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for it gives him a chance to ape the symptoms of the operative case. In some instances the aping is not consciously purposeful. Another suggestion is the attachment of psychiatrists as a regular part of the unit. This would insure the best results, for the psychiatrist can take up his duties where the surgeon leaves off. Problems such as re-education, phobias, etc., can be efficiently attacked by the medical psychologist and so lead to more' satisfactory end results. Removing a bomb splinter from the brain is not always the sole solution of a patient's problem. He must be put into such condition that he can take his place as a useful member of society. So much for Britain. Now as to the United States, in the event of war, it is generally agreed that we would not be immune from air attacks. Steps should and no doubt will be taken to care efficiently for our injured citizens. Our problem is a two-fold one, from the neurosurgical point of view. We have to consider and take steps for the treatment of our people at home. We must attack the problem of neurosurgery as applied to an expeditionary force. In the writer's opinion, the emulation of the British Brain Injuries Unit idea would adequately take care of our "at home" problem.

As for the question of an expeditionary force, we could have special motor buses equipped as neurosurgical operating theatres. To each theatre could be attached a neurosurgical team similar to the British neurosurgical teams. These travelling operating theatres could do all the emergency surgery necessary to tide a patient over until he could reach a stationary Brain Injuries Unit. Neurological and neurosurgical consultants should be available to help solve the difficulties of the "travelling" nuerosurgical teams. It would be most desirable to have a Brain Injuries Committee to solve the more, ,general problems which may arise. We could also benefit from the British solution of numerous technical problems which confronted them. For instance, auxiliary lighting had to be provided in case of the destruction of the original source. Another serious problem which was solved was the radio activity of the diathermy machine which was found to interfere with radio transmission and also gave away the position of the- hospital to the enemy. In the writer's opinion, the neurosurgeons of the United States should take immediate steps to combat most effectively any emergency which may arise.

Diagnosis of Lobar Pneumonia

W. H. GRANT, M.S., M.D.
Associate Professor of Medicine, Aleharry Mlledical College, Nashville, Tennessee

THE typical case of lobar pneumonia offers no difficulty of diagnosis. The history of: (a) an acute onset with a definite chill, (b) cough, expectoration of blood-tinged sputum, (c) pain in the side of the chest, (d) fever, (e) dyspnea, (f) herpes, (g) and sometimes nausea and vomiting is more than suggestive of the disease. In some instances, however, the disease does not follow the usual type and may offer great difficulties in diagnosis. Especially is this true in the extremes of life, i.e., children and old age; and in alcoholic patients. During the first 24-36 hours of the disease the only local signs may be diminished

breath sounds, slight dullness and moist rales in the bases of the lungs. Of these, the diminished breath sounds are the most important. Later on, one may find the typical: (1) Limitation of motion on the affected side. (2) Increase in vocal and tactile fremitus over the affected lobe or lobes, especially during the stages of red and grey hepatization. Fremitus is usually decreased during the stage of resolution. (3) Dullness over the affected lobe or lobes is characteristic of the first two stages of the disease. (4) The breath sounds and rales when once understood offer important diagnostic aid. Bronchial breathing without rales is the rule

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during red and gray hepatization; while fine and coarse moist rales usually attend resolution. (5) The pain in the side comes on early in the disease and is due to pleuritis. There may be an accompanying friction rub. The unaffected side is emphysematous. The temperature usually rises early to 10301050F. and fluctuates very little before the crisis. The pulse is in proportion to the temperature. The laboratory is one of the cardinal factors in proper diagnosis and prognosis of lobar pneumonia. Early in the disease there is a leukocytosis reaching 18,000 - 20,000 w.b.c. per cu. mm. In some instances the w.b.c. may reach 50,000. More important even than the total white count is the differential cell count. The polymorphonuclear leukocytes predominate the picture. These cells usually show the "so-called" toxic granulation and a "shift to the left," i.e., an increase in the number of immature forms of neutrophilic cells. It is to be remembered, however, that in an overwhelming infection with highly virulent organisms; in debilitated persons; and in the aged, no leukocytosis may be present. The urine is usually scanty and highly colored. The specific gravity is increased due to the concentration of oliguria. A febrile albumin, together with casts and a few blood cells may persist in the urine throughout the disease. The sputum during the early stages is bloodstreaked or of the so-called "prune juice" type. The causative organism of the disease, which is almost always diplococcus pneumoniae can be found in abundance in the sputum. This organism is a Gram positive diplococcus, containing in its capsule a polysaccharide responsible for the type specificity of the organism. Where facilities are available the organisms should be typed as soon as diagnosis is suspected. The Neufeld method of typing is the one choice since the entire procedure requires only about 1 to 15 minutes. It is difficult to type the organism after sulfapyridine therapy has been instituted. When sputum is not obtainable by coughing, throat swabs or even lung puncture may be employed. The latter methods are reported as being not entirely satisfactory.

DIFFERENTIAL DIAGNOSIS

Specific lobar pneumonia is most often confused with tuberculous pneumonia, Friedlaender bacillus pneumonia, influenza, pleurisy, broncho-pneumonia, pulmonary infarction and rarely such disease processes as appendicitis and cholecystitis. (1) Acute tuberculous pneumonia is usually unsuspected until resolution fails to set in after 8 to 15 days. The physical signs may be identical with those of pneumococcic pneumonia. The finding of tubercle bacilli in the sputum; a history of recurrent chills and general ill health before the onset of the pneumonic process; and x-ray signs of tuberculosis are the surest criteria of differentiation. (2) Friedlaender's bacillus pneumonia should be suspected if the sputum is non-purulent, bloody, slimy and copious in amount. The bacillus of Friedlaender can be isolated from the sputum. Patients with this disease are usually quite toxic and do not have an initial chill. (3) Influenza Pneumonia. It is well known now that during epidemics of influenza many cases of pneumonia are seen in which the chief organisms found are the influenza bacilli. Cole found pure cultures of influenza bacilli in 3.8 per cent of his series of 211 cases while most of Opie's cases showed the presence of other organisms also. In any atypical pneumonia the possibility of the influenza bacillus as an etiological factor should be considered. (4) Pleurisy with effusion can usually be differentiated from pneumococcic pneumonia by a history carefully taken and a physical examination. The affected side is usually larger than the healthy and shows marked lag on respiration. The percussion note is flat and does not limit itself to the anatomical lobular areas. If the infusion is massive there is a mediastinal shift of the heart and aorta and a downward displacement of the abdominal viscera. These changes can also be demonstrated by repeated x-ray films. Finally, an exploratory puncture will settle the diagnosis and should be done. (5) Broncho-pneumonia is usually a secondary disease in all patients except children and the aged. The distribution of pnuemonic patches over

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both sides of the chest and the finding of crepitant rales over the upper and lower lobes of the lungs aids much in the diagnosis. X-ray films are most helpful. (6) Pulmonary infarction is usually secondary ,to cardiac disease, uterine sepsis or an abdominal operation. The patient may complain of pain in the chest, cyanosis, dyspnea, cough and bloody sputum. An absence of leukocytosis and rusty sputum make lobar pneumonia unlikely. (7) Appendicitis and cholecystitis simulate lobar pneumonia by producing leukocytosis, cough, vomiting and pain in the chest. This pain is due to a diaphragmatic pleurisy. A careful physical examination will show an absence of consolidation, "chest lag" on respiration and bronchial breathing. A rectal examination in the former disease and x-ray studies in the latter make the diagnosis almost certain.
SUMMARY

OCCURRENCE OF SYMPTOMS IN 100 CASES OF PNEUMONIA AT GEORGE W. HUBBARD HOSPITAL-MEHARRY MEDICAL COLLEGE, 1937-1940
Per I. ONSET: 1. Cold in head and chest 2. Chill 3. Pain in chest 4. Cough and rusty sputum

Cent of All Cases 43 64 92 96

II. COURSE: Temperature below 1020F. Pulse below 110

0 0

We have presented only the outstanding findings in the history, physical examination, and laboratory results in the diagnosis of lobar pneumonia. In the differential diagnosis we have considered only those disease processes which are frequently found and are most likely to confuse the general practitioner. Further, we have given some idea of the frequency of these signs and symptoms by analyzing one-hundred cases of pneumonia from the Medical Service of George W. Hubbard Hospital of Meharry Medical College.

III. SYMPTOMS: 1. Cyanosis 2. Headache 3. Apathy 4. Sleeplessness 5. Delirium 6. Hiccoughs 7. Herpes 8. Vomiting 9. Icterus 10. Dehydration 11. Pulmonary edema 12. Leukocytosis 10-15 thousand 15-20 thousand 20-25 thousand 25-30 thousand 30-40 thousand 40-50 thousand

28 67 22 32 8 4 3 28 (mostly babies) 54 9 5 0 13 16 46 10 5

PROVIDENT HOSPITAL AND THE CIVILIAN DEFENSE CORP

Provident Hospital has now organized an Emergency Medical Squad and an Emergency Woman's Auxiliary to the Civilian Defense Corp. An order for a Super Ambulance was placed which will include a field operating room and which will provide facilities for taking care of at least seventy-five emergencies in the field. This unit is patterned somewhat after the Bellevue Catastrophe Unit and the Point Pleasant, New Jersey First Aid Squad. It is a radical departure from either of the two plans and an even more radical departure from the usual type of ambulance of first aid medical service. Provident Hospital is the first Negro institution in the country to provide such an organization and also that it is the first hospital in the Middlewest, regardless of race, to embark upon such a program. The Medical Corp consists of approximately seventy-five doctors assigned in squads to cover certain periods. They will answer all mass first aid calls such as explosions, fires, train and other mass accidents. The Women's Auxiliary will consist of approximately 1000 women, of which 250 are already registered, will be divided into four groups.