ï~~172 TORREY, GROSH: ACUTE PULMONARY EMPHYSEMA men. We admitted to the hospital in all about 1800 of these cases. They were characterized by: 1. Prostration-incident to the disease and added to by the fatigue, hunger and lack of care unavoidable during the long journey. 2. Cyanosis-particularly of the face and ears and intensely red conjunctivae and dusky red pharynx. 3. Dyspnea-some degree of dyspnea was invariable; breathing was very shallow. 4. Epistaxis-very frequent, probably in nearly half the cases, and in many instances severe in degree. 5. Bloody sputum. 6. Cough-all had cough and showed signs of bronchitis in varying degrees of severity. 7. Extreme lethargy-a typhoid state, clear sensorium, but apathy and drowsiness; very few were delirious. The patients suffering from influenza who recovered without marked pulmonary complications were, as a rule, convalescent within a few days and did not experience the nervous or renal complications which have been reported as so frequent in previous epidemics. Many of these men developed their bronchitic emphysema during the first day or two of influenza, others were apparently convalescent from the influenza and seemed ready for discharge to duty when there was a sudden onset of the so-called pneumonia, with characteristic change in the physical findings. In the so-called pneumonic cases there was evident absent breathing, with impaired resonance at the bases and hyperresonance over the rest of the chest. We were struck with the burly appearance of these patients. This appearance was due to the distention of the neck vessels and erection of the chest, which was dilated to the full inspiratory limit. These patients showed increased temperature, with bloody sputa, and large areas of absent breath-sounds, diminished vocal fremitus, and above these areas crepitant rales in circumscribed zones and diffuse bronchitis throughout the lungs. Forced breathing might bring out rales where sounds had been absent. If breath-sounds reappeared the expiration was markedly prolonged. In no case was the sputum of the rusty or prune-juice type, but was foamy and bloody, and sometimes mixed so completely as to resemble tomato pur6e. Areas of dulness appeared in the bases, gradually spreading from below upward, and the sputum became frankly purulent or remained bloody, but was not viscid, as in pneumonia. The temperature was irregular, always elevated but not unduly high; these patients might have sweating throughout the entire course of the disease. The pulse was:slow for the temperature, suggesting reflex vagus inhibition from pulmonary distention. There was no arrhythmia and the heart remained apparently good F i 4 ijy f i.; t 1 k 8 E, 1 E 4. I TORREY, GROSH: ACUTE PULMONARY EMPHYSEMA 173 i ' r; k <+V A J } to the end. With the finding of dulness in the bases, which might occur within a few hours of the appearance of the areas of absent breathing, patches of tubular breathing would appear as in bronchopneumonia. These small areas of dulness rapidly coalesced until the whole base of the lung showed signs as in a lobar pneumonia, with marked percussion changes, sometimes flatness, and tubular breathing with egophony and whispered pectoriloquy, as in lobar pneumonia, often without rales. The rapid massive involvement was accompanied or even preceded 'by the generalized pulmonary emphysema. Whether this was due to inflammation of the lung parenchyma, causing a loss of tone, or to nervous or circulatory trophic changes, causing loss of tonicity, or to bronchial blockage with valve action production is not clear and will not be discussed here. The sudden occurrence of profound emphysema in these cases as the outstanding feature of the condition was unmistakable. At this stage of consolidation, as at the prior stage of absent breathing, there was evident above the thus affected area a portion of the lung which was apparently compressed and showed diminished or absent breathing, impaired percussion note, and on forced breathing, or after hard coughing, showers of fine crepitant rales as the compressed lung unfolded. We consider this sign of changing areas of compressed lung a fairly constant sign of emphysema. The total lung volume is too great for the chest capacity, and some portion of the lung is usually compressed with other portions fully distended, these areas changing after deep breathing or coughing, with breath-sounds and percussion resonance being reestablished in the expanding portions. The areas of consolidation appeared usually posteriorly almost always on one side, followed by the other, spreading and coalescing toward the lower limits of the lung until the base was universally involved, then gradually spreading upward, one side more than the other, but seldom with one side wholly free from involvement. The total consolidation appeared as a gradual filling from below up. Bronchitis persisted throughout, but tubular breathing and pectoriloquy became pure in the solid portion, reaching perfection at the lower levels. Subcrepitant rales were typical in some portions. The point that struck us here with great force was the intense dyspnea, with little cardiac disturbance, cyanosis, great air hunger, and erection of the chest fixed in a state of hyperinspiration, with only tidal air movement. As the muscles of respiration failed exitus occurred, a respiratory death, in contradistinction to the toxic circulatory or vasomotor death commonly seen in the early days of true pneumonia. The pulse impressed us as being slowed as if under the influence of cardiac vagotonic inhibition, as in high pulmonary pressure. The pulse in desperately ill or moribund individuals was excellent in volume and quality, and relatively slow; arrhythmias were almost never noted. As this distention of the chest developed