When dilatation of the bronchi occurs in an advanced case of the sub acute variety of catarrhal pneumonia it is important to exclude ulcerative destruction of lung. Thus, in the fifth or sixth week of a bronchopneu monia a child is seen with a temperature of 100° in the morning, rising to or at night. At the same time an examination of the chest dis covers a fine crepitating rhonchus at the base of each lung, with impaired resonance over the lower half posteriorly of each side, and at one base dul ness, loud cavernous breathing, metallic gurgling rhonchus, and broncho phony. These latter signs are evidently significative of a cavity ; but the cavity may be a dilated bronchus or a vomica in the lung. To which of these causes the physical signs are to be attributed must be decided by reference to the general symptoms and the progress of the case. The po sition of the cavity, indeed, at the base of the lung, points rather to bron chiectasis than to a vomica, but this is not conclusive proof. If, however, we find that the temperature begins to fall, the child's appetite to return, the general nutrition to improve, and at the same time notice that the cavernous sounds become less intense, the respiration less shrill, and the gurgling less metallic, we may safely infer that no disintegration of lung tissue has taken place.
Prognosis.—The prospect of the patient's recovery in a case of broncho pneumonia is always doubtful. In new-born infants, indeed, the illness almost invariably terminates fatally ; but even up to the end of infancy the rate of mortality is very high. When the disease succeeds to measles or whooping-cough its course is less acute than when it arises as a consequence of simple pulmonary catarrh, and in these cases there is a greater propor tion of recoveries. If, however, the lobular pneumonia come on during the spasmodic stage of pertussis, or towards the beginning of an attack of measles, it is very commonly fatal. The existence of any debilitating con dition or exhausting disease increases the danger of the case. Thus in diphtheria the occurrence of secondary bronchopneumonia is an event of the utmost gravity ; and in rickets the local weakness of the softened ribs, combined with the general want of power in the patient, militates power fully against a favourable termination to his illness. The danger is usually great in proportion to the degree to which aeration of the blood is inter fered with. Therefore lividity of the face, blueness of the nails, lips, and eyelids, smallness and rapidity of the pulse with dilatation of the superficial veins, great perversion of the pulse-respiration ratio, suppression of the cough, and marked apathy or somnolence are symptoms indicative of serious danger. If convulsions occur at a late period of the illness we must prepare
the child's relatives for the worst.
Treatment.—The occurrence of catarrhal pneumonia may often be pre vented by judicious treatment of the preliminary catarrh, and especially by the employment of energetic measures on the first sign of collapse of the lung. This subject is discussed elsewhere.
When lobular pneumonia has supervened, the indications to be fulfilled are three iu number. We have to reduce the temperature, to promote ex pansion of the lung, and to support the strength of the patient.
In order to lessen the temperature tepid bathing is often resorted to. The child should be placed in water of the temperature of 70°. In this he may remain for ten or fifteen minutes at a time. The bath must be re peated more than once in the four-and-twenty hours, for the reduction of temperature is only a passing improvement, and the pyrexia quickly re turns. This method is highly spoken of by Billet and Barthez, who rec ommend its employment in every case, unless the prostration of the patient be extreme. Another method is that advocated by Bartels. It consists in packing the child in a cold, wet sheet, covered with a thick folded blanket, for three or four hours at a time. The process in this case also requires to be repeated at intervals, so long as no signs of exhaustion are noted, in order to maintain the improvement. The effect of either of these measures is not only to lessen the fever, but also to increase the depth and reduce the frequency of the breathing.
Another very valuable resource is energetic counter-i•ritation of the skin of the chest. A large poultice of mustard and linseed meal (one part of the former to five or six of the latter) should be applied for six or eight hours to the back. Afterwards a similar poultice should be allowed to re main for a like time on the front of the chest. On removal of the poultice the chest should be covered with cotton-wool. These applications will often have to be repeated several times, for in this disease there is great tolerance of irritation of the skin even in the case of a young infant. Even if the surface is blistered by the application, no harm will be done. Indeed, I have been in the habit of ordering the poultices to be continued. until some signs of blistering of the skin have been noticed. The chest can then be covered with cotton-wool. In bad cases, instead of the mus tard poultice, dry cupping of the back is useful. In one severe case of this disease—a child of three years of age—I attribute the recovery of the patient entirely to the timely use of this energetic application.