Page:EB1911 - Volume 21.djvu/903

 percussion, and increase of the vocal fremitus; while on auscultation the breath sounds are tubular or bronchial in character, with, it may be, some amount of fine crepitation in certain arts. In the stage of grey hepatization the percussion note is still dull and the breathing tubular, but crepitations of coarser quality than before are also audible. These various physical signs disappear more or less rapidly during convalescence. With the progress of the inflammation the febrile symptoms and rapid breathing continue. The patient during the greater part of the disease lies on the back or on the affected side. The pulse, which at first was full, becomes small and soft owing to the interruption to the pulmonary circulation. Occasionally slight jaundice is present, due probably to a similar cause. The urine is scanty, sometimes albuminous, and its chlorides are diminished. In favourable cases, however severe, there generally occurs after six or eight days a distinct crisis, marked by a rapid fall of the temperature accompanied with perspiration and with a copious discharge of lithates in the urine. Although no material change is as yet noticed in the physical signs, the patient breathes more easily, sleep returns, and convalescence advances rapidly in the majority of instances. In unfavourable cases death may take place either from the extent of the inflammatory action, especially if the pneumonia is double, from excessive fever, from failure of the heart's action or general strength at about the period of the crisis, or again from the disease assuming from the first a low adynamic form with delirium and with scanty expectoration of greenish or “ prune juice " appearance. Suc cases are seen in persons worn out in strength, in the aged, and especially in the intemperate.

The complications of acute pneumonia are pleurisy, which is practicaily inevitably present, empyema (in which the pneumococcus is frequently present and occasionally the streptococcus), pericarditis and endocarditis, both due to septic poisoning, while perhaps the most serious complication is meningitis, which is responsible for a large percentage of the fatal cases. The pneumococcus has been found in the exudate. Secondary pneumonias chiefly follow the specific fevers, as diphtheria, enteric fever, measles and influenza, and are the result of a direct poisoning. Bacteriologically a number of different organisms have been found, together with the specific microbe of the primary disease; the striking features of primary lobar pneumonia are often masked in these types.

The treatment of acute pneumonia has of late undergone a marked change, and may be divided into 3 heads: (1) General hygienic treatment; (2) the treatment of special symptoms; (3) treatment by vaccines and sera. The same treatment of absolute rest should be carried out as in enteric fever; this absolute rest is necessary to limit the auto-inoculation by the absorption of toxins. Fresh air in abundance and even open air treatment if possible has been attended with good results. Ice poultices over the affected part are useful in the relief of pain, while tepid sponging and tepid or even cold baths may be freely given, and the patient's strength supported by milk, soups and other light forms of nourishment. Stimulants may be called for, and strychnine and digital in are the most valuable; disinfection of the sputum should be systematically carried out. Many trials have been made with antipneumococcic serum, but it has not been shown to have a very marked effect in cutting short the disease. The polyvalent serum of Römer has given the best results. Much more favourable results have been obtained from the use of a vaccine. The results of vaccine treatment obtained by Boellke in 30 cases of severe pneumonia and one case of pneumococcic endocarditis are encouraging. The vaccine, to produce the best effects, should be made from the patient's own pneumococcus, as it is evident there are different strains of pneumococci, the doses (5 to 50 million dead pneumococci) being regulated by the guidance of the opsonic index. The objection to the preparation of the vaccine from the patient's own organisms is the time (several days) which is required, valuable time being thereby lost; but the results are much more certain than with the use of a “stock” vaccine.

2. Broncho-Pneumonia (Catarrhal or Lobular-Pneumonia or Capillary Bronchitis). An acute form of lobular pneumonia has been described, having all the characters of acute lobar pneumonia except that the pneumonia patches are disseminated. The term “broncho-pneumonia” is however here used to denote a widespread catarrhal inflammation of the smaller bronchi which spreads in places to the alveoli and produces consolidation. All forms of broncho-pneumonia depend on the invasion of the lung by micro-organisms. No one organism

has however been constantly found which can be said to be specific, as in lobar pneumonia; the influenza bacillus, micrococcus catarrhalis, pneumococcus, Friedländer's bacillus and various staphylococci having been found. John Eyre, in Allbutt’s System of Medicine, gives 62% of mixed infection in the cases investigated by him. Broncho-pneumonia may occur as an acute primary affection in children, but is more usually secondary. It may be a sequence of infectious fevers, measles, diphtheria, whooping cough, scarlet fever and sometimes typhoid fever. In these it forms a frequent and often a fatal complication. The large majority of the fatal cases are those of early childhood. In adults it may follow influenza or complicate chronic Bright's disease or various other disorders. Broncho-pneumonia also may follow operations on the mouth or trachea, or the inhalation of foreign bodies into the trachea It is a frequent complication of pulmonary tuberculosis.

The following changes take place in the lung: at first the affected patches are dense, non-crepitant, with a bluish red appearance tending to become grey or yellow. Under the microscope the air vesicles and finer bronchi are crowded with cells, the result of the inflammatory process, but there is no fibrinous exudation such as is present in croupous pneumonia. In favourable cases resolution takes place by fatty degeneration, liquefaction, and absorption of the cells, but on the other hand they may undergo caseous degenerative changes, abscesses may form, or a condition of chronic interstitial pneumonia be developed, in both of which cases the condition passes into one of pulmonary tuberculosis. Evidence of previous bronchitis is usually present in the lungs affected with catarrhal pneumonia. In the great majority of instances catarrhal pneumonia occurs as an accompaniment or sequel of bronchitis, either from the inflammation passing from the finer bronchi to the pulmonary air vesicles, or from its affecting portions of lung which have undergone collapse.

The symptoms characterizing the onset of catarrhal pneumonia in its more acute form are the occurrence during an attack of bronchitis or the convalescence from measles or whooping cough, of a sudden and marked elevation of temperature, together with a quickened pulse and increased difficulty in breathing. The cough becomes short and painful, and there is little or no expectoration. The physical signs are not distinct, being mixed up with those of the antecedent bronchitis; but, should the pneumonia be extensive. there may be an impaired percussion note with tubular breathing and some bronchophony. Dyspnoea may be resent in a marked degree; and death frequently occurs from paralysis of the heart. Broncho-pneumonia is a serious disease, the death-rate in children under five has been estimated at 30 to 50%.

The treatment of broncho-pneumonia is mainly symptomatic. At the outset a mild purgative is given, and should the secretion accumulate in the bronchial tubes an emetic is useful. Inhalations are useful to relieve the cough, and circulatory stimulants such as strychnine are valuable, together with belladonna and oxygen. When orthopnoea and lividity are present, with distension of the right heart, venesection is necessary. The treatment of broncho-pneumonia by serum and vaccines is not so successful as in lobar pneumonia, owing to the difficulty of ascertaining the precise bacterial infection. The great danger of broncho-pneumonia is the subsequent development of pulmonary tuberculosis.

3. Chronic Interstitial Pneumonia (Cirrhosis of the Lung) is a fibroid change in the lung, chiefly affecting the fibrous stroma and may be either local or diffuse. The changes produced in the lung by this disease are marked chiefly by the growth of nucleated fibroid tissue around the walls of the bronchi and vessels, and in the intervesicular septa, which proceeds to such an extent as to invade and obliterate the air cells. The lung, which is at first enlarged, becomes shrunken, dense in texture and solid, any unaffected portions being emphysematous; the bronchi are dilated, the pleura thickened, and the lung substance often deeply pigmented, especially in the case of miners, who are apt to suffer from this disease. The other lung is always greatly enlarged and distended from emphysema; the heart becomes hypertrophied, particularly the right ventricle; and there may be marked atheromatous changes in the