Chapter XXIII: Part 23

In children pneumonia is so frequently accompanied by marked nervous symptoms that it may be mistaken for meningitis. Meningitis is developed insidiously; has but slight febrile symptoms (102-103° F.), which remit with comparatively great regularity; has a pulse which is often slower than normal; has no thoracic symptoms, no dyspnoea nor accelerated breathing; the face is pale and anxious; and the physical signs of pneumonia are absent.

Sometimes a latent pneumonia with typhoid symptoms is mistaken for typhus fever: especially is this the case when the latter is prevailing. I frequently saw cases where such a mistake had been made while in charge of the typhus-fever patients on Blackwell's Island during a typhus epidemic. In these cases there will be active typhoid symptoms, such as dry tongue, delirium, high temperature, etc. The countenance in this pneumonia, although the cheeks may have a purplish hue, does not exhibit that dull, heavy leaden expression so commonly seen in typhus fever. Although there may be delirium in both instances, the delirium in the former disease is of a milder type than in the latter. The characteristic pneumonic expectoration is often absent in this class of cases; therefore it cannot be relied upon as a point in the differential diagnosis. If pulmonary consolidation is a complication of typhus fever, it will not be developed until after the sixth day of the fever, the time when the eruption is visible. If no eruption is present, the pneumonic consolidation may be regarded as the primary affection, and the symptoms which simulated those of typhus fever may be regarded as secondary.

Pneumonia with typhoid symptoms is sometimes mistaken for typhoid fever. It is called typhoid pneumonia. The differential diagnosis is not difficult if one remembers that the pneumonia which complicates typhoid fever does not come on until late in the fever, and the regular history of typhoid fever precedes its development. On the other hand, when the typhoid symptoms are present from the beginning or come on at the end of the second stage of pneumonia, the physical signs of pneumonia will attend or precede the typhoid symptoms. If a patient over sixty years of age with this type of pneumonia is not seen until the second or third week of his sickness, although evidences of lung-consolidation may be found, it will be very difficult to decide whether the pneumonia is or is not complicating a typhoid fever; and under such circumstances a differential diagnosis may be impossible.

PROGNOSIS.--The mortality-rate of pneumonia is shown by the following statistics: Of 12,421 cases treated in the hospitals at Stockholm, 11 per cent. died. In the Vienna hospitals 24 per cent. died. The Basle hospital's report for thirty-two years gives 23 per cent. of deaths, Grisolle reports 59 per cent. of deaths in those over sixty years of age. In the United States medical reports from May 1, 1861, to July, 1866, of 61,202 cases which occurred among the white troops, 14,738 died, or a little more than 24 per cent.; and of 16,133 among the colored troops (for the same period) 5233 died, or nearly 33 per cent. The deaths from all other inflammatory diseases of the respiratory organs for the same period were only one-seventh as many as from pneumonia. The Confederate hospital reports give the rate of mortality from pneumonia for twenty-five months of the same period as 33-1/3 per cent. Of 255 cases treated in my wards in Bellevue Hospital during a period of four years, the rate of mortality was 34 per cent.

{343} The statistics given of private practice differ remarkably from those of hospital reports, and are somewhat contradictory. Of Lebert's 205 cases, 7-3/10 per cent. died. Ziemssen lost only 3-1/3 per cent. of his cases. Bennett (mentioning, however, that no complication existed) lost none of his 105 cases. Brundes of Copenhagen lost more than 21 per cent. of his 142 cases. Wilson Fox gives to pneumonia the fifth, and Walsh the third, place among fatal diseases. The mortality-average from all the published reports to which I have had access gives 20.1 per cent. of deaths.

From such facts it must be admitted that a disease in which death occurs in 1 out of every 5 cases should be classed among the very fatal diseases. But the death-rate varies very much at different times: it is to-day the same as when Andral wrote, nearly fifty years ago. He stated that it varied from 33 to 2 per cent. There can be no doubt but that treatment somewhat influences the variations in the mortality-statistics, but not to such an extent as to account for the great differences in the reports of different observers.

The prognosis depends more upon the age of the patient than upon any other single element. In infancy the mortality is greater than in early childhood, in which period statistics give from 4 to 6 per cent. as the ratio. The period of dentition seems to influence the prognosis in children. Between the ages of forty and sixty the death-rate is from 10 to 25 per cent.; uncomplicated cases will recover. After sixty the prognosis is exceedingly grave, and the greater the age of the patient the less are the chances of recovery.

Statistics do not give pneumonia its proper place among the fatal diseases of old age. My own experience leads me to believe that it is the most fatal of all acute diseases at this period of life, for the large number of autopsies in which it has been found to be the cause of sudden death in individuals of advanced years, and the frequency with which red or gray hepatization is found at the autopsy when pulmonary disease was not suspected during life, must greatly increase the statistical rate of mortality. Many modern authorities, who have had large experience in the hospital practice of the aged, state that nearly nine-tenths of those who die over sixty-five die of pneumonia. Pneumonia is more fatal in females than in males, in the proportion of about 3 to 2.

Statistics vary in regard to the influence of seasons on the prognosis in pneumonia. In some years the proportion of deaths is far greater in summer than in either the spring or winter. And it must be acknowledged that certain as yet unknown atmospheric influences are of the utmost importance in determining the death-rate in different years. Statistics do not show that the mortality-rate is greatest during cold weather.

The prognosis is greatly influenced by the extent of the pneumonia. Double pneumonia is not often recovered from, and pneumonia of an entire lung is more dangerous than when only a single lobe is involved. In pneumonia at the apex in infancy and old age the prognosis is unfavorable. The more feeble the patient at the time of the attack, the less are his chances of recovery. Previous attacks have no influence over the prognosis.

Most authors make mention of certain diseases that complicate pneumonia. Few give condensed statements of their influence on the death-rate. In 255 cases of my own, 87 were fatal and 168 recovered. Of these 255 cases, 124 were complicated and 131 were uncomplicated. Of the complicated cases, 75 died; of the uncomplicated, 12. Of these complications, alcoholism was present in 30 cases, pleurisy in 17, Bright's disease in 13, pericarditis in 9, hypertrophy and dilatation of the heart in 3, peritonitis in 2, fibrinous bronchitis in 1, and rubeola in 1. Lebert in his statistical report on pneumonia states that he lost only 5½ per cent. of his uncomplicated cases and all of his complicated cases. Huss of Stockholm lost 6 per cent. of his uncomplicated {344} and 20 per cent. of his complicated cases. Wilson Fox says that, according to the reports of English physicians, pneumonia complicated by endocarditis is fatal in 75 per cent. of the cases; complicated by pericarditis, in 54 per cent.; by Bright's disease, in 50 per cent.; and by alcoholism, in 25 per cent. Brundes of Copenhagen in 120 uncomplicated cases lost only 6-2/3 per cent., while of 22 complicated cases he lost all, or 100 per cent. Thus it is evident from my own records, as well as from those of others which I have given, that the rate of mortality in complicated pneumonia is much greater than in uncomplicated.

By a careful study of these complications it is apparent that they all exert a direct influence upon the heart, diminishing its power and crippling its action by obstructing the blood-current from the right ventricle toward the lungs. It is unnecessary to discuss these complications in detail; it is sufficient to state that weakening of the contractile power of the cardiac muscle is an essential feature of endocarditis, pericarditis, Bright's disease, and alcoholismus. In all acute infectious diseases such complications are regarded as dangerous, because they increase the liability of heart-failure when such failure is especially to be feared.

Other complications in addition to those already mentioned which increase the mortality-rate in pneumonia are chlorosis, phthisis, emphysema, laryngitis, oedema glottidis, bronchitis, pleurisy, parotitis, pregnancy, erysipelas, and rheumatism. Bronchitis, pleuritis, and jaundice do not seem to increase the mortality-rate very much, although they certainly influence it; while pregnancy, parotitis, and affections of the joints are very serious complications. Excepting small-pox and cholera, abortion is more apt to occur during the course of pneumonia than in any other acute disease.

A case of pneumonia may be called mild so long as the temperature does not rise above 104° F.; an elevation of temperature above 106° F. for two days renders the prognosis unfavorable. Wunderlich[48] says that a gradual rise in temperature after the fourth day is always an unfavorable symptom. A low temperature is dangerous only when the respirations are very much accelerated.

[Footnote 48: In _Die Eigenwärme in Krankheiten_.]

When the pulse is 120 or 130 for two or three days, the prognosis is bad; if the pulse reach 150 per minute, a pneumonia patient rarely recovers. An irregular and intermittent pulse, and one whose tracing exhibits dicrotism, has a most unfavorable prognosis. In children the rapidity of the pulse is not of so much importance, while in old age the pulse is seldom or never a reliable element in prognosis. A feeble, irregular, and intermitted pulse is always an unfavorable symptom.

Prune-juice expectoration is also an unfavorable sign, as it indicates extensive blood-changes or a depraved condition of the patient. If there is an entire absence of expectoration in the second or third stage of a pneumonia, or if it becomes scanty and difficult, the prognosis is unfavorable. Any sudden suppression of the expectoration, with coincident tracheal râles, in any period of the disease, indicates impending death.

In adults delirium is an unfavorable symptom, except when it occurs at the onset of the pneumonia. When delirium occurs late in one who is the subject of chronic alcoholismus, it generally indicates a fatal termination. Convulsions in children with great jactitation, and in old age subsultus tendinum and a tendency to coma, are unfavorable signs. Great exhaustion and signs of prostration, accompanied by a sunken, pallid countenance and cold, clammy perspiration, are always attended with danger. In children bronchial breathing after the seventh day, numerous subcrepitant râles, copious and persistent diarrhoea, and swelling of the veins of the hands, are unfavorable.

In old age a sudden rise or fall in temperature, apathy, somnolence, and a {345} sallow countenance, are all symptoms indicative of great danger. Any complication renders the prognosis unfavorable, and the occurrence of pulmonary oedema or congestion in the unaffected parts of the lung is to be regarded as a forerunner of death.

Purulent infiltration, the formation of an abscess, and the development of gangrene are all attended with danger. Recovery from gangrene is very rare.

Death does not result from heart-clot, for the conditions which favor the forming of the clot precede its formation. The fibrin factors in pneumonia are increased--often 400 per cent. more than normal. The heart is so enfeebled that the right ventricle cannot empty itself; the columnæ carneæ and the chordæ tendineæ whip up the residual blood (already prepared for clotting). Heart-clot, it is well known, is the rule when the death struggle is prolonged and the cardiac contractions gradually become weaker and weaker. Such heart-failure is always the beginning of death.

In seeking for the causes of death in pneumonia, observers have taken the results of their post-mortems as a standard of their observations. One finds oedema of the lungs at the majority of his autopsies, another finds a clot in the heart in most of his fatal cases; hence the conclusion is reached that pulmonary oedema and heart-clot are causes of death in pneumonia. But it must be remembered that in every disease there is a great difference between the cause and the mode of death. If, as a result of the failure of heart-power during the last hours of life, pulmonary congestion and oedema are developed and clots are found in the heart-cavities, it ought not to be assumed that these conditions are the cause of death. Jürgensen states that in fatal cases of pneumonia oedema of the lungs is always present, and heart-clots are frequently met with.

Death may occur, then, from heart-insufficiency, from some of the complicating diseases (cardiac especially), or from asphyxia. In some cases death seems to come from the overwhelming of the system with a poison which acts primarily and principally upon the nervous system. In a few cases fatal collapse has followed an apparently regular, well-marked crisis.

TREATMENT.--The treatment of croupous pneumonia involves not only many unsettled questions in modern therapeutics, but it embraces a history of the therapeutics of inflammation. An heroic, antiphlogistic plan of one period gave place to the rational plan of another, and that in turn to the expectant plan of a later period, while to-day an antiseptic method finds many advocates.

Regarding it as a general disease with characteristic local lesions, and not a local inflammation with constitutional symptoms, its treatment must vary with the constitutional condition of the patient and the type of the disease. When uncomplicated and occurring at certain periods and in certain conditions of life, it will terminate spontaneously in recovery. But when certain complications exist and certain conditions are present, and at certain ages, it is almost necessarily fatal. Any plan of treatment in such a disease, if resorted to indiscriminately, must needs be unreliable and unsatisfactory.

Although there is no doubt that a large percentage of cases of croupous pneumonia will recover without treatment, there is also little doubt but that well-directed therapeutical efforts can save lives and render convalescence less tedious. If it is remembered in the treatment of pneumonia that the pneumonic lung no more requires treatment than do the intestinal ulcers in typhoid fever, and that we are to be governed by the patient's general condition, and not by the physical changes in the lung as indicated by the physical signs, it is evident that all those measures which have been employed for the arrest of a local inflammatory process have no place in our therapeutics. It is for this reason that venesection, which at one time had its stronghold in {346} the treatment of pneumonia, has now fallen into disuse. A summary of the arguments against its practice seems to be conclusive, and the numerous discussions that have so often distracted the most careful and truthful observers are well expressed in the following terms:[49] 1st. That indiscriminate bleeding immensely increases the mortality of the disease. 2d. That it is specially fatal in old people and in young children, in patients of exhausted constitutions, and in those suffering from chronic diseases, and particularly from Bright's disease. 3d. That it is absolutely unnecessary in the majority of cases of young adults and also young children. 4th. That in the majority of cases it has no influence whatever either in cutting short the disease, in lessening its duration, or in diminishing the pyrexia, but that occasionally these results appear to follow from its use when practised early. 5th. That in the majority of cases it hinders the critical fall of temperature and delays convalescence. 6th. That in the majority of cases, as shown especially by Bennett's and Didel's data, recovery is equally if not more rapid when it is not practised as when it is resorted to. 7th. That in a few cases a moderate venesection may be necessary in the early stages to avert immediate danger of death from asphyxia.

[Footnote 49: Wilson Fox, _Reynolds's System of Medicine_.]

Not only does indiscriminate bleeding increase the death-rate and have no influence over the progress, course, or severity of pneumonia, but it postpones crisis and convalescence, and in the old, young, and enfeebled is very often nothing less than a fatal procedure. In a robust, vigorous individual, in spite of the fact that a free bleeding at the very onset will temporarily relieve the urgency of some symptoms, it nevertheless diminishes by so much the chances of recovery, lessens the power to fight against the disease, and makes the patient far more pregnable to subsequent dangers and complications.

Venesection has no influence upon the temperature. It may sometimes postpone imminent death from asphyxia; and the fact that there is one condition in which bleeding may be practised is no contradiction to the foregoing statements, for venesection is then resorted to on account of conditions that must be treated independently of the coexistent pneumonia, such as sudden engorgement of the heart with blood, attended with all the signs of sudden and extensive pulmonary oedema and congestion. When the patient is vigorous and the above-mentioned emergencies exist, free bleeding gives prompt relief. In no case should more than ten ounces of blood be taken.

A careful study of the pathology of pneumonia not only leads one to the conviction that venesection must do harm, but it strongly contraindicates the employment of all those remedial agents which have been used to arrest a simple pulmonary inflammation. Hence tartar emetic, veratrum viride, aconite, and all other cardiac sedatives which at one time were used so extensively have now fallen almost entirely into disuse, as by their effects they can only add to the burden of a heart already overtaxed by the venous stasis and the lack of arterial blood. They may for a time lower the temperature and diminish the pulse-rate, but they will accomplish this at the expense of heart-power, and will almost certainly favor the earlier and more certain development of that heart-insufficiency which must be regarded as the most powerful death-producing agent in pneumonia. Dangerous collapse has frequently followed the free use of these drugs.

Veratria is claimed to be a cardiac depressant; and this fact should make us hesitate before we administer it in pneumonia. It acts promptly in slowing the pulse, but its effects are only temporary, and when used for a couple of days the larger doses that are necessary to bring about the desired results interfere with the nutrition of the patient, often causing vomiting and diarrhoea. Aconite is also a cardiac sedative, but my experience with it has {347} convinced me that it is in all respects inferior to veratria. Digitalis, which may be regarded as a cardiac stimulant, is to be preferred to either veratria or aconite. It not only lowers the temperature, but lessens the frequency of the pulse, steadies it, and produces in the majority of cases its well-known tonic action upon the heart. Its use in children is sometimes followed by an intermittent pulse, but it is a symptom of no dangerous import.

Calomel and antimony have been almost entirely discarded from the therapeutics of pneumonia: there is no evidence that the former has any influence either upon the progress of the disease or the absorption of the pneumonic exudation. Those who advocated its use believed it to be most advantageous after the patient had been freely bled and large doses of tartar emetic had been given. The latter was also a part of the treatment where bleeding was practised. It exercises a depressant effect upon the heart, and hence, although it may diminish the frequency of the pulse and lower the temperature temporarily, it is an exceedingly dangerous relief, as it is obtained at the expense of vital power. It is absurd, with our present knowledge of the pneumonic process, to discuss what was once claimed for tartar emetic--namely, that it had the power of arresting the pneumonic process as well as preventing pulmonary congestion in the unaffected portion of lung. These drugs, while they at best afford only temporary relief, require most careful watching to guard against their dangerous and prostrating effects.

Expectorants have no place in the treatment of pneumonia, as only a very small portion of the exudative matter in the lung is removed by expectoration. If mucus or other secretions accumulate in the bronchial tubes in sufficient quantities to cause inconvenience, it is in consequence of the exhaustion and a loss of muscular power which attend the disease, for which expectorants will afford no relief.

Counter-irritation, by blisters or other irritants applied to the surface of the chest in the earlier stages of pneumonia, is of questionable utility. Occasionally, blisters may be applied during the third stage to hasten the process of resolution and promote the absorption of plastic exudation. The application of leeches, followed by a linseed poultice or some other soothing fomentation, will often relieve the pain in the side which is so urgent at the onset of a pneumonia. If extensive pulmonary oedema occurs, dry cups applied to the chest will afford relief to the dyspnoea and temporarily remove the oedema.

It has come to be a quite universal practice in this city to encase the chest in a layer of cotton batting or flannel covered with an oil-silk jacket. While this procedure has no direct influence on the course of the pneumonia, it promotes diaphoresis and protects the surface from sudden changes of temperature, and is always grateful to the patient. It is especially serviceable in children.

A pneumonic patient should be kept in bed, as nearly as possible in a horizontal position. Every appliance for promoting rest should be employed. He should be cautiously moved for the necessary examinations of the chest, and should be kept as short a time as possible in a constrained position. If there are evidences of heart-failure, the sitting posture should be avoided and talking should be prohibited. The sick-room should be large, cheerful, and well ventilated, and its temperature should range between 65° and 70° F. In acute febrile disease there is no danger of catching cold from draughts, and the idea of the laity that the moment a person is sick or has a fever he must be put in a dark, close room is one of the superstitions of ignorance. Pneumonic patients always demand air, and the cooler the more grateful it is. Pure fresh air has a marked antipyretic power. It is a good rule to allow adults to regulate the temperature of the sick-room to suit their feelings.

One of the most important things in the successful treatment of pneumonia is a carefully-regulated diet. The food should be fluid or semi-fluid and {348} highly nutritious, such as milk, eggs, beef-tea, and concentrated meat-broths. Milk is to be preferred to all other forms of nutrition. It should be given in small quantities at short intervals.

When not contraindicated wine may always be administered with milk. Such administration of wine is not a part of the stimulating plan of treatment hereafter to be considered, but it is a means of increasing the digestive power of a feeble stomach.

If expectoration becomes difficult, it may be from a loss of muscular power in the bronchial tubes, when stimulants are indicated; or from extreme viscidity of the sputa, when alkalies will be of service. Just here it may be mentioned that alkalies and neutral salines possess a diuretic and diaphoretic power which often affords relief from the pungently hot skin, and may aid the elimination of effete material by the kidneys.

It should be remembered that in the treatment of croupous pneumonia we have to do with a self-limited, acute febrile disease, which usually runs a cyclical course.[50] Routine treatment is therefore always harmful.

[Footnote 50: Fernet ("De la Pneumo. franche aigue," etc. _Arch. gén. de Méd._, 1881, pp. 5-155) has demonstrated the regular and cyclical course of pneumonia. The evolution of the malady is represented by the march of the fever and is figured by the thermometric curve.]

The nervous shock which attends the ushering in of a severe croupous pneumonia is greater than in any other acute disease, unless it may be peritonitis, and the important question presents itself at its very onset, What measures shall be employed to overcome or mitigate the impression made upon the nerve-centres by the morbific agent which is operating to produce the pneumonia? The experience of the last few years leads me to the conclusion that during the developing period of the disease, when the pneumonic blow is first struck, and until the pneumonic infiltration is completed (usually for the first four days of the disease), if the patient is brought under the full influence of opium, and held in a condition of comparative comfort by hypodermic injections of morphia repeated at regular intervals, he is placed in the best condition not only for resisting the shock, but also for combating the activity of the pneumonia. Opium does not, when thus administered, interfere with a stimulating or antipyretic plan of treatment which may be demanded, but it does very greatly diminish the chances of heart-failure, cases often recovering under its use which from age and condition of life seemed hopeless. Then the great relief and comfort which it gives to the sufferer in the first four days of his struggles are sufficient to commend it, especially in those cases where pain is severe and the restlessness of the patient is exhausting.

After the pneumonic infiltration is completed opium should be administered with great caution, for paralysis of the bronchi (which it induces), and the consequent accumulation of secretion in the bronchial tubes, may greatly increase the already existing difficulty of respiration.

In all severe types of croupous pneumonia there are two prominent sources of danger: heart-insufficiency and high temperature. There are consequently two prominent indications for treatment--viz. to sustain the heart and reduce temperature.

A large proportion of deaths from pneumonia result directly or indirectly from heart-failure. Alcoholic stimulants, judiciously employed, are the most efficient means which we possess for sustaining a flagging heart, but their indiscriminate use is more dangerous than indiscriminate venesection. It may be that only a few ounces of brandy will be required to carry a pneumonia patient through a critical period, or it may be that its free administration will be required to save life. In the old and feeble, and in those who have been accustomed to the use of alcohol, stimulants may be indicated from the commencement of the attack, and their free use required throughout the whole course of the disease. Each case demands careful study. In no {349} other disease is so much discretion and judgment required in the administration of stimulants as in croupous pneumonia. The pulse, being the indicator of the condition of the heart, must be carefully studied. A frequent, feeble, irregular, or intermittent pulse always indicates heart-insufficiency. The quantity of stimulants to be administered in any case must be determined by their effect upon the pulse. It is advisable to commence their use in small quantities, and carefully watch their effects. If the effect is beneficial, a favorable result will follow within a few hours, and then the quantity to be administered can be increased according to the necessities of each case. It is seldom necessary to give more than six or eight ounces of brandy in twenty-four hours, yet if the necessity of the case demands it may be given in much larger quantity, twelve or twenty-four ounces often being required in twenty-four hours. A dicrotic pulse is a certain indication for the administration of stimulants.

The period immediately following the crisis is the one in which stimulants are usually most serviceable. Delirium is a symptom which calls for their administration, whether it is due to asthenia, pyrexia, or is an expression of blood-poisoning. When muscular tremor and subsultus tendinum are present, alcohol may usually be freely given. A critical collapse in the aged and weak, attended by great prostration and a subnormal temperature, is a condition in which alcohol shows its best effects, and the amount of asthenia will determine the amount of stimulation required.

It has been claimed that carbonate of ammonium in large doses stimulates the heart and prevents the formation of heart-clots by its action on the blood. The cause of heart-clot is the heart-failure, and there is no evidence that carbonate of ammonium prevents the coagulation of the blood when the blood-current is slowed. Besides, large doses of carbonate of ammonium irritate the stomach, and on this account interfere with nutrition, and thus diminish the chances of recovery. As a diffusible stimulant it is inferior to champagne. Moreover, champagne can be administered for a much longer period without causing gastric disturbances.

Camphor and musk have been highly recommended as cardiac stimulants, but they are inferior to alcohol.

Digitalis of late years has been extensively used to counteract heart-insufficiency, but it is very uncertain in its action in the heart-insufficiency of pneumonia, and has seemed to me more frequently to do harm than good. The nervous element of the heart-failure contraindicates its use.

The second important indication in the treatment of croupous pneumonia is to lower the temperature. The plan of applying cold compresses to the chest in pneumonia, though far from being a new one, still has its strongest advocates in the modern school of therapeutics. It is proposed to apply thick compresses wet in ice-water over the seat of the inflammation, changed every five minutes. Some use the Esmarch ice-bag for the same purpose. Patients who were moribund have, it is said, been revived by immersion in a cold bath. The advocates of this treatment claim that the temperature is lowered; that the patient experiences a feeling of relief during the bath; that the pain, dyspnoea, pulse-rate, restlessness, and severity of the attack are all ameliorated; and that the duration of the disease has been cut short by the continued use of cold baths or cold packs.[51]

[Footnote 51: Rules for the employment of cold as an antipyretic in pneumonia:

Cold Bath.--As soon as the axillary temperature in the evening rises above 103° F., place the patient at full length in a bath with a temperature of 70° F. or 80° F. Gradually lower the temperature of the bath by the addition of cold water or ice until the temperature of the patient begins to fall. It may be necessary to lower the temperature of the bath to 60° F. before the temperature of the patient is affected. After the temperature begins to fall, thermometrical observations must be taken every two or three minutes; the rectal temperature only can be relied upon. If the temperature falls {350} rapidly--that is, two or three degrees in five or six minutes--as soon as the fall reaches 102° F. the patient should be removed from the bath; if it falls slowly, as soon as it reaches 101° F. he should be removed and immediately placed in bed. The patient should never be kept in the bath until the temperature reaches the normal, for it continues to fall for some time after his removal from the bath, and he may pass from a condition of fever into a state of collapse. The duration of the bath should rarely exceed fifteen minutes. While the patient is in the bath cold should be applied to the head by means of a sponge or by an ice-bag.

In the young, the feeble, and the aged the duration of the bath should never exceed five minutes. Once commenced, the baths must be persisted in until the crisis is reached.

Cold Pack.--This is much less effective than the bath, but if the patient is too feeble to be moved it may be employed. The patient should be wrapped in a sheet wrung out of tepid water, and over this a sheet should be applied wrung out of ice-cold water; the latter may be removed as often as it becomes warm. Its application and removal may be continued until the desired fall in temperature shall be obtained.

Cold Compresses.--The method of applying cold compresses in pneumonia is as follows: A cloth of some thickness is to be wrung from ice-cold water and applied every five minutes to the affected side, or an ice-bag is employed instead of the compresses. It is claimed for this method that it not only relieves the local symptoms, but lowers the temperature and hastens the day of crisis.

If cold is to be applied to the chest, either moist or dry, all the disadvantages arising from repeated exposure and frequent changes of temperature can be avoided by the use of the rubber coil, and it should always be employed in preference to wet compresses.]

The experience of American practitioners, so far as I have learned, is against this plan of treatment. It is found that under it pneumonia is more liable to extend; that the shock of the cold to the surface causes a nervous depression from which the old and feeble do not rally; that although a reduction of temperature may be effected, heart-insufficiency is more rapidly reached and is more difficult to overcome. Besides, the statistical results of this plan of treatment are decidedly against its use. The above statements do not prohibit cold sponging of the limbs and face if it is grateful to the patient.

If the high temperature in pneumonia is due to rapid tissue-metamorphosis, the result of the action of some morbific agent in the blood, it follows that we must look for an antipyretic which can check this rapid tissue-change. It is claimed with reason that the sulphate of quinia is a sedative to the arterial system, and has a stimulating effect, sui generis, upon the capillary circulation; that it can arrest cell-development, and also check the amoeboid movements of the white corpuscles. Theoretically, therefore, it is a remedy par excellence for the lowering of the temperature in this disease; and clinically and empirically it has been found to reduce temperature more permanently and with greater certainty than any other agent. None of the objections brought against the other antipyretics can be urged against this one, for it possesses the twofold power of reducing temperature and sustaining the heart-power from its action on the nervous system. To act antipyretically, quinia must be given in large doses. From twenty to forty grains must be given within two hours, or the whole quantity may be given at a single dose. The greatest reduction of temperature will be reached in about seven hours after the quinia is taken.[52]

[Footnote 52: When quinia is employed as an antipyretic in pneumonia it must be given in large doses. The administration of two grains every two hours, or a larger quantity administered in divided doses within a period of twenty-four hours, will not act as an antipyretic; but from twenty to forty grains must be administered within a period of two hours. If the stomach is irritable, ten grains may be given every half hour until the desired quantity has been administered. Usually in from four to six hours after the antipyretic dose has been taken the fall of temperature will begin, and in about twelve hours it will reach its minimum height; then it will remain stationary from twelve to twenty-four hours. After the temperature has once been reduced by the quinia, its administration may be discontinued until the temperature shall again rise to 105°. As a rule, the temperature does not reach as high a point as before the quinia was administered. This mode of administering quinia rarely produces any symptom of cinchonism {351} other than transient deafness after the first dose. In a large proportion of cases the temperature by this method can readily be kept below 103° F.

In Ringer and Gill's experiments with quinia on temperature it took at least twenty grains to produce a fall of a degree. From fifty to eighty minutes were required before the fall occurred, and the effects lasted from forty-five minutes to three hours. Ringer states that in pneumonia the quinia does not readily pass out with the urine, but is delayed in the system for a considerable time.

Lately, antipyrine has been brought before the profession as a valuable and powerful antipyretic. I have used it in both private and hospital practice, and have found it a prompt and efficient means of reducing temperature. It has not seemed to me, however, to have any other beneficial effect either in mitigating the severity or shortening the course of the disease. In two cases its use was followed by collapse, which in one case terminated fatally. My experience has seemed to bear out the belief that this drug is a decided cardiac depressant, and I should for this reason consider it much less desirable as an antipyretic than quinia.]

During convalescence tonics and restoratives--iron, quinia, the mineral acids, cod-liver oil, or strychnia--should be administered, and the highest degree of nutrition should be maintained. If bronchitis complicates pneumonia, it may be treated with muriate of ammonium, ipecacuanha, and senega. If severe gastric catarrh occurs, hot fomentations may be applied to the abdomen, and calomel, followed by a saline purgative, may be administered.

Diarrhoea is rarely so severe as to require treatment; five grains of Dover's powder usually suffices to control it.

In the delirium which occurs in alcoholic patients small doses of the tartrate of antimony and potassium are said to be useful. I have controlled this form of delirium best with small doses of hydrate of chloral.

By some, camphor, musk, and turpentine are recommended during the stage of gray hepatization, but it seems to me that the requirements are far better fulfilled by alcoholic stimulants.

In the first stage of senile pneumonia an emetic, when not specially contraindicated, is given in the Salpétrière Hospital. The physicians of the Montpellier General Hospital regard ipecacuanha as an heroic remedy in senile pneumonia. The English regard nitrate of potassium as the most efficacious, while the Germans prefer hydrochlorate of ammonium. Antipyretics are rarely necessary in senile pneumonia; the most important thing is to sustain the heart by stimulants and concentrated fluid nutriment combined with iron and quinia. In senile pneumonia the diarrhoea occurring with the typhoid form must be promptly checked by vegetable astringents.

In children, as in old age, leeches and blisters should never be used. The whole chest should be enveloped in a linseed-meal poultice, to which some anodyne may be added (opium, aconite, or belladonna) if there is severe pain.

In asthenic pneumonia, in addition to the nutritious diet, burgundy, port wine, or brandy should be used, and stimulant embrocations should be applied to the chest. In children the state of the bowels must be most carefully watched. Stimulating expectorants are more frequently necessary than at any other period of life.

In conclusion, I would urge that all remedial measures which tend to paralyze the heart should be excluded from the treatment of pneumonia, and great care should be exercised not to over-stimulate the heart, for over-stimulation often results in paralysis. It must always be remembered that in the milder cases there is necessity for no treatment except a regulated diet and attention to those general hygienic measures which have already been referred to.

I shall not attempt to discuss the treatment of the complications which may occur in the course of a pneumonia, for it is impossible to even mention every contingency that may arise. The rule is to treat the pneumonia so long {352} as it is the controlling disease, and the complication when it shall have become the most prominent and dangerous element in any given case. In prolonged convalescence it is of the utmost advantage that the pneumonic patient shall have a change of scene and climate.

Antiseptics.--The use of antiseptics in the treatment of pneumonia has as yet given no definite results. I have employed hypodermically phenic acid after Declat's method in several well-marked cases of simple pneumonia, without being able to determine that the temperature or course of the disease was at all influenced by its use.

F. Schwarz[53] states that the very favorable results which he has obtained in croupous pneumonia can only be due to one thing--_i.e._ the specific action of iodine, which renders inert the exciting cause of the disease, which he regards as an organism, and that its efficacy is limited exclusively to the very early stage of the pneumonia. He believes that its action in acute lobar pneumonia is the same as Von Willebrandt claimed for it in typhus, typhoid, and in malarial fevers. He even states that he regards iodine as a genuine specific in pure uncomplicated croupous pneumonia if employed within twenty-four or thirty-six hours after the ushering-in chill, that hinders its development and arrests its progress.

[Footnote 53: _Deutsche medicinische Wochenschrift_, January, 1881, No. 2.]

After using benzoate of soda in diphtheria, scarlet and puerperal fever--drachm ij in the twenty-four hours--E. B. Cady[54] states that when an epidemic of pneumonia visited his town in Wisconsin he had equally good results from the similar use of this salt in pneumonia, cases recovering which had a temperature of 106° F. and 107° F.

[Footnote 54: _N.Y. Med. Record_, 1880, July, 3, "Benzoate of Soda in Pneumonia."]

Orth[55] has recently written an interesting account of the treatment of pneumonia (lobar) with iodine.

[Footnote 55: _Allg. med. Centr. Zeitschr._, Berlin, 1881, i. p. 181.]

T. H. Buckler strongly recommends its treatment with salicylate of sodium and fresh lemon-juice.[56]

[Footnote 56: _Phila. Med. News_, 1882, xl. p. 652.]

Phenic acid, boracic acid, and the salicylates are highly recommended by many as the best drugs in the antiseptic treatment.

{353}

CATARRHAL PNEUMONIA.

BY WILLIAM PEPPER, M.D., LL.D.

SYNONYMS.--Broncho-pneumonia; Lobular pneumonia. Although numerous other names have been used to designate this affection, it is undesirable to perpetuate them.

DEFINITION.--Catarrhal pneumonia is an inflammation of the parenchyma of the lungs, frequently bilateral, and affecting scattered groups of lobules, which may, however, coalesce, so that considerable areas of lung-tissue become continuously involved. This anatomical distribution explains the name lobular as opposed to that of the lobar or croupous form. As implied by its other titles, it has close associations with bronchial catarrh, and occurs nearly always either as an extension of inflammation from the larger tubes or in connection with capillary bronchitis. In consequence, it is often combined with pulmonary collapse, with which latter condition it was until recently confounded. The affected areas show lesions of the bronchioles, together with a morbid product filling the alveoli, and consisting in varying proportion of altered epithelial cells from the alveolar walls, of cells drawn by aspiration from the bronchioles, and of exudation from the blood-vessels. Catarrhal pneumonia may be circumscribed or diffuse, and acute, subacute, or chronic. Its course and duration vary greatly: at times it terminates fatally in a few days, or runs a lingering chronic course, while recovery rarely occurs in less than fourteen days. The mortality is always considerable, and it acquires additional gravity from its tendency to leave behind it organic lesions of the lungs or even to induce phthisis.

ETIOLOGY.--As catarrhal pneumonia is so closely associated with bronchitis, and so commonly preceded by it, it may be premised that all the causes of bronchial catarrh must be considered as liable to induce this form of pulmonary inflammation, whether they do so by exciting bronchitis, which subsequently extends to the alveoli, or whether, as more rarely happens, they affect simultaneously the lining membrane of the bronchi and of the lobules.

There are, however, several influences which must here be carefully considered, since they have a special tendency to determine the production of the more grave form of disease.

The effect of age in predisposing to catarrhal pneumonia is undoubtedly great, and yet it seems to have been often over-estimated, since by many this has been regarded almost as a disease peculiar to childhood. The great frequency with which young children were formerly held to be affected by this form of pneumonia has, however, been found to be due in part to the fact that many cases of pulmonary collapse were included with it; while, on the other hand, there is strong reason to believe that the frequency with which adults are attacked has been greatly under-estimated in consequence of the failure on the part of the profession at large to clearly recognize this affection. It seems in the highest degree important that more {354} correct views on this subject should be generally received. While it is probable that the more severe and widely-disseminated pneumonias of catarrhal type are commonly recognized now-a-days, it appears undoubted that in very many instances of apparently mild sickness, of acute or subacute character, which are regarded as simple febrile colds or as the result of malaria, the true condition is one of circumscribed catarrhal pneumonia, which, while threatening no immediate danger to life, may if neglected leave lesions of grave significance. Still, it is undoubted that it is during the early years of childhood, and particularly the first five years, that catarrhal pneumonia, and more especially its grave and fatal form, is of frequent occurrence; while the period of next greatest liability is at the other extreme of life, among aged and debilitated subjects.

Under the head of Pathology we shall have occasion to dwell on the relations between defective respiratory power, pulmonary collapse, and catarrhal pneumonia; and it is evident that this connection helps to explain the relative frequency of the latter in early childhood, when conditions of debility are so common, and when rickets not rarely is superadded as an important factor. Another potent cause of the liability of young children to catarrhal pneumonia is the prevalence at that period of life of the infectious diseases, which are apt to be complicated with bronchitis, and which then present a combination of conditions favoring its development. This is especially true of measles, of whooping cough, and of diphtheria, while influenza, which is also frequently complicated with this form of pneumonia, is operative at all ages. Among predisposing causes which operate chiefly at a later period of life must be mentioned organic diseases of the heart and vesicular emphysema. The latter especially has shown itself important in our experience, both as predisposing to the occurrence of catarrhal pneumonia and as adding to the gravity of the attack.

Unquestionably, all states of bad nutrition and depressed vitality render the system much more liable to attacks of catarrhal pneumonia. The bad air of crowded houses or of ill-ventilated public institutions, especially if conjoined with the effect of improper food and of other defects of hygiene, plays an important part in inducing the fatal forms of this disease which are common among children exposed to such conditions. It is equally evident that among adults the effect of overwork, with insufficient sleep and outdoor exercise, is to develop a peculiar sensitiveness and weakness of system which make the ordinary causes of bronchitis capable of exciting a deeper and more serious catarrh. Finally, there are many individuals who possess a catarrhal diathesis--that is, in whom the epithelial layers are especially vulnerable, and when attacked are especially prone to take on cellular proliferation of a deep-seated and obstinate character. Such constitutions, which are frequently found in the subjects of phthisical heredity, furnish a ready soil for the development of catarrhal pneumonia.

Nor must the practical lesson be here overlooked that when acute or subacute bronchitis exists, an additional motive for prompt and thorough treatment is to be found in the fact that undue fatigue or exposure may be followed by an extension of the inflammation and by the onset of catarrhal pneumonia.

PATHOLOGY AND MORBID ANATOMY.--Allusion has already been made to the relation existing between catarrhal pneumonia and collapse of the lung; and the present seems to be the proper place to speak more fully of it, since in order to appreciate the lesions in any case it is necessary to distinguish between those which are the result of the inflammatory process and those which can be explained by simple collapse of the lung-tissue. It is indeed true that in some cases the development of catarrhal pneumonia takes place in areas already the seat of collapse. This is only what would {355} naturally be expected. For the production of both conditions the existence of preceding bronchial catarrh is, if not necessary, at least highly favorable. The folds of the swollen mucous membrane of the smaller tubes come into contact with each other, or else the diminished lumen of the tubes is occluded by the viscid mucus formed as the result of the catarrh. The normal activity and rhythm of respiration is disturbed by the fever and the lowered innervation. During expiration more and more of the air escapes from the alveoli of the affected area through these partly-obstructed tubes, while during inspiration, owing to the less force of that part of the respiratory act and to the shape of the bronchial tree, air cannot enter to replace it. Thus, or by the action of a plug of mucus in a conical bronchial tube, serving as a ball-valve, a condition of airlessness or of collapse is induced in a more or less extensive area. It is not, indeed, to be supposed that the mere occurrence of such collapse serves in any way to excite inflammation of the alveoli. But at the same time it is evident that there will be a strong likelihood that the catarrh which has advanced so deeply into the finer tubes will extend in some spots to the alveoli, and consequently that in a collapsed area of some extent there will be one or more foci of pneumonia developed. Moreover, it must be remembered that the collapsed lung-tissue becomes more or less hyperæmic and disposed to take on inflammatory action, and that the irritating bronchial secretions, the suction of which into the alveoli plays an important part in these affections, would necessarily be less apt to be dislodged by cough and expectoration from areas which had become collapsed. On the other hand, it is evident that when areas of catarrhal pneumonia have occurred directly from extension or establishment of catarrh in air-containing alveoli, the conditions will exist which favor the development of collapse in the surrounding zones of lung-tissue. Thus it happens that while the lesions either of collapse or of catarrhal pneumonia are found separately, it is common to find more or less evidences of alveolar inflammation in connection with collapse, especially if it has lasted any length of time; and still more common to find a considerable proportion of collapse coexisting with catarrhal pneumonia.

A simple practical rule must therefore be here insisted upon: that in all post-mortem examinations of the lungs in cases of catarrhal pneumonia, after careful study of the external appearances, a moderate inflation by means of a blowpipe must be practised, and the effects of this upon the consolidated areas be carefully studied before the lung be incised, in order that any element of collapse may be recognized and eliminated.

The external appearance of the lungs usually presents evident lesions. There are patches or layers of soft lymph on the pleura over the affected areas, and when the former are removed the serous membrane is found roughened, congested, and ecchymosed. On the other hand, while the pleura over a collapsed patch usually presents small ecchymoses, there is rarely any evidence of inflammation. More or less evident signs of vesicular emphysema are also usually present, bearing some proportion to the extent of the pulmonary collapse. When the areas affected are small and scattered, the emphysema is limited to their neighborhood; but when, for instance, both lower lobes are extremely involved, the upper lobes may present a high degree of emphysematous distension. In rare instances subpleural emphysema, from separation of the membrane over a pneumonic focus, may be observed; and even, as in a case published by me some years ago,[1] perforation of the separated pleura may occur, leading to pneumothorax.

[Footnote 1: _Philada. Med. Times_, Aug. 15, 1872, p. 425.]

After section of the lungs there will always be found lesions of the bronchial mucous membrane, which presents evidences of catarrh extending as high as the trachea or larynx in some cases, but habitually growing more {356} intense in the finer tubes, where the membrane is reddened and swollen. Frequently the infiltration extends throughout the structure of the bronchial walls, so that the tubes stand out prominently above the surface of the section. Delafield[2] has insisted with especial emphasis upon these alterations in the bronchial walls, and on the view that the inflammation extends from the bronchi, not to the group of air-vesicles into which they lead, but directly outward to the peribronchial zones of lung-tissue. In severe cases of longer standing the bronchial tubes often present in addition dilatations, either cylindrical or more rarely globular.

[Footnote 2: "The Pathology of Broncho-pneumonia," _Medical News_, Nov. 15, 1884, p. 534.]