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VI. Diseases of the Lungs.

Problems:

Bronchopneumonia

Synonyms:—Capillary bronchitis; lobular pneumonia; catarrhal pneumonia.

Definition:—An acute inflammation of the terminal bronchioles and surrounding tissues, and with these the adjacent air vesicles of the lung structure. In involving the lung structure the disease includes areas of ultimate consolidation, which involves the lobules rather than the entire lohe, but which may be ultimately scattered throughout the lobes.

Correctly speaking the disease is cither of primary or of secondary origin. It is primary when the inflammatory lesion originates in these structures, there having existed no previous illness. It is secondary when the disease is the result of inflammatory invasion which has been caused by a pre-existing lesion elsewhere.

Etiology:—The micro-organisms which are found present in this disease are the pneumococcus, when the disease is of primary origin; the streptococcus most frequently, when secondary; although the two named may be found together. When the disease fellows influenza, the bacillus of rfeiffcr is found, and when following diphtheritic invasion, the Klebs-Loeffler bacillus.

The factors which predispose a patient to an attack of bronchopneumonia are prolonged exposure to cold, the inhalation of irritating substances, the use of the voice in the open air and bad sanitation. Among children this is the most common of the acute inflammatory lung diseases, occurring most frequently as a primary invasion. It is that form of pneumonia to which new-born children are liable. The aged are especially liable to it also, but with these the secondary form is the most common. The disease occurs in children secondarily and closely associated with whooping cough, measles—a most common inducing cause—and scarlet fever. With these also, and with adults, it follows pneumonia, influenza, erysipelas, gouty conditions, typhoid fever and smallpox.

The disease is of frequent occurrence among those who suffer from protracted chronic and debilitating diseases, and with children who suffer from rachitis, inherited syphilis or tuberculosis. It is also a common accompaniment of pulmonary tuberculosis in adults.

Symptomatology:—In a primary case developing idiopathically there is cough, accompanied with fever. These may have been preceded by a chill, more or less severe in character, but usually not pronounced. It will be found that there has been exposure to cold, or the patient has worn insufficient or damp or wet clothing, or that he has been subjected to a sudden sharp change of the temperature. The fever is not as high as that of croupous pneumonia at first, but the temperature will ultimately reach 104.5° F. perhaps, and maintain this high point for some days. The pulse increases in rapidity until it may reach, with children, from 160 to 180 beats per minute. Ultimately it becomes small and feeble, easily compressible and irregular. The influence of this disease upon the respiration is characteristic. This may be said to be always difficult. It increases rapidly at the onset, especially in the secondary form, to from forty to sixty respirations per minute. The cough, which has been named as perhaps the first symptom, is severe and aggravating almost from its onset, but unlike that of acute bronchitis, it is seldom dry, but is usually accompanied with expectoration, which is not uniformly rusty colored, as in croupous pneumonia, but is streaked with blood, or contains minute particles of coagulated blood. The pain is not a conspicuous symptom. There is usually diffused soreness and little, sharp, quick, transient pains, which are apparent both with the inspiration and with the expiration.

In the primary form the disease terminates by resolution generally at the expiration of from ten to fourteen days. In the secondary form it is of slower development, often following acute catarrhal bronchitis. It may develop insidiously during the progress of some other disease, to which the attention is directed, and thus the invasion of the pneumonic complications is not discovered until the disease is well established. The increase in the temperature and the rapid breathing should direct the attention at once to pulmonary invasion. There is anorexia, nausea and occasionally vomiting, with usually constipation and rapidly increasing prostration. With children, like croupous pneumonia, the onset may be marked by the presence of pronounced cerebral symptoms. The patient is dull, stupid, is easily startled and has severe muscular twitchings. There may be mild delirium, with pronounced convulsions, and, as with the latter condition, the respiration may be very rapid; these phenomena may mask the pulmonary symptoms entirely.

In the aged the symptoms are by no means distinctly marked. There may be increased feebleness, but slight fever, with perhaps an entire absence of cough. The respiration, while rapid, is not as apt to be difficult as in childhood. The presence of the disease must be determined almost solely by the physical signs.

Upon physical examination it is only when the disease has become general, that fremitus is increased or that there is plainly apparent defective chest expansion, and dulness upon percussion is also present in the more advanced stages. Early in the case there are normal percussion sounds or they may be slightly tympanitic. There are at first sibilant and sub-crepitant rales as lobular consolidation occurs. These circumscribed areas can be readily detected. With the rapid breathing the face becomes ultimately engorged and dusky colored, finally cyanotic; the lips blue and the countenance somewhat distorted.

Diagnosis:—It is sometimes almost impossible, especially in very young children, to discriminate between this disease and the phenomena of croupous pneumonia, but if the indications for treatment are rigidly adhered to no serious results may obtain by such a failure. The plainly apparent symptoms are the unusually rapid breathing, of sudden development, the characteristically very rapid and feeble pulse and the development of cyanosis with the increase in the temperature. This disease is more frequently secondary, while acute lobar pneumonia is nearly always primary, with a history of previous good health. Lobar pneumonia has the rusty colored sputum, general lobar consolidation and absence of bronchial symptoms. This form is usually bilateral, has a sputum that is streaked with blood, which may be tenacious and mucoid in character, with the bronchial symptoms conspicuous.

Prognosis:—In very small children and in the aged the prognosis is bad. Among young adults and in middle life the prognosis is good, and the mortality should not exceed five per cent, except in those where the disease follows a severe attack of other inflammation or where the patient is an alcoholic.

Treatment:—The conditions of environment, care and auxiliary treatment must be exactly the same as those of croupous pneumonia, to which we refer the reader. The necessity of maintaining a high degree of moisture in the room is, however, of more importance. To the vessel which contains the boiling water, a few drops of the oil of eucalyptus or of the oil of turpentine should be added once in six or eight hours. If possible, an open grate fire should be maintained or fire from a stove if the room is not steam or water heated. Furnace heat should be avoided. As with croupous pneumonia, the nutrition of the patient must have the closest attention from the very first, and nauseating expectorants or emetics must be avoided, as well as other agents which disturb the stomach, destroy the appetite or interfere with the digestion. As the disease is usually more diffuse in character than the croupous type, the entire chest should be enveloped from the first, for twenty-four hours at least, in a plastic dressing, and if soreness on respiration is present, this may be continued for three or four days, and external heat must be maintained. A cotton jacket should be applied over the plastic dressing and continued until the inflammation abates.

In severe primary cases, where the initial symptoms are pronounced and alarming, libradol is of immense value. It should be watched, however, and if applied strong to young children, should be removed before nausea is apparent—after from perhaps one to three hours—when it should be substituted by other plastic dressing. Later in the case the application of a turpentine stupe is of much service. As stated, heat must be constantly applied during the development of the disease.

Depressing measures of every kind must be studiously avoided, the physiological action of the special sedatives must be obtained only when no depression results therefrom. In giving aconite and ipecac the dosage must be small, and when so administered in accordance with their indications the influence will be satisfactory. The secondary influence of both remedies is thus exercised and only good results will accrue.

Veratrum should usually be avoided in children and in those at all feeble, and the aged. It will exercise a depressing influence in the line of its physiological activities if given in sufficient dosage, similar to that of the coaltar antipyretics, which are always contra-indicated because of the disintegration of the blood corpuscles which they induce. If used at all veratrum should be given only in sthenic cases and especially where there is much nervous excitement or convulsions.

Bryonia is most frequently indicated of any of the specific remedies. If a mixture of ten drops of the specific medicine in four ounces of water be given in half-dram doses every half hour there is absolutely no depression, and yet the temperature, pulse and respiration are controlled as well as the pain. The action of this medicine in small doses is exceedingly rational and is in every way consistent with a correct antagonism of the exact pathological processes.

Belladonna exercises a primary stimulating influence upon the capillary circulation, which antagonizes the local hyperemia, and subsequently the hepatization. It prevents an excessive outpour of secretion, which is apt to occur, and thus anticipates the possibility of the asthmatic form of respiration which may occur. It prevents difficult breathing from other causes also, and cyanosis, maintaining a uniform circulation in the capillaries of the entire system, and assists aconite in the diffusion and dissipation of heat.

Lobelia has been advised, and is often used indiscriminately. We would recommend it only in its secondary action, ten drops of the tincture of the seeds in a four-ounce mixture, in half-dram doses, is sufficiently active. This avoids any depressing or nauseating effect, and the results are harmonious with those of belladonna upon the local congestion. Administered in this manner it is very soothing in its influence upon the entire respiratory tract.

With the phosphate of iron, thoroughly triturated, the author has sometimes controlled the high fever of this class of diseases, all other remedies being excluded. The remedy should be given in solution, in hot water, for a period of from two to four hours at a time, every ten or fifteen minutes during the period of excessively high temperature. It will certainly surprise those who have not used it and is sometimes much more satisfactory than some better known remedies.

The author has had but little experience in the use of sanguinaria in this disease. If administered, it must be in small doses, and for its primary stimulating influence upon the respiratory structures. No nausea or irritation must be induced by it.

Phosphorus is valuable after the acute stage or stage of development has passed, and during the period of convalescence. It is valuable when the prostration is extreme, when nervous exhaustion is conspicuous and typhoid symptoms are apparent and where the general nutrition of the patient is of primary importance.

Rhus toxicodendron, baptisia tinctoria, cactus, apocynum, avena sativa, gelsemium or the bromids for extreme nervous excitement, quinin, digitalis and strychnin or nux vomica and iron may be indicated in this disease. Care must be taken to select and adapt the exact remedy to the specific indication.


The Eclectic Practice of Medicine with especial reference to the Treatment of Disease, 1910, was written by Finley Ellingwood, M.D.



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