler, 1911

There have been rapid advances in the field of medicine in the last few years but
the three most significant developments in India and several other countries
relate to the fast expansion of drugs and devices for diagnosis and treatment of
diseases as well in the numbers of medical manpower. This has been particularly
so in case of the specialties such as Pulmonary and Critical Care Medicine. In India
for example, there have been introduction of post-doctoral DM courses in the
subject at the super-specialty level at several new centers. These developments
have created, at least temporarily, a relative shortage of resources and lack
of standardization. There also exists an imbalance between the demand for
and availability of good teaching and learning resources. It is true that there
is an enormous amount of knowledge available on the internet and various
publications which have increased in an exponential fashion. Caught with
contradictory and sometimes antagonistic information, a student finds it often
confusing and sometimes misguiding. It is therefore important to maintain the
credibility of the source of information.
In medicine, a textbook is usually the most credible source since it contains
the distilled and critical information which has stood the test of time as well as the
standards of practice. Moreover, a good textbook contains chapters contributed
by eminent and experienced teachers of different subjects. Our Textbook of
Pulmonary and Critical Care Medicine adequately fulfils those criteria. But it
requires time and focussed attention to absorb the contents of the textbook
which is not often feasible in a busy clinical practice when quick decisions are
needed. Handbook of Pulmonary and Critical Care Medicine which contains the
concise information on important subjects serves the purpose. It is a summarized
version of the Textbook published last year. Some of the important chapters of
the textbook had to be excluded from this abbreviated edition because of the
limitation of total page requirement. I am sure that the students and medical
practitioners including the pulmonary physicians will find it easy to carry as a
'vade mecum'—it should serve as a pocket-reference in their day-to-day practice.

SK Jindal
 Preface to the First Edition

“The physician ought to know literature…. To be able to

understand or to explain what he reads”.
Isidore of Seville (570–636)

The specialty of Pulmonary and Critical Care Medicine has quickly grown in size
and expanded in scope in a short span of time. So also has increased the need of
a wider availability of reliable, authoritative and multidimensional educational
resources in the subject. Today’s pulmonologists are required to know a lot more
about systemic illnesses and sister-specialties, besides the primary diseases of
the lungs. Pulmonary critical care and invasive interventions have also become
essential in pulmonary practice.
It is less than a year when the Textbook of Pulmonary and Critical Care Medicine
edited by ourselves was first published. Since then, there has been a growing
demand to come with an abridged version for convenience and easy readability.
This handbook is an effort in that direction to enable the busy and ever on-the-
run students and practitioners to quickly go through the contents. Needless to
say that the postgraduates as well as the students need to consult the textbook
for a more comprehensive and in-depth knowledge of the subject.
For purposes of brevity, it was not possible to include all the chapters in the
handbook. For the same reason, the bibliography as well as a large number of
figures and tables of the original chapters were excluded from the handbook.
The handbook, however, not just serves the purpose of quick browsing of the
contents but also provides an opportunity to read the carefully dissected factual
information of the subjects. I do hope that the readers will find it useful and
informative.

SK Jindal
 Acknowledgments

I am thankful to Drs Suhail Raoof and PS Shankar as well as my departmental

colleagues Drs D Behera, AN Aggarwal, Ritesh Agarwal, Navneet Singh, Sahajal
Dhooria and Inderpaul Singh Sehgal who had contributed and edited the 2nd
edition of Textbook of Pulmonary and Critical Care Medicine—the main source
of this Handbook even though myself and my son, Dr Aditya Jindal take the
onus of abridging. I am also obliged to a large number of friends and eminent
authors from across the globe to spare their time with valuable contributions.
I greatly appreciate the help rendered my erstwhile secretary, Ms Manju
Aggarwal in the preparation of the manuscript and M/s Jaypee Brothers Medical
Publishers (P) Ltd, New Delhi, India in taking the challenge of publication.
 Contents

1. Introduction 1
SK Jindal
•• History 1
•• Respiratory System Function 2
•• Ventilation-Perfusion (V/Q) Relationships 2
•• Respiratory Defenses 3

2. Applied Respiratory Physics 4

SK Jindal, VK Jindal
•• Atom, Element, Molecule, and Compound 4
•• Molecular Movement 5
•• Atomic and Molecular Weights 5
•• Physical Properties of Gases 5
•• Gas Laws 8
•• Gas Solution and Tension 10
•• Vapor 10
•• Expression of Gas Volumes and Pressures 11
•• Flow of Gases 11
•• Deposition 13
•• Diffusion 13

3. History and Physical Examination 15

Prahlad Rai Gupta
•• History Taking 15
•• History of Treatment 17
•• Physical Examination 18

4. Pulmonary Function Tests 22

AN Aggarwal
•• Spirometry 22
•• Peak Expiratory Flow 25
•• Static Lung Volumes 26
•• Diffusing Capacity of Lungs 27
•• Exercise Testing 28
•• Other Tests 30

5. Interpretation of Arterial Blood Gases and

Acid–Base Abnormalities 32
Aditya Jindal
•• Basic Concepts 33
•• Overview of Acid–Base Pathophysiology in the Body 33
•• Types of Acid–Base Disorders 34
•• Anion Gap 36
•• Acid–Base Disorders 37
xxvi Handbook of Pulmonary and Critical Care Medicine

6. Tuberculosis: Overview 40
Stuti Agarwal, Romica Latawa, Indu Verma
•• Route and Spread of Infection 40
•• Mycobacterial Groups 41
•• Mycobacterial Identification 42
•• Mycobacterial Drug Resistance 43

7. Immunology and Pathogenesis 44

Madhur Kalyan, Krishna K Singh, Indu Verma
•• Mycobacterium Tuberculosis Infection and
Overview of Immunopathogenesis 44
•• Immune Responses to Tuberculosis 46

8. Pulmonary Tuberculosis: Clinical Features and Diagnosis 50

S Kashyap, Malay Sarkar
•• Postprimary Pulmonary Tuberculosis 50
•• Symptoms and Signs 51
•• Tuberculosis in the Elderly 52
•• Miliary Tuberculosis 52
•• HIV and Tuberculosis 53
•• Pleural Effusion 53
•• Paradoxical Response 53
•• Physical Examination 53
•• Diagnosis of Tuberculosis 54
•• Extrapulmonary Tuberculosis 57

9. Molecular Diagnosis of Tuberculosis 58

Rama Murthy Sakamuri, Mamta Kalra, Indu Verma, Suman Laal
•• Diagnosis of Tuberculosis: Beyond the Microscopy 58

10. Management of Tuberculosis 63

D Behera
•• Prevention of Drug Resistance 63
•• Early Bactericidal Activity 64
•• Sterilizing Action 64
•• New Patients 65
•• Previously Treated Cases 67

11. Prevention of Tuberculosis 68

Rajesh N Solanki, Jaydeep Odhwani, Kumar Utsav
•• Primordial Prevention 68
•• Primary Prevention 68
•• Secondary Prevention 70
•• Tertiary Prevention 73

12. Extrapulmonary Tuberculosis 74

AK Janmeja, PR Mohapatra, Deepak Aggarwal
•• Diagnosis 74
•• Treatment of Extrapulmonary Tuberculosis 75
•• Lymph Node Tuberculosis 75
•• Pleural Effusion 76
•• Bone and Joint Tuberculosis 76
•• Central Nervous System Tuberculosis 79
 Contents xxvii
•• Abdominal Tuberculosis 81
•• Genitourinary Tuberculosis 82
•• Skin Tuberculosis 83
•• Pericardial Tuberculosis 83
•• Hepatic Tuberculosis 84
13. Multidrug Resistant Tuberculosis 86
Surendra K Sharma, Dinkar Bhasin
•• Definitions 86
•• Diagnosis 87
•• Management 87

14. Treatment of Tuberculosis in Special Situations 91

Rajendra Prasad, Nikhil Gupta
•• Treatment of Tuberculosis in Pregnancy and Lactation 91
•• Treatment of Tuberculosis in Renal Insufficiency 92
•• Treatment of Tuberculosis in Liver Disease 93

15. Tuberculosis and Human Immunodeficiency Virus Infection 95

Aditya Jindal, SK Jindal
•• Epidemiology 95
•• Pathogenesis 95
•• Clinical Features 97
•• Diagnosis 98
•• Management 98

16. Nontuberculous Mycobacterial Diseases 102

PS Shankar, SK Jindal
•• Classification 102
•• Human Disease 103
•• Summary 105

17. Community-acquired Pneumonia 106

Charles Feldman, Ronald Anderson
•• Microbial Etiology 106
•• Risk Factors 107
•• Pathogenesis with Particular Reference
to the Pneumococcus 107
•• Diagnostic Testing 108
•• Prognosis 109
•• Treatment 110

18. Pulmonary Fungal Infections 112

Arunaloke Chakrabarti
•• Types of Infections 112

19. Nosocomial Pneumonia 118

Vishwanath Gella, SK Jindal
•• Definitions 118
•• Pathogenesis 119
•• Prevention of Hospital-acquired Pneumonia and
Ventilator-associated Pneumonia 119
•• Diagnosis 121
•• Treatment 123
xxviii Handbook of Pulmonary and Critical Care Medicine

20. Lung Abscess 125

C Ravindran, Jyothi E
•• Epidemiology 125
•• Classification 125
•• Etiology 126
•• Pathogenesis 126
•• Pathology 126
•• Clinical Features 127
•• Laboratory Diagnosis 127
•• Complications 128
•• Treatment 129
•• Prognosis 130

21. Bronchiectasis and Cystic Fibrosis 131

David Honeybourne 131
Bronchiectasis 131
•• Pathology 131
•• Physiology 132
•• Etiology 132
•• Symptoms and Signs 132
•• Diagnosis 133
•• Microbiology 134
•• Treatment 134
•• Complications 136
•• Prognosis 136
Cystic Fibrosis 136
•• Diagnosis 137
•• Clinical Features 138
•• Infections and Treatment 138

22. Anaerobic Bacterial Infections of the Lungs and the Pleura 141
Ashok Shah, Chandramani Panjabi
•• Pathophysiology 141
•• Other Predisposing Factors 141
•• Natural History and Clinical Classification 142
•• Anaerobes and Upper Respiratory Syndromes 143
•• Clinical Features 144
•• Laboratory Diagnosis 145
•• Treatment 145

23. Bronchial Asthma Epidemiology 147

SK Jindal
•• Epidemiology 148
•• Disease Burden 149
•• Risk Factors of Asthma 149

24. Airway Inflammation and Remodeling 153

Ruby Pawankar, Shu Hashimoto, Miyuki Hayashi,
Shingo Yamanishi, Manabu Nonaka
•• Chronic Inflammation in Allergic Rhinitis and Asthma 154
•• Remodeling in Asthma 156
 Contents xxix
25. Asthma Diagnosis 158
Liesel D’silva, Parameswaran Nair
•• Clinical Diagnosis 158
•• Tests for Diagnosis and Monitoring 159
•• Diagnostic Challenges 162

26. Control and Management of Stable Asthma 165

Sidney S Braman, Gwen Skloot
•• Goals of Asthma Treatment 165
•• Essential Components of Asthma Care 166

27. Acute Asthma Exacerbations 171

Aditya Jindal
•• Triggers Causing Exacerbations 171
•• Diagnosis and Evaluation of Severity 172
•• Management 173

28. Allergen Desensitization 177

Vikram Jaggi
•• Definition 177
•• Mechanisms of Allergen Immunotherapy 177

29. Patient Education in Asthma 184

Bharat Bhushan Sharma, Virendra Singh
•• Goals of Asthma Education Programs 184
•• Benefits of Asthma Education Programs 185
•• Methods and Settings 185
•• Asthma Education Program Components 185
•• Problems in Patient Education 186

30. Pharmacotherapy of Bronchial Asthma 187

Nusrat Shafiq, Samir Malhotra
Controllers: Anti-inflammatory Agents 187
•• Corticosteroids 187
•• Leukotriene Receptor Antagonists 189
•• Mast Cell Stabilizers 191
Relievers—Bronchodilators 192
•• Beta-2 Adrenergic Agonists 192
•• Methylxanthines (Xanthines) 196
•• Anticholinergic Agents 198

31. Allergic Bronchopulmonary Aspergillosis 200

Ritesh Agarwal
•• Epidemiology 200
•• Pathogenesis 201
•• Pathology 201
•• Clinical Features 202
•• Laboratory Findings 202
•• Diagnosis and Diagnostic Criteria 205
•• Management 205
•• Allergic Bronchopulmonary Mycosis 207
xxx Handbook of Pulmonary and Critical Care Medicine

32. Burden of Chronic Obstructive Pulmonary Disease 208

Monica Barne, Sundeep Salvi
•• Mortality due to Chronic Obstructive Pulmonary Disease 208
•• Prevalence of Chronic Obstructive Pulmonary Disease 209
•• Disability Adjusted Life Years (DALYS) due to Chronic Obstructive
Pulmonary Disease 211
33. Risk Factors for Chronic Obstructive Pulmonary Disease 213
Sneha Limaye, Sundeep Salvi 213
•• Tobacco Smoking 213
•• Environmental Tobacco Smoke 214
•• Household Air Pollution 214
•• Mosquito Coil Smoke 215
•• Outdoor Air Pollution 215
•• Chronic Obstructive Pulmonary Disease Associated
with Occupational Exposures 215
•• Chronic Obstructive Pulmonary Disease Associated
with Pulmonary Tuberculosis 216
•• Chronic Asthma 216
•• Genetic Factors 216
•• Socioeconomic Status 217

34. Pathophysiology of Chronic Obstructive Pulmonary Disease 218

Bill Brashier, Sundeep Salvi, Baishakhi Ghosh
•• Inflammatory Changes 218
•• New Insights into Small Airway Obstruction 221
•• Chronic Obstructive Pulmonary Disease as a Disease of
Systemic Inflammation 221
35. Systemic Manifestations and Comorbidities of
Chronic Obstructive Pulmonary Disease 223
SK Jindal, PS Shankar
•• Pathogenesis 223
•• Systemic Manifestations 224
•• Therapeutic Considerations 228

36. Treatment of Chronic Obstructive Pulmonary Disease 229

Peter J Barnes
•• Risk Factors and their Prevention 229
•• Pharmacotherapy 230
•• Supplementary Oxygen 235
•• Antibiotics 236
•• Other Drug Therapies 236
•• Nonpharmacological Treatments 238

37. Acute Exacerbations of Chronic Obstructive

Pulmonary Disease 239
Raja Dhar, AG Ghoshal
•• Copd Exacerbation 239

38. Pulmonary Rehabilitation 245

Rachael A Evans, Roger S Goldstein
•• Role and Definition of Pulmonary Rehabilitation 245
•• Changing Pulmonary Rehabilitation Population—
Whom to Refer? 246
 Contents xxxi
•• Outcome Measures 247
•• Core Components of a Pulmonary Rehabilitation Program 248
•• Maintenance 249
•• Mobility Aids 250
•• Rehabilitation Team 250
•• Setting 250
•• Exacerbations 250
•• Performance Enhancement 250
39. Bullous Lung Diseases 252
Aditya Jindal, Gyanendra Agrawal
•• Pathogenesis 252
•• Etiology 253
•• Clinical Presentation 254
•• Radiologic Features 254
•• Pulmonary Function Tests 254
•• Natural History 255
•• Complications 255
•• Treatment 255

40. Upper and Central Airways Obstruction 257

VR Pattabhi Raman
•• Physiological Considerations 257
•• Clinical Features 258
•• Diagnosis 258
•• Acute Upper Airway Obstruction 259
•• Chronic Upper Airway Obstruction 261
•• Therapeutic Considerations 264

41. Interstitial Lung Diseases 266

Nagarjuna V Maturu, Dheeraj Gupta
•• Etiology and Classification 266
•• Epidemiology 268
•• Pathology 268
•• Pathogenesis 268
•• Diagnostic Approach 269
•• Treatment 271
•• Acute Exacerbation of ILD 273
•• Prognosis 274

42. Idiopathic Interstitial Pneumonias 275

H Shigemitsu, Ngozi Orjioke, Carmen Luraschi-Monjagatta
•• Diagnosis 275
•• Histological Features 276
•• Idiopathic Pulmonary Fibrosis 276
•• Nonspecific Interstitial Pneumonia 278
•• Desquamative Interstitial Pneumonia 279
•• Respiratory Bronchiolitis-associated Interstitial
Lung Disease 280
•• Cryptogenic Organizing Pneumonia 281
•• Acute Interstitial Pneumonia 282
•• Lymphoid Interstitial Pneumonia 282
•• Idiopathic Pleuroparenchymal Fibroelastosis 283
•• Unclassifiable Idiopathic Interstitial Pneumonia 284
xxxii Handbook of Pulmonary and Critical Care Medicine

43. Sarcoidosis 285

Dheeraj Gupta, Sahajal Dhooria, Om P Sharma
•• Etiology and Risk Factors 285
•• Pathogenesis and Immunology 286
•• Pathology 286
•• Clinical Features 287
•• Diagnosis 289
•• Treatment 291
•• Prognosis and Mortality 293

44. Pulmonary Eosinophilic Disorders 294

Subhash Varma, Aditya Jindal
•• Eosinophils 294
•• Pulmonary Eosinophilic Disorders 296
•• Approach to Diagnosis and Conclusion 304

45. Infiltrative and Deposition Diseases 305

Pralay Sarkar, Arunabh Talwar
•• Pulmonary Amyloidosis 305
•• Lysosomal Storage Disorders 307

46. Bronchiolitis 312

Gyanendra Agrawal, Dheeraj Gupta
•• General Features of Bronchiolar Disorders 312
•• Clinical Presentations 312
•• Practical Approach for Diagnosis of Bronchiolar Disorders 315

47. High-altitude Problems 317

Ajay Handa
•• Physical Changes with Altitude 317
•• Physiological Adaptation to High Altitude 317
•• Specific Altitude-related Illnesses 318
•• Effects of High Altitude on Existing Lung Diseases 320

48. Aviation and Space Travel 322

Ajay Handa
•• Respiratory Physiology with Altitude 322
•• Preflight Assessment 323
•• Prescribing In-flight oxygen 324
•• Space Travel 325
•• Microgravity and Weightlessness 325

49. Lung Disease in Coal Workers 327

Harakh V Dedhia, Daniel E Banks
•• Clinical Features of Coal Dust Exposure 327
•• Pathology of Coal Worker Pneumoconiosis 329
•• Management of CMDLD 330

50. Silicosis 333

PS Shankar, SK Jindal
•• Occupational Exposure 333
•• Pathogenesis 334
•• Forms of Silicosis 334
•• Clinical Features 336
 Contents xxxiii
•• Diagnosis 336
•• Prognosis 339
•• Treatment 339

51. Berylliosis 340

PS Shankar
•• Acute Beryllium Disease 340
•• Chronic Beryllium Disease 340
•• Pathogenesis 341
•• Clinical and Radiological Features 341
•• Diagnosis 342
•• Treatment 342
52. Metal-induced Lung Disease 344
Dilip V Maydeo, Nikhil C Sarangdhar
•• Types 344
•• Epidemiology 344
•• Pathogenesis 345
•• Types of Immune Responses in Metal-induced
Lung Disease 345
•• Clinical Presentation and Diagnosis 345
•• Approach 346
•• Treatment 347

53. Health Risks of Asbestos Fiber Inhalation 348

Daniel E Banks, Harakh V Dedhia
•• Asbestosis 349
•• Asbestos Fibers and the Pleural Space 350
•• Diffuse Pleural Thickening: Fibrosis of the Visceral Pleura 350
•• Pleural Plaques: Fibrosis of the Parietal Pleura 351
•• Malignant Mesothelioma 352
•• Lung Cancer 353

54. Occupational Asthma 354

PS Shankar, G Gaude
•• Agents Causing Occupational Asthma 355
•• Pathogenetic Mechanisms of Occupational Asthma 357
•• Diagnosis 357
•• Management 359
•• Prognosis 360

55. Hypersensitivity Pneumonitis 361

PS Shankar
•• Etiology 361
•• Pathogenesis 362
•• Pathology 363
•• Clinical Presentation 363
•• Diagnosis 364
•• Management and Prevention 365
•• Prognosis 366

56. Toxic Inhalations and Thermal Lung Injuries 367

VK Vijayan, N Goel, R Caroli
•• Determinants of Inhalational Lung Injury 367
•• Clinical Presentations of Inhalational Injury 368
xxxiv Handbook of Pulmonary and Critical Care Medicine

•• Systemic Illnesses from Inhaled Toxins 371

•• Smoke Inhalation Lung Injury 372
•• Management 372
57. Drug-induced Respiratory Disease 373
William J Martin Jr
•• Drugs Associated with Respiratory Toxicity 373
•• Diagnosis and Management of Drug-induced
Respiratory Disease 376
58. Epidemiology and Etiopathogenesis of Lung Cancer 378
Nagarjuna V Maturu, Navneet Singh
•• Lung Cancer in India 378
•• Histological Patterns 378
•• Risk Factors 379
•• Molecular Biology of Lung Cancer 383
59. Pathology of Lung Tumors 385
Amanjit Bal, Ashim Das
•• Preinvasive Lesions 385
•• Classification of Lung Cancer 386
•• Epithelial Tumors 386
•• Neuroendocrine Lesions of the Lung 388
•• Staging of Lung Tumors 389
60. Lung Cancer: Clinical Manifestations 391
Javid Ahmad Malik
•• Local Manifestations 391
•• Metastatic Manifestations 393
•• Endocrine Syndromes 396
•• Neurological Syndromes 397
•• Hematological Syndromes 399
•• Skeletal 399
•• Miscellaneous Syndromes 400
61. Diagnosis and Staging of Lung Cancer 401
Nagarjuna V Maturu, Ajmal Khan, Navneet Singh
•• Diagnosis of Lung Cancer 401
•• Staging of Nonsmall-cell Lung Cancer 403
•• Staging of Small-cell Lung Cancer 405
62. Approach to Management of Lung Cancer in India 407
Navneet Singh, Nagarjuna V Maturu, Digambar Behera
•• Treatment of Lung Cancer 407
•• Palliation 413

63. Targeted Agents for Nonsmall Cell Lung Cancer 415

Nagarjuna V Maturu, Navneet Singh
•• Epidermal Growth Factor Receptor–Tyrosine
Kinase Inhibitors 415
•• Anaplastic Lymphoma Kinase Inhibitors 418
•• Vascular Endothelial Growth Factor Inhibitors 419

64. Hematopoietic and Lymphoid Neoplasm of Lungs 420

Gaurav Prakash, Pankaj Malhotra
•• Lymphomas 420
•• Lymphomatoid Granulomatosis 425
 Contents xxxv
•• Secondary Involvement of Lung by Other Systemic
Hematopoietic and Lymphoid Disorders 426

65. Solitary Pulmonary Nodule 428

Alladi Mohan, B Vijayalakshmi Devi, Abha Chandra
•• Terminology 428
•• Etiology 429
•• Clinical Evaluation 430
•• Imaging Studies 430
•• Management 435

66. Mediastinal Disorders 436

Arjun Srinivasan, SK Jindal
•• Imaging of Mediastinum 437
•• Diseases of Mediastinum 438
•• Tumors and Cysts of Mediastinum 441

67. Diseases of the Chest Wall 447

Balamugesh T
•• Kyphoscoliosis 447
•• Thoracoplasty 449
•• Pectus Excavatum 450
•• Pectus Carinatum 450
•• Ankylosing Spondylosis 450
•• Obesity 451
•• Flail Chest 452
•• Miscellaneous Conditions 452

68. Diffuse Alveolar Hemorrhage 454

Stagaki E, Karakontaki F, Polychronopoulos V
•• Diffuse Alveolar Hemorrhage Syndromes 454
•• Causes 457
•• Other Causes of Diffuse Alveolar Hemorrhage 464

69. Pulmonary Hypertension: A Third World Perspective 466

Lakshmi Mudambi, Zeenat Safdar
•• Clinical Features 467
•• Physical Examination 468
•• Diagnostic Evaluation 468
•• Pathophysiology 470
•• Management 471

70. Pulmonary Thromboembolism 473

Devasahayam J Christopher, Richa Gupta
•• Pathophysiology 473
•• Risk Factors 475
•• Clinical Features 475
•• Diagnosis 476
•• Management 478

71. Pulmonary Vascular Malformations 482

Gautam Ahluwalia
•• Hereditary Hemorrhagic Telangiectasias or
Rendu–Osler–Weber Syndrome 483
xxxvi Handbook of Pulmonary and Critical Care Medicine

•• Pathogenesis 483
•• Clinical Features 484
•• Investigations 484
•• Management 485
•• Other Pulmonary Vascular Malformations 485

72. Approach to Respiratory Sleep Disorders 488

Ruchi Bansal
•• Sleep History 488
•• Physical Examination 489
•• Nocturnal Polysomnography 490
•• Out-of-center Sleep Testing 490
•• Sleep Questionnaires 491
•• Respiratory Disorders During Sleep 491

73. Respiratory Sleep Disorders 493

Aditya Jindal
•• Classification 493

74. Respiratory Failure 499

Abinash Singh Paul, Ritesh Agarwal
•• Classification 499
•• Mechanisms 500
•• Clinical Manifestations 502
•• Diagnosis 502
•• Treatment 503

75. Acute Respiratory Distress Syndrome 507

Jean I Keddissi, D Robert McCaffree
•• Etiology 507
•• Clinical Picture 508
•• Pathophysiology 508
•• Management 509
•• Prognosis and Outcome 513

76. Sepsis 514

Sean E Hesselbacher, Walter G Shakespeare, Kalpalatha K Guntupalli
•• Pathogenesis 514
•• Clinical Features and Evaluation 515
•• Prognosis 516
•• Management 517
•• Goals of Care 520
•• Special Considerations 521

77. Nonpulmonary Critical Care 522

Liziamma George, Mark Astiz
•• Gastrointestinal Disease in Critical Care 522
•• Hematology in Critical Care 526
•• Renal Disease in Critical Care 528
•• Endocrine Emergencies in Critical Care 529
•• Neurological Disorders in Critical Care 531
 Contents xxxvii
78. Critical Care in Nonpulmonary Conditions: Poisoning,
Envenomation, and Environmental Injuries 535
Dhruva Chaudhry, Inderpaul Singh Sehgal
•• Poisoning 535
•• Envenomation 541
•• Environmental Injuries 544

79. Pulmonary Hypertension in the Intensive Care Unit 548

Charles Peng, Roxana Sulica
•• Right Heart in Health and Disease 548
•• Pulmonary Hypertension in the Critically Ill Patient 549
•• Right Ventricular Failure in Patients with Preexisting
Pulmonary Arterial Hypertension 551
•• Management of the Pulmonary Arterial Hypertension
Patient with Decompensated Right Heart Failure 552
•• Perioperative Management of the Patient with
Pulmonary Arterial Hypertension 554

80. Mechanical Ventilation: General Principles and Modes 555

GC Khilnani, Vijay Hadda
•• Indications of Mechanical Ventilation 555
•• Basic Aspects of Mechanical Ventilation 556
•• Modes of Mechanical Ventilation 557
•• Newer Modes of Mechanical Ventilation 565
•• Initiating Mechanical Ventilation 567
•• Complications of Mechanical Ventilation 568

81. Noninvasive Ventilation 570

GC Khilnani, Vijay Hadda
•• Technical Aspect of Noninvasive Ventilation 570
•• Steps to Successful Provision of Noninvasive
Positive Pressure Ventilation 573
•• Clinical Uses of Noninvasive Positive Pressure Ventilation:
Evidence and Recommendations 575

82. Blood Gas Monitoring 579

Inderpaul Singh Sehgal, Ritesh Agarwal
•• Arterial Sampling 579
•• Arterial Cannulation 580
•• Noninvasive Blood Gas Monitoring 581

83. Cutaneous Capnography 585

Preyas Vaidya, Arvind H Kate, Prashant Chhajed
•• Site for Measurement 585
•• Factors Influencing PcCO2 Monitoring 586
•• Medical Applications of PcCO2 Monitoring 586
•• Clinical Settings for the Use of Cutaneous Capnography 587

84. Nutritional Management and General Care in the

Intensive Care Unit 591
Inderpaul Singh Sehgal, Navneet Singh
•• Malnutrition in Critical Illness 591
•• Refeeding Syndrome 593
xxxviii Handbook of Pulmonary and Critical Care Medicine

•• Assessment of Nutritional Status in Critically Ill Patients 593

•• Goals and Principles of Nutritional Support 593
•• Timing of Initiation of Nutritional Support 594
•• Route of Administration of Nutritional Support 594
•• Quantity and Volume of Nutrition Support 595
•• Delivery of Enteral Nutrition and Its Determinants 596
•• General Care in ICU 598

85. Management of Complex Airways Diseases 601

Rubal Patel, Atul C Mehta
•• Difficult Airway Situations 601
•• Indications for Artificial Airway 602
•• Techniques 605
•• Alternative Airway Techniques 607

86. Analgesia and Sedation in the ICU 609

Karan Madan, Ritesh Agarwal
•• Teamwork (Multidisciplinary Management) and
Patient-focused Care 609
•• Initial Evaluation and Medication Reconciliation 610
•• Consequences of Off-target Sedation and Analgesia 610
•• Assessment of Pain, Sedation, and Agitation in the ICU 610
•• Objective Measurement of the Cerebral Activity in the ICU 612
•• Management of Analgesia and Sedation in the ICU 612
•• Recent Developments and Novel Approaches 618

87. Weaning from Mechanical Ventilation 621

Ajmal Khan, Ritesh Agarwal
•• Pathophysiology of Weaning 622
•• Outcome of Weaning 623
•• Assessment for Weaning 623
•• Techniques of Weaning 624

88. Hyperbaric Oxygen Therapy 628

PS Tampi, SK Jindal
•• Rationale of Hyperbaric Oxygen 628
•• Other Physiological Effects of Hyperbaric Oxygenation 629
•• Beneficial Effects of HBO2 629
•• Mechanism of Action of HBO2 629
•• Indications 630
•• HBO2 in Pediatric Age Group 633
•• Potential New Indications 633
•• Contraindications 633
•• Complications 634

89. Pleura: Anatomy and Physiology 635

Srinivas Rajagopala
•• Anatomy of the Pleura 635
•• Development of the Pleural Membranes 636
•• Histology of the Pleura 636
•• Pleural Fluid: Normal Volume and Cellular Contents 636
•• Physiology and Pathophysiology of Pleural Fluid Turnover 637
•• Physiological Changes with a Pleural Effusion 638
•• Physiological Changes with Pneumothorax 638
 Contents xxxix
•• Pleural Manometry 638
•• Pleural Ultrasound 639

90. Tubercular Pleural Effusion 640

Pranab Baruwa, Kripesh Ranjan Sarmah
•• Pathology and Pathogenesis 640
•• Clinical Features 641
•• Diagnosis 641
•• Management 645
•• Complication of TB Pleural Effusion 646

91. Parapneumonic Effusion and Empyema 648

Devasahayam J Christopher
•• Definitions 648
•• Pathogenesis 649
•• Epidemiology 649
•• Bacteriology 650
•• Clinical Features and Diagnosis 650
•• Treatment 652

92. Malignant Pleural Effusions and Pleurodesis 655

Srinivas Rajagopala
•• Etiology of Malignant Effusions 655
•• Pathogenesis of Metastasis and Effusions 656
•• Clinical Presentation 656
•• Radiological Findings 657
•• Diagnosis 657
•• Management 659
•• Prognosis 663

93. Pneumothorax 664

Uma Devraj, GA D’Souza
•• Definitions 664
•• Pathophysiology 665
•• Resolution of Pneumothorax 665
•• Etiology 665
•• Laboratory Investigations and Diagnosis 667
•• Recurrence Rates 668
•• Treatment 668

94. Malignant Pleural Mesothelioma 674

Arun S Shet, Girish Raju, GA D’Souza
•• Epidemiology 674
•• Pathogenesis 675
•• Pathology 675
•• Clinical Presentation 676
•• Diagnostic Approach 676
•• Treatment 676

95. Pulmonary Involvement in Connective Tissue Diseases 680

Om P Sharma, Aditya Jindal
•• Rheumatoid Arthritis 680
•• Systemic Sclerosis 684
•• Sjögren’s Syndrome 686
xl Handbook of Pulmonary and Critical Care Medicine

•• Systemic Lupus Erythematosus 687

•• Dermatomyositis and Polymyositis 691
•• Ankylosing Spondylitis 692
•• Mixed Connective Tissue Disease 693

96. Pulmonary Manifestations of Other System Diseases 695

Ajmal Khan, SK Jindal
•• Cardiovascular Diseases 695
•• Neuromuscular Diseases 697
•• Endocrine Disorders 703
•• Gastrointestinal Diseases 706
•• Hepatic Disorders 709
•• Renal Diseases 712

97. Pulmonary Involvement in Tropical Diseases 714

Sanjay Jain, SK Jindal
•• Malaria 714
•• Typhoid 716
•• Leptospirosis 717
•• Dengue 718
•• Amebiasis 719

98. Pulmonary Diseases in Pregnancy 721

Lakhbir K Dhaliwal, Preeti Verma, Umesh Jindal
•• Dyspnea During Pregnancy 722
•• Asthma in Pregnancy 722
•• Pneumonia in Pregnancy 726
•• Tuberculosis and Pregnancy 730
•• Pulmonary Thromboembolism 732
•• Pregnancy-specific Problems 734

99. Rare Lung Diseases 737

Sanjeev Mehta, PS Shankar
•• Pulmonary Alveolar Phospholipoproteinosis 737
•• Pulmonary Calcification and Ossification Syndromes 740
•• Pulmonary Alveolar Microlithiasis 742

100. Ethics in Respiratory Care 744

Basil Varkey
•• Ethics Education 744
•• Ethics in End-of-life Care 749
•• A Conceptual Model for Patient Care 751

101. End-of-Life Care 753

Jeba S Jenifer, SK Jindal
•• Components 754
•• Common Symptoms 754
•• Diagnosing Dying and Providing Terminal Care 757
•• End-of-life Care in the Intensive Care Unit 758

Index 761
 1
CHAPTER

Introduction

SK Jindal

HISTORY
Breathing was perhaps the most vital physiological sign of life noticed by the
ancient man. The number of total breaths was supposed to be fixed during life
of an individual. Though there is little mention on the role of the lungs in the
archaic Medicine, the anatomy of lungs was perhaps known in those periods.
The oldest and best known image of the respiratory tract which dates back to
30th century BC comes from an Egyptian hieroglyph that depicts a wind pipe
with a pair of lungs. Ancient Egyptians also believed that breathing was the
most vital to life. Ebers Papyrus (c. 1550 BC), a detailed document on medicine
of that time, written on papyri was accidently unearthed in Thebes in 1862. The
papyrus, more than 20 meters long, was purchased and translated into German
in 1873 by Georg Ebers. Considered to be knowledge imparted by Thoth the
Egyptian God of learning and medicine, it mentioned about remedies for a
number of diseases, including asthma.
The presence of lung diseases such as tuberculosis and asthma was
variously described in the ancient Egyptian, Greek, Indian (Vedic) and Chinese
civilizations of the prebiblical periods. The concept of gas exchange and the role
of the lungs to maintain life, however, were not known until the 12th century
of the medieval era. The saga of both tuberculosis and asthma independently
runs back by 3000 years. The two are also amongst the few diseases which
continue to exist in a manner that was recognized in the past.
The earliest mention of respiration can perhaps be traced to Erasistratus
of Alexandria in Egypt who in 300 BC had postulated that it was the interplay
between the air and the blood which produced the “pneuma” or the spirit
essential for life.
2 Handbook of Pulmonary and Critical Care Medicine

RESPIRATORY SYSTEM FUNCTION

The thoracic cavity bound externally by the thoracic-cage contains the lungs
and the mediastinal structures between the two lungs. The thoracic cage is
formed by the ribs and intercostal muscles, lined internally by the parietal
pleurae. The lungs are lined on the surface by the visceral pleurae.
The respiratory systems essentially comprise of three different structural
and functional units:
1. Respiratory tract (from the nose and the mouth to the alveoli), meant for
air conduction.
2. Lung parenchyma (the alveoli and the surrounding interstitium, which
includes the blood capillaries, lymphatics and interstitial matrix with
several different kinds of cells).
3. Respiratory regulatory system.
The chest wall, respiratory muscles and the respiratory center constitute
the ventilatory apparatus or the pump responsible for movement of air in and
out of the lungs. On the other hand, gas exchange happens in the lungs at the
alveolar level.
Gas exchange by human lungs is achieved with the help of four processes,
which are also variably interdependent:
1. Ventilation: To and fro movement between the atmosphere and the gas
exchanging units of lung
2. Circulation: Supply and distribution of blood through the pulmonary
capillaries
3. Diffusion: The movement of O2 and carbon dioxide across the air-blood
barrier between alveoli and pulmonary capillaries
4. Ventilation-perfusion relationships

VENTILATION-PERFUSION (V/Q) RELATIONSHIPS

The ratio of pulmonary ventilation to pulmonary blood flow for the whole
lung at rest is about 0.8–1 (4–6 L/min ventilation divided by 5–6 L/min blood
flow), and this matching of distribution of ventilation and perfusion is the most
important determinant of gas exchange. The ventilation-perfusion mismatch
is the final common pathway to cause hypoxemia in most pulmonary diseases.
An area of lung that is well perfused, but under ventilated acts as a right to left
shunt (physiological shunt) whereas an area that is well ventilated, but under
perfused acts like a dead space (physiological dead space). The spectrum
of V/Q ratios in a healthy lung would vary between zero (perfused, but not
ventilated) to infinity (ventilated, but not perfused).
The ideal V/Q ratio of one indicates perfectly matched ventilation and
perfusion. Although V/Q mismatch includes both physiologic shunt and
physiologic dead space, but in clinical parlance, the term generally denotes
physiologic shunt as physiologic dead space, is rarely, if ever the cause of
hypoxemia.
The alveolar PO2 appears to be the most important factor involved in
regulating the distribution of ventilation-perfusion within the lung. In this
 Introduction 3
respect, hypoxic pulmonary vasoconstriction can be considered as part of a
negative feedback loop. For example, in lung units with low V/Q ratios, there
is a fall in local alveolar PO2, and constriction of associated microcirculation
reduces the local pulmonary blood flow. This tends to restore the local V/Q
ratio toward its normal value. This effect can be appreciated in the residents of
high altitudes, who are exposed constantly to lower ambient O2 concentrations.
Residents of high altitudes have better V/Q matching than sea level residents,
as reflected by a smaller alveolar-arterial PO2 difference.
The intensity of hypoxic pulmonary vasoconstriction varies among different
lung regions, and probably depends on the smooth muscle tone in different
vessels. The nitric oxide-mediated mechanism may also be important in
patients with inflammatory lung diseases, in whom the production of nitric
oxide is increased. The loss of local hypoxic vasoconstriction would worsen
ventilation-perfusion mismatch.

RESPIRATORY DEFENSES
The respiratory tract is exposed to environmental toxic substances, such as
the smoke, soot, dust and chemicals in the atmosphere, and also to a wide
range of organisms such as viruses, bacteria, fungi and parasites. It has been
calculated that the average individual inhales about 8 microorganisms per
minute or about 10,000 per day. The magnitude of this atmospheric insult on
the respiratory tract is much greater in the developing countries.
The defense against foreign material within the lungs is a critical
physiological function. This is accomplished by passive mechanisms, such
as the branching nature of the respiratory tract and the regulation of airway
lining fluid composition. The first line of respiratory defense consists of
mechanisms, such as the physical barrier; reflexes, including sneezing and
coughing; production of mucus; mucociliary clearance; transport of IgA and
antimicrobial mediators (defensins, lysozyme, lactoferrin, lectins).
These defenses can be overcome by a large number of organisms and
inhibitory factors of pathogens, by compromised effectiveness resulting from
air pollutants (e.g. cigarette smoke, ozone) or interference with protective
mechanisms (e.g. endotracheal intubation or tracheostomy) or genetic defects
(e.g. cystic fibrosis). Following exposure to airborne microorganisms (bio-
aerosols) in air, the defense mechanisms are able to eliminate most of the larger
microorganisms; however, smaller particles and spores may be trapped within
the lung tissue, which pose health risks. The impact on health depends on the
interaction between genetic differences in the host, agent and environments
(duration and exposure dose).
The vulnerability of individuals to the inhaled substances varies widely
depending on age, atopic status, nutrition and coexisting conditions. It is,
therefore, vital for respiratory clinicians to have a clear understanding of the
normal defenses of the respiratory tract.
 2
CHAPTER

Applied Respiratory Physics

SK Jindal, VK Jindal

Matter can exist in three different forms in nature—solid, liquid, or gas;

although plasma, a fourth state of matter has also been identified under the
extremes of temperature and pressure. In nature, matter is either an element
made from similar atoms, e.g. iron or a compound made from two or more
types of atoms, e.g. water (H2O).

ATOM, ELEMENT, MOLECULE, AND COMPOUND

An atom is the smallest part of an element, which acts like a “building block”.
On the further subdivision of an atom, the elemental properties are lost and
therefore, subatomic constituents of all atoms are identical. Atoms of certain
elements (e.g. hydrogen and helium) can exist in free state (H, He) and there
is no difference between the atoms and molecules of these elements. Atoms
of many other elements (such as oxygen) do not exist free, but combine with
other atoms of the same element to form molecules (e.g. O2, i.e. O + O). Atoms
of different elements may form molecules or compounds. Hydrogen can exist
in atomic or molecular form; whereas, nitrogen and oxygen occur in molecular
form (N2 and O2).
All substances consist of exceedingly small particles called molecules.
There are about 1019 molecules in 1 mL of air under the normal conditions
of temperature (T) and pressure (P). A molecule possesses the distinctive
properties of the parent element or compound. A molecule is found to consist
of two or more atoms of same kind or of different kinds. The number of
molecules comprising a macroscopic quantity of a gas is enormous typically
around 1023 molecules. The number of molecules and their velocity determine
many properties of gases.
 Another Random Document on
Scribd Without Any Related Topics
 Here was a hospital, or rather an asylum for invalids, into which,
on easy conditions, a poor body could get admission, and be kindly
cared for at the expense of the state. Many of these institutions are
scattered over the world, the fruit of Christianity, and when I find
them in places where I least expect, they tell me that love works the
same results everywhere. I soon found Dr. Stolberg, in a modest
dwelling, in a garden retired from the street, and he received me
with great courtesy and warmth.
In Sweden a physician makes no charge whatever for medical
attendance; and, what is more remarkable still, very many of the
people who can afford to pay for the services of a doctor are willing
to avail themselves of such aid without paying any thing for it. One
physician told me that of ninety-six cases that he had treated within
a certain time, only six paid him at all! It is customary for those who
do pay to pay by the year, and fifty-six dollars, or about twelve
American dollars, would be a large sum for persons in good
circumstances to give for the benefit of a physician’s counsel for a
whole year. There is, therefore, no great inducement, in the way of
profit, to go into the medical profession. Nor is it an introduction to
society, the physician not being in this respect materially above the
apothecary in social standing.
The clergy, as a profession, are not materially better off than the
physicians. Their pay comes from the state, but their salaries are
very small, and, with only here and there an exception, they have
very little influence, social or political. They are not men of learning,
and perhaps they are as influential as they could be expected to be.
The established religion is Lutheran, with one archbishopric, eleven
bishoprics, with 3,500 clergymen. They are said to be “highly
educated,” but I was assured that there is a great lack of education
among the clergy, and the very small salaries which even the
dignitaries receive would confirm the statement that the church does
not retain the aid of learned and able men.
The press is free, and when a man is called to account for the
abuse of this freedom, the case goes to a jury, whose action is final,
and there is no appeal from it.
 Only one in a thousand of the population is ignorant of letters;
they can read, and nearly all can write.
A common laborer gets about twenty-seven cents of our money
for a day’s work, and a mechanic at his trade earns a little more. The
cost of living must be very little, where the working classes can
support themselves and families on incomes so small as these!
Yet they do live comfortably, and if it were not for drinking
intoxicating liquors, they would be well off.
They are, as a people, as little given to other vices as in any
country of Europe, perhaps I might say, in the world. The statistical
tables show that many, very many, children are born into the world
whose parents are not lawfully married, and it is therefore set down
to the discredit of Sweden and Norway that they are very lax in their
social morals. There is this, however, to be said on this delicate
subject, the law forbids the marriage of any parties who have not
taken the Lord’s Supper, and many do not wish to become
communicants in the church, who are also quite willing to be
married. But the church will not sanction their union, and they live
together in the marital relation, true to each other, but without the
blessing of the church. Their children are returned in the census to
the discredit of the morals of Sweden! Here is an interesting point
for moralists to study. The practice is wrong, and so is the law that
has made the practice so common.
The mysterious words, Riddarholm kyrkan, provided always your
education has not extended into the language of Sweden, are used
to define a kyrkan or kirk, the Riders’ or Horsemen’s or Knights’
Church in Stockholm, decidedly the most peculiar and interesting of
all I have seen in the north of Europe.
Divine service is celebrated within its walls but once a year. It is
not a house for the living to pray in, but for the dead to lie in. It is
not for the dead of common clay, but for the dust of kings only,—a
royal mausoleum. It is a structure of nameless architecture, once
Gothic doubtless, but worked over until small trace of its original
design appears. A spire once almost reached the clouds, and when
the lightnings played too fiercely on it, it was replaced by one of cast
iron, which tapers finely to a lofty height, and defies the thunders.
It is a symbol, the whole church is, of a rude age and land. The
doors were opened at noon of a bright summer day, and yet as we
entered, a sense of gloom, of ruin, of vast antiquity, and the utter
emptiness of this poor life of ours, came over me like a thick cloud.
Every stone of uneven, broken pavement was a tomb, and the
inscriptions long since were worn away by the feet of strangers. In
dumb silence, for centuries the royal remains of successive dynasties
have been resting here, and their names are forgotten, rubbed out,
and unwritten elsewhere. The flags, spears, drums, swords, guns,
and implements of war unused in modern times, are hung around
the walls, as if this were an arsenal and not a sepulchre. In front of
the high altar, with recumbent effigies of ancient kings, and in the
midst of inscriptions hard to read and some still harder to
understand, was one epitaph in these words:—
Justitiæ Splendor
Patriæ Pater
Vivas in Eternum
O Magne Beate.

On either side of the door, and on elevated pedestals, are

equestrian statues, cased, both horse and rider, in solid armor; and
that of Charles IX. is said to have been made by Benvenuto Cellini.
The armor is more interesting from its association with the name of
its maker than the king who wore it. Such is fame.
On the right of the high altar, and within the choir, is the tomb
which every Protestant who comes to the north visits as a shrine,—
not to pray for the repose of a soul, but to testify his reverence for
the name of Gustavus Adolphus. The trophies of his victories adorn
his sarcophagus of green porphyry, which was made in Italy to
receive his remains. His own “garments rolled in blood,” in which he
fell while fighting on the field of Lutzen, November 16, 1632, are
preserved remarkably in their stains, for more than two centuries!
His epitaph is short and fitting: “Moriens triumphavit,”—
 “Dying he triumphed.”

The cause of truth, religious liberty, and the rights of man, all
denied and crushed by the Papal power,—the cause which woke the
soul of Luther and inspired the Reformation for these three
centuries,—has been struggling on toward the universal empire of
the human soul. That was the cause in which Gustavus Adolphus
died covered with wounds and glory, and his epitaph says that he
triumphed when he died. I think he did. True, the battle goes on
still, and many a hard field is to be fought over yet, before He whose
right it is shall reign unquestioned in His dominion over the souls of
the race. But the grand foe of the Church of Christ was then the civil
power of the Papacy. Rome had the armies of all papal kings at her
command, and they moved at her ghostly will, propagating her
religion, like that of the Moslem, by the sword. It was to roll back
this tide, more terrible than the waves of the Crusades, that
Gustavus Adolphus was called to lead the armies of the Protestant
powers, and the result was complete success. There is not now one
crowned head on earth that acknowledges the supremacy of the
popes. Austria has cast off its allegiance, and it was Austria that led
the South of Europe against Gustavus Adolphus. Italy is independent
of Rome. And Spain, the birthplace of the Inquisition, and the most
abject to the Pope, has cast out the principle of intolerance, and
proclaimed the rights of worship. What Luther did for the truth in the
pulpit, Gustavus Adolphus did for the same cause in the field.
We went down the stone stairway, worn deeply by the tread of
generations, into the lower regions, where lie whole rows of dead
kings turned to dust, coffins tucked away on shelves and in niches,
reminding me of the Bible words: “All the kings of the nations, even
all of them, lie in glory, every one in his own house.” What’s the
glory, though, of such a resting-place, it is hard to say. Their dust is
no better than that of other men. Their names, even among kings,
have ceased to be distinguished from other names. No man could go
among these walks of tombs, these shelved kings, and pick out one
or another, and say who is who. And if he could, I do not see that it
would be any particular satisfaction to the quiet gentleman on the
shelf. If the visitor should say, “Is this the man that made the earth
to tremble, that did shake kingdoms?” no answer would come back
from the tomb.
We did not set foot within the gates of his majesty, the King of
Sweden, and this neglect was much to the disgust of some of our
Swedish friends, who consider the royal residence a marvel of
architectural grandeur and beauty. We could not see it, even when
they pointed to its magnificence with the same exalted opinion of its
splendor that possessed the Jews in sight of their temple. The Lion’s
Staircase, rising from the water’s edge and leading to the main
entrance, adorned with two bronze, and therefore quiet, lions,
presents a grand front to the palace, and within the same
interminable suites of apartments, and the same gaudy furniture,
and the same sort of pictures and statuary, with nothing that has a
title to any distinction above what is common in all palaces.
The picture-gallery has some five hundred paintings, some by Van
Dyck, Paul Veronese, Domenichino, and others equally well known to
fame, and the sculpture gallery boasts a sleeping Endymion, and a
few other gems; but we are out of the enchanted zone, and must
not expect to be charmed with the brush or the chisel in Sweden.
We shall find Thorvaldsen when we come to Denmark.
But the royal library has 75,000 volumes, and if it had the library
that Queen Christina sent to the Vatican at Rome, it would be still a
greater wonder, and then would be increased if the ancient collection
made by Charles X., and consumed by fire in 1697, had been
preserved. The Codex Aureus, a Latin manuscript of the gospels,
dating in the sixth or seventh century, “is written in Gothic
characters of gold, on folio leaves of vellum, alternately white and
violet.”
“This book is additionally interesting, from its containing an Anglo-
Saxon inscription, of which the following is a translation: ‘In the
name of our Lord Jesus Christ, I, Alfred Aldorman (Senior or Prince),
and Werburg, my wife, got up this book from a heathen war-troop,
with our pure treasure, which was then of pure gold. And this we
got for the love of God, and for our souls’ behoof, and for that we
would not that this holy book should longer abide in heathenesse;
and now will we give it to Christ’s Church, God to praise, and glory,
and worship, in thankful remembrance of his passion, and for the
use of the holy brotherhood, who in Christ’s Church do daily speak
God’s praise, and that they may every month read for Alfred, and for
Werburg, and for Alhdryd (their daughter), their souls to eternal
health, as long as they have declared before God that baptism (holy
rites) shall continue in this place. Even so I, Alfred, Dux, and
Werburg, pray and beseech, in the name of God Almighty, and of his
saints, that no man shall be so daring as to sell or part with this holy
book from Christ’s Church, so long as baptism there may stand.
(Signed) Alfred, Werburg, Alhdryd.’ No trace appears to exist of the
history of this volume from the time it was thus given to Canterbury
Cathedral until it was purchased in Italy, and added to this library.
Here also is a huge manuscript copy of the Bible, written upon
prepared asses’ skin. It was found in a convent at Prague, when that
city was taken by the Swedes during the Thirty Years’ War. A copy of
Koberger’s Bible, printed at Leyden, 1521, and the margins of which
are filled with annotations by Martin Luther. Besides these, the
library is rich in manuscripts and rare editions.”
The King of Sweden is the most affable and approachable
monarch in Europe. In his daily walks, or while going about in the
public steamers that ply through the waters of the city, as
omnibuses do in New York, he enters freely into conversation with
the people. To strangers, especially Americans, he is exceedingly
kind, or, as his subjects would say, gracious. I saw him frequently
while he was riding, but came no nearer to his Majesty. He had one
of the most splendid reviews that I had ever seen, when the whole
of the Swedish army that is stationed in this part of the country,
together with the militia, all liable to be called on to do military duty,
are put through a drill for a few days and nights every year, in the
summer season. A vast open country, hill, wood and plain, is chosen,
tents pitched, and for a few days mimic war goes through all its
motions, saving and except that there is no blood shed. This annual
exercise does something to keep up a martial spirit, and makes a
few grand holidays, when the whole city is agog with the
excitement. A fête day in Rome, an emperor’s day in Paris, or Derby
day in London, would not exceed the annual review in Stockholm.
The nobility and fashion, the beauty and folly, the masses of people
in all sorts of conveyances, and more on foot than on wheels, were
out at the parade. The squadrons were set on the hills, so far apart
that a telescope was needed to see what was going on, and the
marching and countermarching made a pretty show that delighted
the people, and gave the soldiers a taste of the amusements they
would have when rushing into battle under a blazing sun, and
blazing guns in front of them.
The wars of Sweden occupy a large place in European history. Yet
when we see how small the population, how limited the resources,
and remote the situation of the country, it seems incredible that
human wisdom has been so foolish as to permit a race of kings to
waste the lives and wealth of a nation of honest men, in the
miserable game of war.
But the genius of Sweden is seen in a very clever arrangement to
make the burden of soldiering as light as possible. The standing
army proper is very small and has little to do at present. But the
reserve is large, and consists of men who are distributed about the
kingdom and quartered on the government lands, which they work
in time of peace, and thus earn their own support. If the crown
lands are leased to others, a certain number of these soldiers is set
apart for, or quartered on the land; and the lessee has their labor,
and is responsible for their support. In this ingenious way the
government makes its land pay the expenses of its army in peace.
We might take a leaf out of the royal book of Sweden, and, by a
wise administration of our vast national landed property, make it
contribute something to the support of the government, while we
improved its value. That would be certainly more statesmanlike than
to give it away by millions every year to speculators. The Swedish
soldiers are also employed in making roads, and on other public
works, as ours might be, greatly to their own moral benefit, and to
the advantage of the country.
 It strikes me that there is more order and less crime in this
northern part of Europe than in any other country I have yet visited.
I see little evidence of abject poverty and low vice. By night or day I
have not seen a person on the streets at Stockholm who seemed to
be of the abandoned class. Longer acquaintance may correct this
impression and reveal another state of facts. Two American travellers
were robbed of their watches and money, at the hotel where I am
lodged, but a few days ago. It is not at all likely the thief is a native
of these regions. He has probably followed the travellers, or, what is
quite as likely, been one of their travelling companions. The landlord
paid the losses without a lawsuit, and the Americans went on their
way.
 CHAPTER XXXIV.

SWEDEN (Continued).

BY the beautiful island of Drottningholm, on which the king’s mother

resides in a palace within a park, that seems the abode of peace and
plenty, and along the shores of other islands small and picturesque,
but lovely to look on as we pass them on our way, we sail out into
Lake Malar.
It is a wide, winding, beautiful sheet of water,—one of the many
noble lakes that Sweden holds in her bosom. Two islands in it come
so nearly together, that a drawbridge for a railroad stretches across,
and opens for us to pass through, and then we sweep out into
another expanse of water, the shores skirted with pines and
hemlock; no hills in sight, but the scenery is lovely, though lacking
grandeur. We are going into the heart of Sweden. Now the shores
are cultivated to the water’s edge, and fine farms rise to view, with
here and there a red cottage, with a tile roof: all the peasant houses
and fisherman cottages are painted with red ochre, cheap, but
unpleasant to the eye. Now the shores are bolder, rocky, and great
forest trees, fir and spruce, are abundant.
The oldest place in Sweden, and that carries us back into far
antiquity, is Sigtuna, and we have come to it, on the shores of Lake
Malar, about four hours from Stockholm. We are in the midst of the
remains of the old pagan worship of Scandinavia, where the altars to
heathen deities, whose graves (!) we are going to see to-day, have
smoked with human sacrifices.
 Odin or Woden (whence comes our Wedensday or Wednesday), a
hero of the north,—in time to which history, at least reliable history,
runneth not back,—here established the seat of his power, and it
took its name from his original title, which was Sigge, and Tuna,
which is our word town. Here Sigge, or Odin, reared stone temples,
of which the ruins are before us. Here his power became so great,
and such the reverence of rude peoples for power, that the temples
and altars which he reared to gods whom he worshipped, became,
in the eyes and hearts of the people, dedicate to him, whom they
came to revere and worship as a god. From this spot the worship of
Odin, and afterwards of his son Thor (whence our Thursday), spread
through the whole of the North of Europe, and, in spite of the
subsequent triumph of Roman Christianity, and then of the Lutheran
Reformation, the Odin superstition—a secret, unconfessed, but
controlling reverence for those heroic human deities, the hero
worship of the human soul—still obtains among the more ignorant
classes of the people over all this northern country. The legends that
have come down from sire to son, keep alive in successive
generations the hidden fear of these false gods, and form the largest
part of the unwritten poetry and romance of all Scandinavia.
Pirates from Finland came here and laid waste the fortified town of
Odin, and it has again and again been built and destroyed; but here
is the remnant of an ancient temple or church, and three towers,
which have the highest interest of antiquity (whatever that is)
hanging, like mantling ivy, all about them. No one but an antiquary
would wish to spend more than a moment in Sigtuna, among its 400
inhabitants. Tyre and Sidon on the sea coast are not so desolate as
this spot, which seems accursed for its pagan crimes and impostures
in days long since gone by.
Sweet pictures of rural life in Sweden were seen this morning as
we sailed through this Lake Malar. Opposite Sigtuna, and a little
farther on, we touched the shore, and landed Professor Olivecrona,
of the University of Upsala, with his wife and a party of English
friends. He had been to Stockholm to meet them, and bring them up
the lake to his country residence in summer. It was a beautiful
mansion, very near to the water’s edge, in the midst of woods and
delightful walks. The children and servants came down to the
landing just in front of the house, to a private wharf, and as the
parents went ashore, and four lovely children in their light summer
dresses welcomed them, and greeted the friends coming with them,
it was a scene of domestic beauty and happiness that quite touched
an old man’s heart some three or four thousand miles from home.
More islands, among which our boat makes its tortuous course,
coming so near to the rocks that we might easily scrape them; now
and then a bare white rock holds its peak solitary above the water,
and a bird of prey perches on its top, looking into the deep for his
dinner. Now the shores are clothed with green forests, and again we
emerge among meadows, and in the bright sun the contrasts of light
and shadow, as we pass by the pines and fir trees, are constantly
pleasing. An air of infinite quietude pervades the region, and it is
painful to believe that it was once a “habitation of cruelty.”
Suddenly a grand old chateau, the ancient residence of the Brahe
family, one of the oldest and most illustrious in Sweden, opened on
our view. It was built in 1630, and each one of its four towers is
surmounted by an orrery, in honor of the famous astronomer whose
name alone has made the family famous. A boat comes off from the
shore, and takes passengers who wish to visit the house. Its library
and museum and galleries of art make it a popular resort. On its
walls are portraits of Tycho, and the Ebba Brahe, whom Gustavus
Adolphus loved, and would have married but for more ambitious
schemes of her mother that never came to pass.
During this delightful passage of six hours through Lake Malar, in
one of the loveliest days of summer, we have not seen a sail nor a
steamer, except the return boat of the line that has brought us. And
this fact is sufficient to show the utter stagnation of commercial life
in the interior of Sweden.
I confess to surprise on coming to Upsala and finding the ancient
university here in high prosperity, with all the appliances of
education that first-class institutions require. Linnæus, the great
botanist, was professor here, and his statue is one of the ornaments
of the university. The Hospital,—a new and extensive building,—a
royal palace on a hill, the Agricultural College, the Library, &c., with a
Botanical Garden and ample parks, suggest to the traveller that in
Sweden one might find a home to his mind, if his lot had been cast
in this part of the earth.
You have a fondness for old books and manuscripts. Here they are
in abundance; not of the sort, perhaps, that most antiquarians
would run after, but, nevertheless, very precious and costly.
Bishop Ulfilas, toward the close of the fourth century, translated
the four gospels into the Gothic language, and his translation was
copied in letters of silver upon vellum of a pale purple color, in
characters very like the Runic. This manuscript is the very oldest
extant in the Teutonic tongue, and was probably made by the Ostro-
Gothic scribes in Italy. It was once owned by an abbey in
Westphalia. Then it was treasured up in Cologne; then by the
fortunes of war it passed to Konigsberg, and to Amsterdam, with
Vossius, on whose death the Swedish chancellor bought it and
presented it to the University of Upsala. It is known among biblical
scholars as the Codex Argenteus, or Silver Copy, from the style of
the lettering.
 Upsala.

If you have a taste for Icelandic literature, so refreshing in the

heats of summer, here you can find the oldest and coldest of the
Eddas; and alongside of them is a Bible with the marginal notes of
Luther and Melancthon. Students in and out of the university have
free access to these treasures, and the reading-room is a pleasant
resort for those who love to refresh themselves in the midst of a
hundred thousand books, in all tongues and every realm of human
thought.
About fifty professors and fifteen hundred students compose the
faculty and attendance of this famous university. It was founded in
1477, and has but one rival in Sweden, that at Ludd, founded in
1666. The expense of a student’s education, including board, fees,
&c., is about three hundred dollars a year.
No one can be admitted to practise in any of three professions,—
law, medicine, or divinity,—without taking his degrees at one of the
two universities. This ensures a high order of acquirements in
professional men, and when we state one fact in addition, that one
male person in every 688 in Sweden enjoys an education at the
universities, it will be seen that these institutions reach the whole
people, and extend their advantages into the midst of the masses.
Sweden, and in this respect she is not singular in Europe, has not
made the mistake which we in the United States have been making,
of multiplying little colleges, and little theological seminaries, one-
horse institutions, with the idea that, by bringing a school to the
door of every man, or of every church, we should be enlarging the
area of education, and multiplying the number of educated men.
Thus we have reduced the standard of fitness for professorships.
Thus we have diminished the number of students. Lowering the
mark to which scholars should aspire, we have cheapened
education, suppressed literary ambition, made the professions less
attractive, and filled them with an inferior order of men, compared
with what they would have been had the standard of great
universities, with their high qualifications of professorships and
degrees, been maintained. If all the money which has been
expended in the maintenance of feeble and famishing colleges and
divinity schools had been applied to the education of youth in two,
three, or four universities, they would have been far better taught,
and the surplus of money over and above the expenses of their
education would endow a new university as often as the extension
of territory and the increase of population render it necessary.
 A student of the university is required to wear a cap of peculiar
make, to distinguish him, not in the university town only, but
wherever he may travel in Sweden. The cap is white, with a black
border, and a rosette of the national colors in front. This requisition
is useful in keeping the student upon his good behavior, and also as
a peripatetic advertisement of the educational institutions of the
country. It is only by slow degrees that our people come into the
habit of putting classes into uniform. It is but recently that the police
were so clad: now we have letter-carriers, railway officials, &c. The
clergy formerly were generally known by a white neckcloth, but that
has ceased to be their distinction.
The old cathedral had the appearance of neglect; it was out one
side from the busy haunts of men, and this was in its favor, but it
seemed to be neglected. Twenty-four whitewashed columns support
the roof. In side chapels are the tombs and the remains of the old
kings of Sweden. And when I had spelled out some of the Latin
inscriptions, and had linked the names of these sleepers with the
old-time stories of the land, the venerable cathedral began to take
upon itself the form of a great monument of the dead past. And well
it might, for the first stones were laid for its foundation in the year
1289, and it was consecrated in 1435. Its dimensions rise into the
sublime, for it is 370 feet long, 141 feet wide, and 115 feet high.
The columns within are capped with carvings of grotesque beasts,
strangely out of taste in the house of God. Linnæus lies buried here,
and a splendid mural tablet and bronze medallion portrait of him
adorn the wall. Here lie Gustavus Wasa and two of his wives, and a
long series of fresco paintings in seven compartments celebrate the
great events in the life of this illustrious man. Here, too, is a tomb of
John III., remarkable for this,—that it was made in Italy, was lost at
sea on its way here, was fished up sixty years afterwards, and
brought to this spot.
The sacristan was very kind in revealing to our not very reverent
eyes the precious things here kept for special exhibition to those
who would pay for the privilege. With this understanding we were
permitted to behold crowns and sceptres, a gold cup two feet high,
a dagger that had been stuck into a king, and a statue of the old
god-king Thor! This last is not worshipped here, but is cherished as
a memorial of the times when paganism was prevalent, and as a
trophy of the triumph of Christianity over the powers of darkness.
About three miles north of Upsala, the seat of the great university,
is Old Upsala, more sacred than any other spot in Sweden: for here
are the lofty mounds which tradition has consecrated as graves of
the gods,—the gods who aforetime were held in reverent awe and
honor by the Scandinavian race, and who, to this day, hold some
sort of sway over the rude masses of the North.
We rode out in carriages from the university, and passed in sight
of the house which covers the Mora Stone, on which the kings of
Sweden were chosen and crowned. It is made of about twelve
different stones joined and inscribed with the names of the
monarchs who have been elected by the voice of the people. In
1780 the house was built over it by Gustavus III., but that was
seven centuries after the first inscription upon it; for here it is
written that Sten Kil was chosen in 1060, and seven others, down to
Christian I., in 1457. Gustavus Wasa met his subjects here in mass-
meeting and addressed them from this stone in 1520. The hoar of
ages, with all the memories of the revolutions of these centuries,
gathers on this spot. It is now only a shrine for pilgrims with
antiquity on the brain, who wander the world over to see what the
world has been. I have a large development of that weakness, and it
has a great gratification in this part of Europe: more, indeed, than it
had in Egypt; less than in Palestine. In the Holy Land the sacred
associations with the religion we love makes every acre of it dear to
the heart: we take pleasure in every stone, and favor all the dust of
Judea. With less awe,—indeed, with no awe,—but with wonder, we
now come to Old Upsala, to the graves of the pagan deities.
They are three conical mounds, about fifty feet in height, very
regular in shape, with a broad plateau at the summit, and the
unvarying tradition of the country is, that the largest of the mounds
is the grave of Odin; the next, that of Thor; and the smallest, the
grave of Freytag, Odin’s daughter. In all probability these are natural
hillocks artificially reduced to these regular forms, and superstitiously
set apart in the minds of the people as the graves of persons to
whom their ancestors paid divine honors. To this hour, the name of
Odin is used as that of a demon king, and “Go to Odin” is the
profane execration which answers to the modern imprecation, “Go to
the devil.”
On this spot the great temple to Odin was erected, and his
worship maintained with horrid rites and ceremonies. The altars here
have smoked with human blood and burnt sacrifices. In the sacred
groves that surrounded the temple these savage deities were
propitiated with all manner of offerings, parents laying their children
with their own hands upon the altars, and slaying them in the face
of heaven. A record still exists of seventy-two bodies being seen
suspended at one time from the limbs of trees in this grove; men,
and lower animals than men, if any animals are lower than such
men, being offered in company to please the deities of the wood.
We entered the old church, the tower of which is said to be a part
of the temple. This tower is the most ancient building in
Scandinavia. A rude stone image of a human being, uncared for and
lying in total neglect and dirt, was pointed out as an idol of Thor,
that had once and often been worshipped on this spot and honored
with these human sacrifices. It seemed more likely that it was a
bogus image, and, therefore, all the more fitting to be presented as
one of the false gods of a superstitious race, whose reverence is not
yet so thoroughly extinguished as to prevent them from leaving hay
on the highway at night, to feed the horses of Odin when he comes
riding through the country on his missions of destruction.
On the reach of the Reformation to this region, the great battle of
faith was fought on this spot. Here Gustavus Wasa, in his robes of
royalty, addressed the crowds of pagan people, and besought them
to turn from their idols to the living God. They replied with sullen
rage, and threatened him with death. He finally flung off his robes,
and told them they might have Odin for their king if they would, but
he would not be their king unless they would worship the Lord God
Almighty and his Son Jesus Christ. This was the decisive hour and
word. They yielded, but only an outward obedience, a lip service,
and it required long years and generations to extirpate the pagan
worship from the minds of the people. One king of Sweden, Domold,
was actually offered in sacrifice on Odin’s altar to propitiate the gods
when the people were suffering by famine. And when Eric V., in
1001, embraced the Christian religion and destroyed the temple, the
tower of which is said to be standing now as part of this church, the
people in their fury put him to death.
From Odin, or Woden, as he was called, comes our Weden’s-day,
and from Thor our Thur’s-day, and from Fry-tag our Fri-day; and
these every-day words make links of association to connect our
times with those fearful days, now past and gone for ever.
I was surprised by finding the practice of dining out of doors in
summer quite as common here as in France. On our return from
Upsala to Stockholm, Dr. Scholberg went with us to spend part of a
day at the Deer Park, a vast tract of land in easy reach from the
capital, that has been set apart for the use of the people. It is
entered through a grand gateway, ornamented with a bronze deer
on each side; within are villas and cafes, and theatres and concert-
rooms. Long drives over country roads take us under majestic old
trees,—oaks and elms, pines and spruce; and now and then we pass
parties taking their mid-day or evening meal under the trees, or
among the beautiful gardens that surround their houses. Our ride
takes us up and down hill, in sight often of the sea: one has a taste
of the country, rare indeed to be had so near the town. The quickest
way to get there is to take one of the many little steamers that ply,
like our omnibuses or street-cars, among the waters of this northern
Venice; but many of them do not hold as many passengers as a
horse-car carries. They are just like a large row-boat, with sharp
bows and stern, and a boiler in the middle. They require but very
little coal, and, being driven with great care, very seldom, if ever,
blow up the people sitting so near to the boiler and all its works, as
to suggest continually the idea that it would require no great effort
to scald the company. If our American people could do any thing
with moderation, they might introduce these little iron steamers with
great usefulness into the North and East Rivers, and, indeed, into
the waters of all our great cities. We often availed ourselves of them,
for they run everywhere, and the fare is lower than in our city cars.
A few minutes of fast running brought us to Deer Park, and our
Swedish doctor led us to what was considered the best restaurant in
the place. Hundreds of people were already there to dine, and at the
middle of the day. It did not speak well for the industry and habits of
the people, that so many of them could thus quit business at such
an hour and go off out of town to their dinner. And Stockholm is the
only city in the North where there is such a class of people. The city
has the name of being very like Venice in this matter. And here they
were in the middle of the day, hundreds of people, away from home,
and making a business of eating and drinking.
Dinner was a study and an art. They had some science in it. There
was an ante-prandium and the prandium, and the dessert and the
post-prandium, and more post that I did not see; but what I did may
be set down to give you an idea of the Swedes at dinner. First, every
gentleman steps to a side table and takes a glass of schnapps, or
gin, or other liquor that he prefers, and appetizes himself by eating
of salt fish, dried tongue, cold meats, bread and cheese, making a
very satisfactory snack or lunch, which would serve most of men for
a fair dinner. The second course is soup, and one who is recently
from Paris needs a little education to make it pleasant to his taste.
Then follow salmon, chicken, roast beef, pudding, ice cream, jellies;
and with these dishes, which are served one after another, and all to
be eaten, are the usual trimmings of bread and butter, with
vegetables to any extent. When this bill of fare—a dinner to order,
and exquisitely cooked and served in good style—is disposed of, you
are expected to indulge in the national punch, an oily, fiery, pungent
liquor, that should not be taken without medical advice; yet it may
be that it assists digestion after the organs have been overladen
with such a dinner as I have just eaten and described. Now, it is not
unlikely that such dinners are very largely enjoyed by the people, for
all that I have mentioned may be had for seventy-five cents! And as
you pay for just what you order, and no more, it is possible to make
a sufficient dinner for half the money, and thousands do. We
protracted our stay till the evening (not the dark) came on, and rode
to the charming rural retreat for the royal household, and had the
pleasure of gratifying our democratic eyes by seeing the ladies of the
family taking their tea out of doors, so much in the same way that
other people take theirs, we should not have suspected them of
being any thing more than common, had we not been told of it, and
actually had seen the august servant, with a white wig and pompous
strut, bringing the “tea things” out to the little table in the garden.
So many other little family circles did we see enjoying themselves in
the same way, that we could readily see it was a national habit, and
quite in harmony with those domestic pictures which Frederika
Bremer has made us so familiar with in her letters about Swedish
homes.
 Costumes of Sweden.

One thing impressed me daily in these north countries of Europe,

—the general content and comfort of the people. The climate has
not helped them to this, for it is far less favorable to general
enjoyment than that of the south. But there is an amount of
industry, intelligence, and morality, that make a contrast easily
marked between the people of Sweden, Norway, and Denmark, and
the inhabitants of Spain and Italy. I find no such masses of squalid
vice and misery here, as one may easily see in Naples or Seville.
 Sweden has all the elements of a great and good people. She is
making progress, too, in moral and intellectual culture, and her
people are rising in the scale of social enjoyment. I notice these
things in the rural districts even more than in the cities, which are so
much the same all the world over.
 CHAPTER XXXV.

SWEDEN (Continued).

WE are going across the kingdom, from Stockholm to Gottenburg.

We might be carried through by rail in a day; but what should we
see of life in Sweden if we went flying over it in that style? We will
take the slower and better way, by the raging canal. This canal is the
Erie of Sweden. It extends from lake to lake, and so connects sea
with sea, the Baltic with the Atlantic; it leaves Malar lake, and takes
lakes Wetter and Wener in its way, and all the chief towns of the
interior; and as the travelling is rationally moderate, the pauses
frequent and long, we have a fine opportunity to study the country
and the people whom we have come to see.
It is a steam canal; that is, a canal for steam navigation, as the
Erie and other canals of our country ought to be, and might be, but
for the penny-wise and pound-foolish policy of politicians. The
steamers are small. We embarked for this inland voyage on the
Oscar, a royal name. The cabin had ten state-rooms, with two berths
in each; a wash-stand in the middle had a movable cover, making a
table, on which I am writing. The boat is furnished with great
simplicity, but is comfortable. It is crowded with passengers; several
families, with children and luggage immense, probably emigrants on
their way to the land of promise. Their friends in troops thronged the
wharf to see them go, and when the hand-shakings and hugging
and kissing were finished, the boat was off, and the tears and
waving of rags continued as we steamed away.
 The clouds wept too, for a few moments, and then, like the
passengers, dried up; smiles and the sun came out again, and
beautiful Stockholm seemed more beautiful as we left it than it did
while we were in it. The green slopes around the city were joyous in
the sinking sun. The iron steeple of the Ridderkolm, and the white
palace, and many spires, glistened in the light. Gems of islands, with
pretty bridges uniting their shores, neat villas, with lawns carpeted
with rich verdure, abodes, we may hope, of sweet content and
comfort, are on either hand, and now and then, from a window or
balcony, a white handkerchief greets a friend on board, who
responds, and we have a telegraphic communication at once with
the people we are leaving. I do love to find in strange lands, and
among those whose language is all unknown to me, the same ties,
the same loves and hopes, that fill our own hearts at home. It
makes me know that all these people are my kin, children of my
Father.
We have been passing across Lake Malar. But now, at seven in the
evening, we enter a lock, and the Gota Canal begins. The village of
Sodertelje receives us here. So sweet does it seem to be, in its quiet
repose, that every house appears to invite you to stop and make a
visit. It was at this point that St. Olaf, when a viking, was shut in by
the fleets of the Swedes and Danes, and he cut his way out, not
through the enemies’ fleets, but by digging a canal to the Baltic! This
was in the eleventh century, and no such feats of rapid canalling
were known from that time down to the Dutch Gap ditch, during the
late war in America. The story of the saint is history, and the other
one will not be forgotten.
The passage of the lock from the lake to the canal is tedious, but
in the mean time the villagers come on board and greet friends, the
children, as in all other countries, ply their sales of cake and fruit, till
we are out and enter the Gota Canal. The banks for some time are
fifty feet high, but they slope away gradually, and are beautiful in
their green sod. Neat cottages and wooded walks and gardens, signs
of taste and culture, and plenty, are on our right hand and left; and
these dwellings are so near that the canal seems a street like those
of Venice, where you step from the gondola to the marble threshold
of your house. Passengers on board recognize their acquaintance,
and exchange salutations. Now and then an old mansion, with many
out-buildings, shows that an extensive farm is behind; and
occasionally we pass a village which appears to be of modern
creation, as if progress was making even in Sweden. We are
following the course of the very same canal that St. Olaf, the viking,
cut in such a hurry eight hundred years ago, and we soon come to
the end of it, and run again into the sea, or a bay of the Baltic, and
keep along the coast, among a wilderness of islands, touching now
and then at one of them to drop or take a passenger. Heaps of rock
on the points are painted white to guide us in the mazes of these
intricate passes, and sometimes trees have been moored in the
water to mark the pathway of the ship. Ruins of castles, each one of
which has its legends as romantic as those of the Rhine, still haunt
these rocks. Stegeborg Castle is the most picturesque in its solitary
grandeur and desolation, and the traditions of the country associate
it with many a hard-fought fight in times so far gone by that history
is rather too romantic to be credited.
The night is now about us, but in these latitudes it makes little
difference for seeing the country whether it is night or day. There
was no sleeping to be done, for some of the rising generation rose
all night, and made the little cabin vocal with their cries, so that only
those who enjoy the music of sleepless babes could be said to have
a pleasant night in that vicinity. Out of my little window I see the
islands, with their stunted firs, shores rarely rising so as to be
entitled to the dignity of hills, sometimes a forest, and here and
there a house, red and neat, with no signs of slovenliness or poverty.
It was very early in the morning when we left the canal-boat, and
in the midst of a drizzling rain followed a porter who had been
directed by the captain to take our luggage to a hotel, the best hotel
in the village of Soderkoping.
This was the village we had selected as a quiet, retired, obscure,
but pleasant place to pass a sabbath in, to see the Swedes in their
rural churches and in their humble homes.
 It was so early when we came to the little wooden tavern that no
one was astir. We went around to the back door, as the porter led
us, and there knocked long and loud, till a maid thrust her head out
of the window, and made signs that she would come down and let
us in, which she did. The American language was of no use now.
French was no better. But we managed to let her know, morning as
it was, we wanted beds. She led us to the chambers, and when we
pointed to the sheets as having already seen service since the last
wash, she took the hint in a moment, and, pulling them off, supplied
their places with linen without wrinkles. After a few hours sleep we
rose for breakfast, taking what should be set before us. It proved to
be comfortable. Coffee with delicious cream, bread and beefsteak on
a novel plan, chopped fine, made into cakes and fried in butter with
spices.
It was our first sabbath in Sweden. An ancient brick church with a
spire, a venerable structure, stood near a swiftly flowing stream of
water, embowered in majestic trees, and surrounded with the graves
of buried generations of those who had worshipped within its old
walls. It was a solemn, yet beautiful spot, and all its surroundings
were in keeping. The graveyard was laid off in little plats, and the
graves were bordered with flowers. On some graves pots of flowers
were set, and on others fresh-plucked flowers were strewn, soon to
wither and to be replaced. The bell was tolling and the people were
assembling; all came on foot and by walks leading through the yard
from various parts of the village. Some had come evidently from a
distance in the country, with books in their hands. All were decently
devout in their deportment as they came; even among the young
there was no levity, they were on a solemn errand, and were
sensible of the time and place.
The sexton sat at the door, with a big key in his hand, and opened
the door to let the people in, but locked it when prayer began, and
kept it locked till prayer was ended, and then admitted those who
had gathered. Earthen pitchers or jugs stood on stools near the door
to receive the offerings, and many cast in what they had. The floor
was of stone, and many were tombstones, the inscriptions worn by
the footsteps of the living, so that the names of the dead were
illegible. Eight immense whitewashed pillars supported Gothic arches
on which the roof rested. The pulpit was of wood, elaborately
carved, with Scripture scenes and figures. A sounding-board above it
was ornamented with quaint devices, and surmounted by a human
figure, perhaps an image of the Saviour. On the front the word
Jehovah, in Hebrew letters, was inscribed. The pews were very plain,
unpainted slips, with doors locked until the owners came, whose
names were on slips of paper attached. On the sides of the church,
long rude seats were free. We occupied them. The congregation was
very slow in getting in. The same variety of dress that would mark
one of our rural churches was apparent. Rich and poor met together.
Some of the ladies were dressed elaborately with the flat French
bonnet; others in a costume of the country, a small black shawl or
kerchief thrown over the head and pinned under the chin. The men
were all rustic in garb and manner, accustomed to out-of-door hard
work. All appeared devotional, respectful; old and young, on coming
in, bowed in silent prayer; all stood in singing. The service was
Lutheran, the established religion. All had books of the service,
which was read with a loud voice and much intonation by the clerk.
The preacher was a handsome young man, with great energy of
voice and no action. His text had the name Jesus Christ in it, and the
words were often repeated with tenderness and earnestness. I could
understand no other words, and could only hope that as even those
were sweet to my ears, the preacher was commending him to the
congregation as the chief among ten thousand, the one altogether
lovely.
Many of the men took snuff. The man on my right, two on my left,
two in front of me, held the box under their noses to catch what fell
back in the operation. They also offered the same boxes to me. One
of the men sneezed immoderately four or five times. The sexton
going up the aisle, and standing on the tombstone of some old saint,
blew his (the sextons, not the saint’s) nose with his fingers, wiped it
with a blue cotton handkerchief, polished it off with the back of his
hand, and then walked up to the pulpit to do his errand.
 Bating the snuff-taking and the nasal twang in the singing, the
service was pleasing even to us who heard no words that we could
understand. We worshipped in spirit, and felt at home among the
children of our Father, not one of whom knew that two strangers
from beyond the sea were in their village church on this pleasant
summer sabbath morning.
Soderkoping proved to be more of a place than we had
anticipated. It was, and is even a watering-place. Pleasantly planted
on the banks of the great canal, with historic and towering heights
rising by its side, and rejoicing also in the possession of a mineral
spring, whose healing virtues have been spread among the people of
this and other countries, it has become a resort for invalids. It
maintains at one end of the village a series of bathing-houses, and
modest lodgings for visitors, and a “conversation hall” of moderate
dimensions, and some hundreds of the ill-to-do may be carefully
cared for, and, perhaps, cured at the same time. But there is no
hotel, nor any thing worth the name. The village is primitive, simple,
neat as a new pin, not the sign of a new building going on
anywhere. It might have been finished years ago, and kept in order
to be looked at as a curiosity. The dwellings are, all of them, low,
unpretending, small, and usually of wood.
Dr. Gustaff Bottiger, physician and surgeon, called at our lodgings
in Soderkoping. He spoke the French well, and English tolerably, and
we were able to get on with him delightfully. He is a fine looking
man, accomplished in manners, and superintendent of the “Water
Cure.”
The mineral waters of this locality have had a reputation in Europe
through the long period of eight hundred years. They were formerly
resorted to by invalids from Italy and Spain, as well as other
countries. But in the course of time, and after the discovery of other
springs, and the invention of more, the fame of these in Sweden
declined. The town declined also. But when the modern water-cure
idea sprang into being, an establishment was opened here, which
has proved to be a wonderful success. It is resorted to by a
thousand persons every year, who come as patients, and patiently
submit to the hydraulic, hydrostatic, and hydropathic, and all the
hydra-headed processes of scientific treatment requisite to purify the
system and make the patient clean inside and out. The cure is sure
for nearly all diseases to which flesh is heir, but is specially efficient
in expelling such monsters as rheumatism, gout, and dyspepsia. The
College of Health in Sweden, a national institution, has the
establishment under its control, and the company that have taken
out a royal charter, and built the bath and packing houses, have
made provision for ninety patients, who are constantly lodged, fed,
and water-cured at public expense, and one hundred and thirty
more are treated gratuitously, with the use of the establishment,
while they pay for their board and lodging. Six hundred patients can
be supplied with baths at one time.
The establishment thus combines the advantages of a free and
pay hospital, as do many of our asylums for the afflicted in America.
But I am not aware that any of our States have made provision for
sending their invalid poor to water cures. Our inebriate asylums may
be called water cures in the best sense of the term, and it is quite
certain, whether intemperance be a sin or a disease, or both, there
is no hope of a cure without the use of cold water.
Here at Soderkoping the rich and the poor are so mingled and
packed and purified, that the distinction is not palpable, and the
institution is a model of social and medical propriety and equality.
Dr. Bottiger is enthusiastic in his pursuit of the grand idea he is
here set to work out, and the patients catch his enthusiasm, believe
in him and in the cure, and that helps the cure amazingly. It is not
worth while to discuss the reason of the thing, or to inquire whether
the mineral water here flowing at least eight centuries, and probably
eighteen and many more, is any better for the cure than other
waters. I am inclined to believe that there is superior virtue in the
springs. But any waters are good enough, with the advantage of air,
exercise, temperance, and recreation, to make most people whole
who are only partially broken down. Nine-tenths of these invalids,
especially of the richer classes, are victims of their own
imprudences. God gave man reason, but he makes a poor use, or
rather no use of it, when he works his brain so much as to overwork
it, and loads his stomach so as to overload it, and by neglect of the
laws of health, which are just as well defined as the moral laws of
God, brings upon himself dyspepsia, and that long catalogue of evils
that haunt the victim. He must be a bad liver who has a diseased
liver. It was his own fault, in the first place, and the warning that he
had he neglected, and now when he comes to Soderkoping, or goes
to Kissingen, Spa, or Kreusnacht, for the benefit of his health, he is
suffering the penalty of his own indulgence or neglect. If an ante-
mortem coroner’s inquest should be held on his arrival at the
springs, the verdict would be served him right.
There are six or eight water-cure establishments in Sweden, one
in Norway, none in Denmark. The system is popular in this part of
Europe, and in Germany. Patients appear to be attracted to them not
so much by advertisements of special advantages, but by the reports
which patients spread abroad, when they go away relieved of their
maladies.
Just after the doctor left us a young man called who had heard
that two Americans were here, and he wished to get information
respecting the United States. He brought with him a phrase-book in
German and English, or rather in German and American, for the
book was called “The Little American,” and was made to teach the
American language. The most it could do was to aid the young to
pick up a few phrases of the language, and to stimulate their desire
to emigrate to the western world. The book was evidently issued by
the steamship or emigration companies, for it gave all needful
directions as to the expense and mode of getting to America, and it
held out the most encouraging prospects to those who might be
tempted to go. The desire is wide-spread—to seek a home in the
New World. Books and papers and pictures are industriously spread
among the village and rural population to stimulate this desire. The
wages of labor are represented as so great in contrast with their
own earnings, while nothing is said of the cost of living,—the price of
land is said to be so low in comparison with land here, which is not
to be bought at all,—that they are filled with the idea of going to a