and powerful antipyretic. I have used it in both private and hospital
practice, and have found it a prompt and efficient means of reducing
temperature. It has not seemed to me, however, to have any other
beneficial effect either in mitigating the severity or shortening the
course of the disease. In two cases its use was followed by collapse,
which in one case terminated fatally. My experience has seemed to bear
out the belief that this drug is a decided cardiac depressant, and I
should for this reason consider it much less desirable as an
antipyretic than quinia.]
During convalescence tonics and restoratives--iron, quinia, the mineral
acids, cod-liver oil, or strychnia--should be administered, and the
highest degree of nutrition should be maintained. If bronchitis
complicates pneumonia, it may be treated with muriate of ammonium,
ipecacuanha, and senega. If severe gastric catarrh occurs, hot
fomentations may be applied to the abdomen, and calomel, followed by a
saline purgative, may be administered.
Diarrhoea is rarely so severe as to require treatment; five grains of
Dover's powder usually suffices to control it.
In the delirium which occurs in alcoholic patients small doses of the
tartrate of antimony and potassium are said to be useful. I have
controlled this form of delirium best with small doses of hydrate of
chloral.
By some, camphor, musk, and turpentine are recommended during the stage
of gray hepatization, but it seems to me that the requirements are far
better fulfilled by alcoholic stimulants.
In the first stage of senile pneumonia an emetic, when not specially
contraindicated, is given in the Salpétrière Hospital. The physicians
of the Montpellier General Hospital regard ipecacuanha as an heroic
remedy in senile pneumonia. The English regard nitrate of potassium as
the most efficacious, while the Germans prefer hydrochlorate of
ammonium. Antipyretics are rarely necessary in senile pneumonia; the
most important thing is to sustain the heart by stimulants and
concentrated fluid nutriment combined with iron and quinia. In senile
pneumonia the diarrhoea occurring with the typhoid form must be
promptly checked by vegetable astringents.
In children, as in old age, leeches and blisters should never be used.
The whole chest should be enveloped in a linseed-meal poultice, to
which some anodyne may be added (opium, aconite, or belladonna) if
there is severe pain.
In asthenic pneumonia, in addition to the nutritious diet, burgundy,
port wine, or brandy should be used, and stimulant embrocations should
be applied to the chest. In children the state of the bowels must be
most carefully watched. Stimulating expectorants are more frequently
necessary than at any other period of life.
In conclusion, I would urge that all remedial measures which tend to
paralyze the heart should be excluded from the treatment of pneumonia,
and great care should be exercised not to over-stimulate the heart, for
over-stimulation often results in paralysis. It must always be
remembered that in the milder cases there is necessity for no treatment
except a regulated diet and attention to those general hygienic
measures which have already been referred to.
I shall not attempt to discuss the treatment of the complications which
may occur in the course of a pneumonia, for it is impossible to even
mention every contingency that may arise. The rule is to treat the
pneumonia so long {352} as it is the controlling disease, and the
complication when it shall have become the most prominent and dangerous
element in any given case. In prolonged convalescence it is of the
utmost advantage that the pneumonic patient shall have a change of
scene and climate.
Antiseptics.--The use of antiseptics in the treatment of pneumonia has
as yet given no definite results. I have employed hypodermically phenic
acid after Declat's method in several well-marked cases of simple
pneumonia, without being able to determine that the temperature or
course of the disease was at all influenced by its use.
F. Schwarz[53] states that the very favorable results which he has
obtained in croupous pneumonia can only be due to one thing--_i.e._ the
specific action of iodine, which renders inert the exciting cause of
the disease, which he regards as an organism, and that its efficacy is
limited exclusively to the very early stage of the pneumonia. He
believes that its action in acute lobar pneumonia is the same as Von
Willebrandt claimed for it in typhus, typhoid, and in malarial fevers.
He even states that he regards iodine as a genuine specific in pure
uncomplicated croupous pneumonia if employed within twenty-four or
thirty-six hours after the ushering-in chill, that hinders its
development and arrests its progress.
[Footnote 53: _Deutsche medicinische Wochenschrift_, January, 1881, No.
2.]
After using benzoate of soda in diphtheria, scarlet and puerperal
fever--drachm ij in the twenty-four hours--E. B. Cady[54] states that
when an epidemic of pneumonia visited his town in Wisconsin he had
equally good results from the similar use of this salt in pneumonia,
cases recovering which had a temperature of 106° F. and 107° F.
[Footnote 54: _N.Y. Med. Record_, 1880, July, 3, "Benzoate of Soda in
Pneumonia."]
Orth[55] has recently written an interesting account of the treatment
of pneumonia (lobar) with iodine.
[Footnote 55: _Allg. med. Centr. Zeitschr._, Berlin, 1881, i. p. 181.]
T. H. Buckler strongly recommends its treatment with salicylate of
sodium and fresh lemon-juice.[56]
[Footnote 56: _Phila. Med. News_, 1882, xl. p. 652.]
Phenic acid, boracic acid, and the salicylates are highly recommended
by many as the best drugs in the antiseptic treatment.
{353}
CATARRHAL PNEUMONIA.
BY WILLIAM PEPPER, M.D., LL.D.
SYNONYMS.--Broncho-pneumonia; Lobular pneumonia. Although numerous
other names have been used to designate this affection, it is
undesirable to perpetuate them.
DEFINITION.--Catarrhal pneumonia is an inflammation of the parenchyma
of the lungs, frequently bilateral, and affecting scattered groups of
lobules, which may, however, coalesce, so that considerable areas of
lung-tissue become continuously involved. This anatomical distribution
explains the name lobular as opposed to that of the lobar or croupous
form. As implied by its other titles, it has close associations with
bronchial catarrh, and occurs nearly always either as an extension of
inflammation from the larger tubes or in connection with capillary
bronchitis. In consequence, it is often combined with pulmonary
collapse, with which latter condition it was until recently confounded.
The affected areas show lesions of the bronchioles, together with a
morbid product filling the alveoli, and consisting in varying
proportion of altered epithelial cells from the alveolar walls, of
cells drawn by aspiration from the bronchioles, and of exudation from
the blood-vessels. Catarrhal pneumonia may be circumscribed or diffuse,
and acute, subacute, or chronic. Its course and duration vary greatly:
at times it terminates fatally in a few days, or runs a lingering
chronic course, while recovery rarely occurs in less than fourteen
days. The mortality is always considerable, and it acquires additional
gravity from its tendency to leave behind it organic lesions of the
lungs or even to induce phthisis.
ETIOLOGY.--As catarrhal pneumonia is so closely associated with
bronchitis, and so commonly preceded by it, it may be premised that all
the causes of bronchial catarrh must be considered as liable to induce
this form of pulmonary inflammation, whether they do so by exciting
bronchitis, which subsequently extends to the alveoli, or whether, as
more rarely happens, they affect simultaneously the lining membrane of
the bronchi and of the lobules.
There are, however, several influences which must here be carefully
considered, since they have a special tendency to determine the
production of the more grave form of disease.
The effect of age in predisposing to catarrhal pneumonia is undoubtedly
great, and yet it seems to have been often over-estimated, since by
many this has been regarded almost as a disease peculiar to childhood.
The great frequency with which young children were formerly held to be
affected by this form of pneumonia has, however, been found to be due
in part to the fact that many cases of pulmonary collapse were included
with it; while, on the other hand, there is strong reason to believe
that the frequency with which adults are attacked has been greatly
under-estimated in consequence of the failure on the part of the
profession at large to clearly recognize this affection. It seems in
the highest degree important that more {354} correct views on this
subject should be generally received. While it is probable that the
more severe and widely-disseminated pneumonias of catarrhal type are
commonly recognized now-a-days, it appears undoubted that in very many
instances of apparently mild sickness, of acute or subacute character,
which are regarded as simple febrile colds or as the result of malaria,
the true condition is one of circumscribed catarrhal pneumonia, which,
while threatening no immediate danger to life, may if neglected leave
lesions of grave significance. Still, it is undoubted that it is during
the early years of childhood, and particularly the first five years,
that catarrhal pneumonia, and more especially its grave and fatal form,
is of frequent occurrence; while the period of next greatest liability
is at the other extreme of life, among aged and debilitated subjects.
Under the head of Pathology we shall have occasion to dwell on the
relations between defective respiratory power, pulmonary collapse, and
catarrhal pneumonia; and it is evident that this connection helps to
explain the relative frequency of the latter in early childhood, when
conditions of debility are so common, and when rickets not rarely is
superadded as an important factor. Another potent cause of the
liability of young children to catarrhal pneumonia is the prevalence at
that period of life of the infectious diseases, which are apt to be
complicated with bronchitis, and which then present a combination of
conditions favoring its development. This is especially true of
measles, of whooping cough, and of diphtheria, while influenza, which
is also frequently complicated with this form of pneumonia, is
operative at all ages. Among predisposing causes which operate chiefly
at a later period of life must be mentioned organic diseases of the
heart and vesicular emphysema. The latter especially has shown itself
important in our experience, both as predisposing to the occurrence of
catarrhal pneumonia and as adding to the gravity of the attack.
Unquestionably, all states of bad nutrition and depressed vitality
render the system much more liable to attacks of catarrhal pneumonia.
The bad air of crowded houses or of ill-ventilated public institutions,
especially if conjoined with the effect of improper food and of other
defects of hygiene, plays an important part in inducing the fatal forms
of this disease which are common among children exposed to such
conditions. It is equally evident that among adults the effect of
overwork, with insufficient sleep and outdoor exercise, is to develop a
peculiar sensitiveness and weakness of system which make the ordinary
causes of bronchitis capable of exciting a deeper and more serious
catarrh. Finally, there are many individuals who possess a catarrhal
diathesis--that is, in whom the epithelial layers are especially
vulnerable, and when attacked are especially prone to take on cellular
proliferation of a deep-seated and obstinate character. Such
constitutions, which are frequently found in the subjects of phthisical
heredity, furnish a ready soil for the development of catarrhal
pneumonia.
Nor must the practical lesson be here overlooked that when acute or
subacute bronchitis exists, an additional motive for prompt and
thorough treatment is to be found in the fact that undue fatigue or
exposure may be followed by an extension of the inflammation and by the
onset of catarrhal pneumonia.
PATHOLOGY AND MORBID ANATOMY.--Allusion has already been made to the
relation existing between catarrhal pneumonia and collapse of the lung;
and the present seems to be the proper place to speak more fully of it,
since in order to appreciate the lesions in any case it is necessary to
distinguish between those which are the result of the inflammatory
process and those which can be explained by simple collapse of the
lung-tissue. It is indeed true that in some cases the development of
catarrhal pneumonia takes place in areas already the seat of collapse.
This is only what would {355} naturally be expected. For the production
of both conditions the existence of preceding bronchial catarrh is, if
not necessary, at least highly favorable. The folds of the swollen
mucous membrane of the smaller tubes come into contact with each other,
or else the diminished lumen of the tubes is occluded by the viscid
mucus formed as the result of the catarrh. The normal activity and
rhythm of respiration is disturbed by the fever and the lowered
innervation. During expiration more and more of the air escapes from
the alveoli of the affected area through these partly-obstructed tubes,
while during inspiration, owing to the less force of that part of the
respiratory act and to the shape of the bronchial tree, air cannot
enter to replace it. Thus, or by the action of a plug of mucus in a
conical bronchial tube, serving as a ball-valve, a condition of
airlessness or of collapse is induced in a more or less extensive area.
It is not, indeed, to be supposed that the mere occurrence of such
collapse serves in any way to excite inflammation of the alveoli. But
at the same time it is evident that there will be a strong likelihood
that the catarrh which has advanced so deeply into the finer tubes will
extend in some spots to the alveoli, and consequently that in a
collapsed area of some extent there will be one or more foci of
pneumonia developed. Moreover, it must be remembered that the collapsed
lung-tissue becomes more or less hyperæmic and disposed to take on
inflammatory action, and that the irritating bronchial secretions, the
suction of which into the alveoli plays an important part in these
affections, would necessarily be less apt to be dislodged by cough and
expectoration from areas which had become collapsed. On the other hand,
it is evident that when areas of catarrhal pneumonia have occurred
directly from extension or establishment of catarrh in air-containing
alveoli, the conditions will exist which favor the development of
collapse in the surrounding zones of lung-tissue. Thus it happens that
while the lesions either of collapse or of catarrhal pneumonia are
found separately, it is common to find more or less evidences of
alveolar inflammation in connection with collapse, especially if it has
lasted any length of time; and still more common to find a considerable
proportion of collapse coexisting with catarrhal pneumonia.
A simple practical rule must therefore be here insisted upon: that in
all post-mortem examinations of the lungs in cases of catarrhal
pneumonia, after careful study of the external appearances, a moderate
inflation by means of a blowpipe must be practised, and the effects of
this upon the consolidated areas be carefully studied before the lung
be incised, in order that any element of collapse may be recognized and
eliminated.
The external appearance of the lungs usually presents evident lesions.
There are patches or layers of soft lymph on the pleura over the
affected areas, and when the former are removed the serous membrane is
found roughened, congested, and ecchymosed. On the other hand, while
the pleura over a collapsed patch usually presents small ecchymoses,
there is rarely any evidence of inflammation. More or less evident
signs of vesicular emphysema are also usually present, bearing some
proportion to the extent of the pulmonary collapse. When the areas
affected are small and scattered, the emphysema is limited to their
neighborhood; but when, for instance, both lower lobes are extremely
involved, the upper lobes may present a high degree of emphysematous
distension. In rare instances subpleural emphysema, from separation of
the membrane over a pneumonic focus, may be observed; and even, as in a
case published by me some years ago,[1] perforation of the separated
pleura may occur, leading to pneumothorax.
[Footnote 1: _Philada. Med. Times_, Aug. 15, 1872, p. 425.]
After section of the lungs there will always be found lesions of the
bronchial mucous membrane, which presents evidences of catarrh
extending as high as the trachea or larynx in some cases, but
habitually growing more {356} intense in the finer tubes, where the
membrane is reddened and swollen. Frequently the infiltration extends
throughout the structure of the bronchial walls, so that the tubes
stand out prominently above the surface of the section. Delafield[2]
has insisted with especial emphasis upon these alterations in the
bronchial walls, and on the view that the inflammation extends from the
bronchi, not to the group of air-vesicles into which they lead, but
directly outward to the peribronchial zones of lung-tissue. In severe
cases of longer standing the bronchial tubes often present in addition
dilatations, either cylindrical or more rarely globular.
[Footnote 2: "The Pathology of Broncho-pneumonia," _Medical News_, Nov.
15, 1884, p. 534.]
The bronchi contain morbid secretions in the form of clear viscid mucus
in the early stage, while later they are filled with creamy pus. In
some cases there are also found small subpleural collections of more or
less inspissated yellowish secretion contained in dilated alveoli or in
small globular dilatations of terminal bronchioles. The most plausible
explanation of their nature is, as suggested by Fauvel, that they are
caused by the suction of particles of bronchial secretion into the
alveoli in the forcible inspiratory effects which follow paroxysms of
cough, and especially such paroxysms as occur when whooping cough is
complicated with catarrhal pneumonia.
The lung-tissue itself exhibits, associated in varying degrees,
congestion, oedema, emphysema, collapse, and pneumonic consolidation.
The patches of simple collapse are to be easily recognized by their
familiar appearance, being depressed below the surrounding tissue,
bluish in color, non-crepitant and solid to the touch, and on section
smooth, airless, firm, and not friable. They sink in water. As already
stated, they can, when recent, be readily inflated, and thus restored
to their normal condition. Such patches are most common at the
postero-inferior parts of the lungs. They are mostly pyramidal in
shape, and vary in size from a few lines to one or two inches in
diameter, though in severe cases an entire lobe, or even an entire
lung, may pass into this state of collapse. On the other hand, the
areas of pneumonic consolidation appear as slightly prominent nodules,
varying in size from that of a pea to that of a hazelnut, which may be
distinctly felt with the finger, if occurring in the midst of a
collapsed patch, by their elevation above the surrounding depressed
tissue. They are usually scattered throughout both lungs, often with
some symmetry of disposition, especially in the postero-inferior
portions. The surrounding zone of tissue is more or less congested and
oedematous, and when the nodules are closely adjacent they may become
confluent, so that large portions of a lobe or an entire lobe may
become infiltrated. Vigorous inflation will usually show in such cases,
however, that the consolidation is not uniform or complete. Section of
the lung will show that the most varied stages of the inflammatory
process are represented in the different nodules; and this is a highly
characteristic feature of the disease. The recent nodules are
brownish-red or grayish-red, faintly granular, smooth, friable, and
yield on scraping a small quantity of thick reddish secretion. Later
they become reddish-gray and yellowish-gray in color, yield a thick,
airless, milky substance, and finally grow more firm and dry: the
inflammatory product undergoes fatty degeneration, is gradually removed
by absorption or by expectoration, and the affected area of lung-tissue
is slowly restored to its normal state. This is the course in favorable
cases, while in those which run into a chronic form or which terminate
fatally at an early period the lesions undergo various modifications.
In some instances the inflammatory product undergoes more acute
degeneration, with destruction of the pulmonary tissue in the affected
area, and the subsequent formation of abscesses, which are not to be
confounded with the minute aspiration-abscesses above described. I have
notes of autopsies in which the lungs have presented every stage of the
process of catarrhal pneumonia, from the nodules of incomplete
consolidation to {357} circumscribed abscesses. In other cases the
thickening of the walls of the alveoli and of the bronchi, together
with dilatation of the tubes, has become marked, and the interstitial
changes in the zones of peribronchitic pneumonia extend and induce a
slow process of fibroid thickening which results in that form of
chronic pneumonia which has been called cirrhosis of the lung and
fibroid phthisis. In still other cases the morbid products in the
alveoli, with or without an antecedent process of suppuration, undergo
caseation; and the presence of the degenerate cheesy foci, associated
with alveolar and peribronchial thickening, may lead to catarrhal
phthisis with or without true tuberculous formations.
The microscopic examination of the pneumonic nodules shows that the
essential condition consists in a morbid accumulation within the
alveoli, together with changes in the walls of the vesicles, which
become infiltrated with cells in the same way as the bronchial walls.
These changes become more marked after the disease has lasted some
time. The epithelium lining the alveolar walls is the seat of cloudy
swelling, becomes less closely attached, and undergoes proliferation,
with the formation of large epithelial elements. The morbid product
filling the alveoli is composed in varying proportions of these latter
elements, of the richly cellular bronchial secretion which has been
sucked in from the bronchioles, of leucocytes, and much more rarely of
red blood-corpuscles which have escaped from the pulmonary capillaries,
and finally of fibrillated exudation. In contrasting these minute
appearances of catarrhal pneumonia with those of the croupous form it
is to be noted that in the former the fibrinous element is not
constant, or is at most scanty, and that the results of diapedesis,
leucocytes, and especially red corpuscles, are much less prominent. At
a later period of the process fatty infiltration and degeneration of
the alveolar contents usually occur, which is the most favorable
change, since it disposes toward evacuation with restitution of the
lung to its normal state; but at times a larger proportion of pyoid
cells appears, and the alveolar walls become involved and break down,
so that small abscesses are formed, or, again, the contents may become
inspissated and caseous, associated with nuclear growth in the walls of
alveoli and bronchioles.