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He should also drink plenty of water, peppermint tea, or milk and Vichy

water.

When the cough is harassing, five to ten grains of Dover's powder or one tenth of a grain of heroin may be given once at night. Sea air and a change of air are very beneficial in the convalescent stage. The severe form requires powerful expectorants (see Bronchopneumonia).

ACUTE BRONCHOPNEUMONIA (CATARRHAL PNEUMONIA; CAPILLARY BRONCHITIS)

This disease is due to infection and inflammation of the small air cells by various cocci and bacilli. It may be primary, but is usually secondary to bronchitis, influenza, measles, pertussis, scarlatina, variola, etc.

The disease may follow inspiration of food or drink, and is frequently observed after ether narcosis and in intubation cases or following operations on the mouth, nose, or trachea in children. Tuberculosis, malaria, rickets,

FIG. 140.-EFFECT OF ONE DOSE OF QUINIA IN A CASE OF MALARIAL BRONCHOPNEUMONIA.

and diarrhoeal diseases predispose to this infection. It is most frequent in aged persons and young children. The onset is usually gradual and insidious; it is commonly bilateral, but occasionally unilateral. It occurs in endemics as a "house infection" in overheated houses, school dormitories, soldiers' barracks, lumber camps, hospitals, asylums, prisons, etc., and is most prevalent in winter and spring.

Bronchopneumonia may terminate in resolution in a few days (or after weeks by lysis), in suppuration, in gangrene, or in fibrous changes (chronic) bronchopneumonia). When resolution is delayed, we should examine the sputum for tubercle bacilli.

Inspection of a patient suffering from extensive bronchopneumonia reveals rapid, shallow, and difficult breathing (60 to 80 a minute); an anxious, distressed countenance and dilating ale nasi; gradually increasing cyanosis with inspiratory retraction of the base of the sternum and of the lower costal cartilages.

Physical Signs.-On percussion the chest resonance is at first not impaired or may be somewhat tympanitic. After a day or two patches of impaired resonance can be made out.

Auscultation reveals vesiculobronchial breathing with subcrepitant or mucous râles and rhonchi and occasionally patches of tubular breathing. These physical signs are apt to change from day to day as some areas clear up and others become involved in the inflammatory process. Pleuritic pain may be present. The cough may be violent and distressing. The sputum is mucopurulent and sometimes blood streaked. In general we observe rather the signs of bronchitis than those of pneumonia. In severe cases the pulse is rapid, the fever is high, the patient is restless or delirious or comatose, and convulsions may set in toward the fatal end.

Prognosis. The prognosis in feeble children and old people is grave. In older children and middle aged persons the prognosis in cases of ordinary severity is favorable.

Differential Points.-In lobar pneumonia the onset is sudden, the inflammation is generally one sided, defervescence is critical, and the sputum is rusty. In tuberculous bronchopneumonia the physical signs may be identical with those of the ordinary variety, and a discrimination between the two forms may be impossible. In simple bronchitis there is less dyspnoea and distress and the râles are coarse and sibilant.

Clinical Varieties. In adults, as well as children, we see mild cases, severe cases, and grave septic cases with cerebral symptoms.

Prophylaxis.-Bronchopneumonia patients should. be isolated and the discharges disinfected. In all catarrhal troubles the nasopharyngeal toilet should be practised and exposure to street dust and to bad air in crowded places should be avoided.

Treatment. An adult with bronchopneumonia should have a hot foot bath and go to bed. Fever diet and cooling drinks are indicated, also a brisk purge and 10 grains of quinine. High temperatures are controlled by hydrotherapy and early stimulation with whiskey, wine, enteroclysis, and such drugs as camphor and strychnine are indicated in septic cases. Cerebral symptoms require the application of an ice bag to the head. The trunk may be enveloped in a sheet wrung out in cold water, this to be changed every hour or two if necessary. When there is difficulty in raising the secretions, the foot of the bed may be raised from six to eight inches to allow them to gravitate outward. Carbonate of creosote may be given in 5 to 10 grain doses several times a day, but should be discontinued when the stomach becomes irritable. A change of position is also desirable. In the aged and feeble cold baths are not to be used. Sponge baths will answer very well, as the temperature is not very

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high in old persons. Circulatory and respiratory stimulation is to be relied. upon mainly, and digestion should be aided by giving hydrochloric acid after eating. (See General Therapeutics.) The management of bronchopneumonia in children is discussed in the Pædiatric portion of this work.

ACUTE TUBERCULOUS BRONCHOPNEUMONIA (HASTY, OR GALLOPING, CONSUMPTION)

Acute tuberculosis may result from direct infection or may be due to autoinfection from a preexisting tuberculous focus. All exhausting diseases predispose to it. It is met with in adults and in children, and not infrequently occurs after measles and pertussis or in young children, under the clinical picture of marasmus.

Differential Points.-Acute pulmonary tuberculosis is liable to be mistaken for some simple form of pneumonia, because the clinical symptoms and signs are very much alike and because the tubercle bacilli are not present in the sputum at first. When the tubercle bacilli are found, a simple form of pneumonia may be excluded.

In typhoid fever with extensive bronchitis we observe rose spots, tympanites, and the Widal reaction, without tubercle bacilli in the sputum.

Clinical Forms of Acute Pulmonary Tuberculosis

Pneumonic Form.-Abrupt onset with chill, remittent fever, frequent pulse, and hectic sweats; no leucocytosis.

Dulness over one lobe (usually the upper); eventually cavernous or amphoric resonance.

The sputum is scanty, mucoid, then rusty, mucopurulent, or purulent; tubercle bacilli; elastic tissue; perhaps hæmoptysis.

Duration, two to six weeks, occasionally two to four weeks.

Bronchopneumonic Form.-High, irregular fever, frequent pulse, rapid emaciation; chills and profuse sweats or a typhoid state.

Areas of impaired resonance, usually at the apex.

The sputum is purulent, blood stained, nummular; elastic tissue and bacilli; rarely hæmoptysis.

Not infrequent in young children after other acute infections.
Duration, three weeks to three months.

Miliary Form.-Repeated chills, fever (102° to 105°); very rapid, feeble, irregular pulse; profuse sweats; often vomiting at the onset.

Hurried respiration (possibly 50 or 60 in adults); cyanosis generally marked; spleen frequently enlarged.

Diffuse, sibilant or sonorous, mucous or crepitant râles; subpleural tubercle friction murmur, finer and softer than the pleuritic.

Perhaps defective resonance at the bases in children.

Dyspnoea very prominent from the outset without apparent cause.

Sputum mucopurulent; occasionally rusty; may contain tubercle

bacilli; rarely hæmoptysis.

Duration, two weeks to several months.

Prognosis. The prognosis of acute pulmonary tuberculosis is fatal. Treatment. The treatment is symptomatic.

Acute fibrinous or diphtheritic bronchopneumonia is a rare disease observed in children as well as in adults. (See Fig. 141.)

It may begin like a simple bronchitis or the onset may be severe with chills, fever, cough, and dyspnoea. When casts or membranes are expelled, there is a fall of temperature, which rises again if the casts form anew. In severe cases the patient dies of asphyxia and exhaustion in a few days. The mortality is 50 to 70 per cent.

TREATMENT.-Diphtheria antitoxine, in 3,000 unit doses, should be repeatedly given; saline inhalations, pilocarpine, gr. 1, expectorants, and stimulants are indicated, also mercurial ointment inunctions.

ACUTE LOBAR PNEUMONIA; FIBRINOUS PNEUMONITIS IN ADULTS

Lobar pneumonia is an acute, infectious, endemic, and occasionally epidemic disease beginning with a chill. Probably several microorganisms. are pathogenic factors in this disease, especially Friedländer's pneumobacillus and A. Fraenkel's Diplococcus lanceolatus. The latter is of chief importance, since it is found in about 70 per cent of all cases of fibrinous pleuropneumonia.

Both

Fibrinous pneumonia has a catarrhal and a hæmorrhagic stage. are usually included as the stage of congestion or engorgement. The lungs at this period show very little that is characteristic. They are dark red, still contain air, but are slightly firmer in consistence, and resemble mostly lungs affected with beginning hypostatic pneumonia.

The hæmorrhagic stage is followed by the stage of red hepatization; the alveoli become filled with red blood corpuscles and fibrin. The latter coagulates, and the whole hæmorrhagic contents of the alveolus become a firm red plug. The cut surface of red hepatization is red and slightly granular.

In the stage of resolution the fibrin undergoes granular disintegration and the cells undergo fatty metamorphosis.

Fibrinous pneumonia generally attacks but one lobe, more frequently the lower lobe, and the right lung more often than the left. Sometimes both lungs and a number of lobes are attacked at the same time, but more often the invasion is successive, i. e., affection of one lobe is followed by involvement of another, until a whole side is hepatized. In these cases there is an intense collateral hyperemia of the non-hepatized area, because the hepatized parts are always anæmic in the stage of complete hepatization. Acute vicarious emphysema (temporary emphysema) is also observed in the unaffected portions of the lung and presents an additional obstruction to the circulation in the right heart. The collateral fluxion very easily gives rise to a fatal pulmonary adema as soon as the heart begins to weaken as a result of the increased resistance and the injury caused by the high fever.

Fibrinous pleuritis is a constant accompaniment of fibrinous pneumonia as soon as the latter appears in lobar form and involves the pleura.

Every fibrinous pneumonia is attended by a violent bronchitis, acute catarrhal in the large bronchi and often fibrinous in the smaller, which may occasionally lead to filling and occlusion of the bronchi and bronchioli.

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In some cases fibrinous pleuropneumonia is accompanied by a purulent pleurisy in which the Diplococcus lanceolatus is usually found. Sometimes, especially in topers and when putrid processes have previously existed in the lungs, pneumonia goes on to gangrene. Rarely the fibrinous exudate becomes organized and replaced by connective tissue, so that the lung tissue becomes impermeable to air and assumes a fleshlike appearance (carnification).

Under certain conditions fibrinous pneumonia may terminate in caseous hepatization, especially when tuberculosis or caseous processes previously existed in the affected lung and when dissemination of tubercle bacilli can occur from these foci.

Predisposing Factors.-Old age, overwork, debility, alcoholism, trauma, typhoid fever, measles, influenza, bronchitis, diabetes, tuberculosis, ether anæsthesia, chronic visceral disease, cold and damp weather, and previous attacks predispose. It occurs at all ages, and is more frequent in men. Pneumonia has a sudden onset (insidious in the aged) and ends by crisis in from five to nine days.

Physical Signs.--Inspection reveals an anxious expression, bright eye, dilated alæ nasi, labial herpes, pale face, or cyanosed with a mahogany flush on the checks; breathing hurried (30 to 60), but regular and noiseless, usually abdominal with deficient expansion on the affected side; posture often on this side; and the tongue dry and thickly coated. Early jaundice is common.

Palpation shows lack of respiratory expansion over the area involved; vocal and tactile fremitus increased on the consolidated side (absent if pleurisy or bronchorrhoea is present or a main bronchus is occluded); and sometimes pleural friction fremitus. Tenderness on pressure is complained of also, and there is a dry, burning skin followed by profuse critical sweats. On percussion we find sharply defined woody dulness (rarely tympanitic over the upper lobe on the affected side). By the second or third day dulness is observed over consolidation (most marked posteriorly). High pitched tympany or the cracked pot sound is elicited in the stages of engorgement and resolution and above a hepatized area.

On auscultation we hear inspiratory crepitant râles followed by typical bronchial breathing (provided the large bronchi are patulous), and later, in the stage of resolution, all sizes of moist râles; inspiration is short and suppressed, expiration grunting; bronchophony (most marked at the lower level of dulness) in the second stage; pectoriloquy or ægophony above a hepatized area with exaggerated vesicular murmur in normal portions of the lung; and the second pulmonary sound accentuated in the sthenic type. The cough is short, dry, painful, and restrained at first; it may be absent in old people.

The sputum is scanty, glairy, viscid, becoming blood tinged rusty sputum within twenty-four hours; more copious and liquid during resolution; purulent or like prune juice in low types; usually absent in children. microscope shows pneumococci.

The

The pain is unilateral, usually at the nipple or axilla, often agonizing and aggravated by cough or deep inspiration. Diffuse soreness is complained of.