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occasional abscess-like masses of polymorphs. Groupsof fat-containing cells filling alveolar spaces were common,and presented an appearance like that seen in lipoidpneumonia. The bronchi were frequently distorted anddilated, and in some instances were distended and formedthe walls of cavities. The walls of the bronchi in theaffected parts of the specimens showed at some pointscomplete necrosis, at others inflammatory infiltration,and at others fibrosis. Some of the features describedin this section are shown in figs. 22-24.

ILLUSTRATIVE CASES

Before going on to consider the differential diagnosisand treatment, I should like to describe three cases byway of illustration.The first example (case 2 of Logan and Nicholson

(1949)) shows -the effect of long-continued suppurationin the lung.Case 9.-A Libyan Arab, aged 26, was admitted to hospital

in June, 1.942. Five months before, he had become ill withfever, cough, and sputum.On admission, his general condition was fairly good ; he

was febrile to 101°F, and was coughing up 10 oz. offoetid purulent sputum each day. His fingers were clubbed.Radiographic examination (fig. 25) showed a cavity in theright upper lobe, surrounded by consolidation and fibrosis,the transverse fissure being displaced upwards. Sputumexamination showed the presence of a mixed flora with

pneumococci predominating. Bronchoscopy, carried out

shortly after his admission, showed the right main bronchusto be cedematous, with pus exuding from the upper-lobebronchus.For a month the patient improved clinically and his sputum

diminished. Then he had an exacerbation, and sulpha-,pyridine, 1 g. every four hours, was begun. He suffered noill effects, and the chemotherapy was kept up for eighteendays. At the end of this long course he was greatly improvedand had only 3 oz. of sputum each day. The clinical improve-ment was maintained, but radiographs six months afteradmission (fig. 26) showed that although the upper-lobechanges were mainly of fibrosis, there was a large pneumonicarea in the right lower lobe. Two months after this thepatient developed a right basal empyema. At this time thelower lobe contained a cavity with a fluid-level and muchsurrounding consolidation. The empyema was drained andhealed.

After this the patient steadily improved. The radiographicappearance of his chest a year after admission is shown infig. 27 ; there is considerable fibrosis throughout the right lung.He was then well and free from cough and sputum. Broncho-grams (figs. 28 and 29) showed a distorted right bronchialtree with irregular cavities in communication with the bronchiof all lobes.

The second example is of less extensive disease withoutdefinite abscess formation and with a fairly satisfactoryresult after treatment.

Case 10.-A carpenter, aged 43, was admitted to theBrompton Hospital in September, 1946. For twenty yearshe had had a cough with a little mucoid sputum, and hadbeen regarded as having chronic bronchitis. About threemonths before admission he had been taken ill with a pain inthe right side of the chest, fever, and increased cough. After

eight or nine days, his sputum had increased, and had becomepurulent and streaked with blood.When admitted to hospital, he was febrile to 99°F and

was coughing up 3-4 oz. of purulent, non-feetid sputum.His fingers were clubbed, but abnormal physical signswere not detected on examination of his chest. Theradiographs (figs. 30 and 31) showed consolidation, mainly inthe posterolateral segment of the right upper lobe. Sputumexamination showed a mixed flora, and Strep. viridan8,micrococci, and a few colonies of haemolytic streptococci weregrown. Bronchoscopy revealed nothing abnormal apart frommild inflammatory changes at the right upper-lobe orifice.He was treated with postural coughing, and penicillin byintramuscular injection ; clinically his condition improved,with reduction of sputum to less than 1/2 oz. each day. The

radiographic shadow diminished, but did not clear upcompletely.

Fig. 34-(Case It). Anteroposterior radibgriphof right knee showing subperiosteal new bone, _

He left hospital after a little more than a month; and inthe next six months he had two exacerbations, with increasein sputum and in the pneumonic area in his right upper lobe.A radiograph (fig. 32) taken three months after his dischargefrom hospital shows the appearance of the lung n one ofthese exacerbations. After this his cough and sputumdiminished steadily, and radiographs of his chest showedmainly linear shadows, attributed to fibrosis’ in the rightupper lobe. A radiograph taken more than two years afterhis discharge is shown in fig. 33. ’

In the third case lobectomy was carried but.Case 1 l.--The patient was a Greek soldier, aged 37, who

was admitted to hospital in September, 1942. Ten monthsbefore, he had developed fever, cough, and profuse sputum,and a diagnosis of lung abscess had been made.On admission, he was in good general condition and afebrile,

but with a. cough and 2 oz. of purulent, non-fcetid sputumeach day. His greatest complaint was of pain in the kneesand wrists. His fingers were clubbed, but abnormal physicalsigns were not detected in his chest. He had several septicroots in his upper jaw and his oral hygiene was poor. Radio-graphs of his wrists, ankles, and knees showed subperiostealthickening ; that of his right knee (fig. 34) demonstrates thisnew bone formation. Radiographs of his chest (figs. 35 and36) showed consolidation in the left lower lobe, with more

LEGENDS TO ILLUSTRATIONS ON PLATE

DR. NICHOLSON

Fig. 25-(Case 9). Postero-anterior radiograph on admission showingabscess cavity in right upper lobe surrounded by consolidation andfibrosis.

Fig. 26-Same case. Postero-anterior radiograph six months afteradmission showing extension of pneumonia.

Fig. 27-Same case. Postero-anterior radiograph one year afteradmission showing fibrotic changes throughout the lung.

Figs. 28 and 29-Same case. Anteroposterior and oblique broncho-grams one year after admission showing distorted right bronchialtree.

Figs.30 and 31-(Case 10). Postero-anterior and right lateral radiographsshowing consolidation in posterolateral segment of right upper lobe.

Fig. 32.-Same case. Postero-anterior radiograph four months latershowing fresh area of consolidation.

Fig. 33-Same case. Postero-anterior radiograph two years latershowing fibrotic changes in right upper lobe.

Figs. 35 and 36-(Case II). Postero-anterior and left lateral radio-graphs showing consolidation and cavitation in left lower lobe.

Figs.37 and 38-(Case 12). Pulmonary tuberculosisandchronicsuppura-tive pneumonia : postero-anterior and right lateral radiographsshowing consolidation of most of right upper lobe. -

DR. NICHOLSON : SUPPURATIVE PNEUMONIA

DR. NICHOLSON: SUPPURATIVE PNEUMONIA

DR. STOKER: Q FEVER IN GREAT BRITAIN

609

than one cavity. Bronchoscopy showed a normal bronchialtree, apart from the presence of pus in the left lower bronchus.A few days after admission, two roots were removed,

under local anaesthesia., from his upper jaw. Next day thepatient had a rigor and became febrile to 103°F. His

sputum increased and he became very ill, with a rigorevery second day. This continued and was unaffected bya course of a sulphonamide. Other causes for his fever

having been excluded, an attempt was made to drain the mainpulmonary abscess. Rib-resection was carried out, but free

pleura was opened. A firm lump, 21/2 in. in diameter, wasfound in the left lower lobe, with a narrow area of looselyadherent pleura over it. It was not thought justifiable tocarry out the drainage, and the pleural cavity was closed.Over the two months after this operation, the fever graduallysettled and the patient’s general condition improved. Theradiological appearance at the end of this time remainedessentially unchanged. Fourteen months after the onset ofthe disease, a left lower lobectomy was carried out and wasfollowed by complete relief of symptoms.

DIFFERENTIAL DIAGNOSIS

In describing some of the specific pneumonias whichare associated with cavity formation in the lung andwith suppuration, I have indicated how they are dis-tinguished from non-specific suppurative pneumonia.The cavitation which occurs during pneumococcalpneumonia is transient and apparently followed byhealing. Recognition of the chronic pneumonia due toFriedlander’s bacillus may be more difficult ; the courseand radiological appearance may be very similar to non-specific chronic suppurative pneumonia, and the dis-tinction depends on the recovery from the sputum ofBact. pneumoniœ in pure or almost pure culture. In

staphylococcal pneumonia, the clinical features, particu-larly at or near the onset, may strongly suggest the cause.The staphylococcus may be found in pure culture in thesputum or may be recovered from the blood-stream. Inthe more chronic phase of the illness the bacteria recoveredfrom the sputum may be varied, other organisms besidesthe staphylococcus having established themselves in thedamaged lung. In these circumstances it may be possibleto guess the original nature of the infection from the clini-cal course of the disease ; but in general the distinctionfrom the non-specific variety of pulmonary suppura-tion is not then very valuable, since the outlook andtreatment of both are the same. The recognition of

actinomycotic infection of the lung also depends on thefinding of the organism.Pulmonary tuberculosis might be expected to be

commonly confused with suppurative pneumonia. Cer-

tainly the long course of both and the similar radiologicalappearance may give rise to difficulties in diagnosis.Nevertheless, I believe it is usually possible to make thedistinction. In the first place, there is the association ofpulmonary suppuration with sources of infected materialin the respiratory tract. Then, the onset with theproduction of a considerable, and sometimes very large,amount of sputum fairly early in the disease is character-istic of suppurative pneumonia. This is quite unlikethe early stages of pulmonary tuberculosis, in which it is

LEGENDS TO ILLUSTRATIONS ON PLATE

DR. NICHOLSON

Fig.39-(Case 13). Chronic suppurative pneumonia regarded as bronchialcarcinoma : postero-anterior radiograph showing consolidation inleft mid zone.

Fig. 40-Same case. Left lateral tomogram showing consolidation tobe in apical segment of left lower lobe.

DR. STOKER

Fig.I—R. burneti M strain. Intracytoplasmic group of rickettsiae seenin Giemsa-stained peritoneal smear from a guineapig inoculated witha heavily infected yolk-sac suspension. ( x 60CO.)

Fig. 2—R. burneti Henzerling strain. Electron microphotograph, goldshadowed. ( x 27,000.)

Fig. 3-R. burneti Christie strain. Electron microphotograph, goldshadowed. ( 50,000.)

Fig. 4-R. burneti, Christie strain. Electron microphotograph, goldshadowed. ( × 100,000.)

rare for large quantities of sputum to be produced.Finally, repeated examination of the sputum for tuberclebacilli with negative results, both from direct examinationand from culture, may be regarded as adequately dis-tinguishing suppurative pneumonia from tuberculosis.There is, however, a group of cases, of which I propose

to describe an example, in which the two diseases occurtogether.Case 12.-A man, aged 51, was admitted to thd Brompton

Hospital in October, 1947. He had been regarded as havingchronic bronchitis since the end of the 1914-18 war, and sincethen had had some purulent sputum. Six months beforeadmission, he became ill with fever and malaise. After threeor four days of this illness he, as he said, " smelt fumes in hismouth " when lying on his left side. There was no greatincrease in his cough or sputum, but after this the sputum didoccasionally become offensive. A month before admission henoticed streaks of blood in the sputum, and he was seen athis local tuberculosis clinic, where his sputum was repeatedlyexamined and found free from tubercle bacilli.On admission to the Brompton Hospital, he was febrile

to 100°F ; he had some cough, and was bringing up 2 oz.

of purulent, but not fcetid, sputum each day. His fingerswere clubbed, and he had physical signs suggesting consolida-tion over the upper part of his right chest posteriorly. Theradiological appearance, shown in figs. 37 and 38, did notchange much during his stay in hospital. It will be seen thatthere is consolidation in the right upper zone, with probablyirregular cavitation in it. The lateral view shows thata large part of the upper lobe is consolidated.

Examination by smear and concentration of eight successivespecimens of sputum again failed to demonstrate the tuberclebacillus. The sputum contained a mixed flora, and on oneoccasion only Bact. pneumoniœ was isolated from it. Broncho-

scopy revealed no abnormality in the bronchial tree. A trapspecimen of secretion aspirated at bronchoscopy from theupper-lobe bronchus did not contain tubercle bacilli. Acourse of penicillin and sulphamezathine was given, and thiswas followed by reduction in the amount of sputum andgradual clinical improvement. Then, two days after the

bronchoscopy, a few tubercle bacilli were found in his sputum,and successive daily specimens after this showed the organismsto be present in increasing numbers.The patient died at home, nine months after the onset, of

a coronary thrombosis. Necropsy is reported to have shownextensive fibrocaseous tuberculosis of the right upper lobe.

It is difficult to believe that this was simply a case ofpulmonary tuberculosis from the beginning. It is surelyfar more likely that suppurative pneumonia developedin a pulmonary segment that was already the site of ahealed or quiescent tuberculous lesion. The destructive

suppurative process involved the possibly encapsulatedtuberculous focus, and allowed its still living bacilli toinvade the partly destroyed lung.

I have already drawn attention to the relation ofbronchial carcinoma to pulmonary suppuration ; and inpractice the distinction between suppuration associatedwith carcinoma on the one hand, and non-specificsuppurative pneumonia on the other, may be extremelydifficult. For example :Case 13.-A Norwegian seaman, aged 52, was admitted to

hospital in January, 1949. He had been ill for two monthswith a cough and an ounce or two each day of mucopurulentsputum, never fcetid. He had lost 10 lb. in weight. A radio-graph (fig. 39) taken shortly before admission showed con-solidation in the left mid-zone. Lateral views showed theconsolidation to be in the apical segment of the left lowerlobe ; and this was confirmed by lateral tomograms (fig. 40).Bronchoscopy showed pus exuding from the orifice of thebronchus to this segment ; the orifice itself was inflamed, butno growth was seen. A biopsy specimen taken from it showedno evidence of growth. The patient was treated by posturalcoughing and by penicillin and sulphamezathine. As a resultof this, his sputum diminished in amount, but no strikingchange took place in the radiological appearance. ’

*

A month after the patient’s admission, in view of the lackof radiological change, and in the belief that he had a carcinoma,probably of the bronchus to the apical segment of his lowerlobe beyond the range of bronchoscopic vision, it was decided

P 2