[Reprinted fromThe PhiladelphiaPolyclinic,Vol. VII, Jan. 22, 29, 1898, Nos. 4, 5.]

ON THE NATURE AND TREATMENT OF PNEUMONIA. 1

SOLOMON SOLIS-COHEN, M.D.Professor of Clinical Medicine and Therapeutics in the Philadelphia Polyclinic, Clinical Lecturer on Medicine in the

Jefferson Medical College, Physician to the Philadelphia Hospital, etc.

By pneumonia, I mean croupous or acutelobar pneumonia, a disease which in mostcases is to be ranked among the infectiousfevers, having adefinite locallesion. The oldname “lung fever” is much more appropri-ate than the designation pneumonitis, which,for a while, held sway in our modern patho-logic nomenclature. There are cases of in-flammation of the lungs, pneumonitisproperly so-called, which result from trau-matism, from exposure to cold, from inhala-tion of smoke, steam, overheated air, andthe like, just as similar causes excite inflam-mations elsewhere. But the disease to whichI refer at present is caused by infection, thebarriers of normal resistance having beenbroken down by general disease or by specialaccident. It exhibits many varieties to whichI can refer only in passing. Whether or notthe so-called pneumococcus is the infectiveagent lamby no means satisfied; much of ourmodern bacteriologic etiology and pathologyis vitiated by sweeping conclusions from in-sufficient evidence, and by the logical fallacyof petitioprincipii- —begging the question, orreasoning in a circle. But be this as itmay, normal resistance being at fault, infec-tion takes place in some way and throughsome agent, and is followed by intoxication;concomitantly with which, structural changestake place in and around the pulmonary alve-oli, involving a greater or lesscontinuous area;usually, but by no means invariably, in alower lobe. These changes, while analogousto those which we call inflammatory, will, Ithink, in the further course of science beclassed together with those changes whichtake place in the intestine in typhoid fever,in a distinct species, if not genus.

The point to which I desire to direct yourattention now, is their analogy with the in-

Remarks made at the Polyclinic Hospital.

testinal lesions of typhoid fever, as constitut-ing not the disease itself to which the febrileand other general symptoms are secondary,but merely the anatomic expression of aspecial form of infection which likewisemanifests itself by general intoxication, giv-ing rise to fever, dyspnea, and disturbedaction of the heart. The dyspnea and thecardiac disturbances are increased by the factthat this anatomic lesion of which we havespoken involves an important portion of therespiratory apparatus, and mechanically inter-feres with the balance of circulation. Wehave, therefore, two main conditions to dealwith ; First, the intoxication with its fever,prostration, delirium and other nervous con-comitants, including dyspnea and circulatoryimbalance ; and secondly, the mechanical re-sults of pulmonary consolidation—diminutionofair space in the lungs, blocking of a largerorsmaller portion of the vascular canal, and,as results of the action and interaction ofthese conditions, imperfect purification ofthe blood, and opposition to the action ofthe right heart, increasing the respiratory andcirculatory disturbance.

While, therefore, intoxication and its re-sults must receive primary attention, themechanical phenomena spoken of, involving,as they do, two physiologic systems of thehighest importance, must receive proper con-sideration. In a strong patient seen early,I have no hesitation in commending resort tovenesection. The removal of, say, sixteenounces of blood, removes considerablepneu-motoxinm&, likewise, relieves themechanicalcongestion of the lung, favoring the earlytermination of the local process. So, too,in a case not in its earliest stage, in whichthe right heart is laboring against pressurewhich it can scarcely overcome, the relief

afforded to this viscus by depletion of thegeneral venous circulation is sometimes suffi-cient to turn the scale in favor of recovery.

This fact is not to be proved either by therelation of individual cases or by the mass-ing of statistics. No case-description canconvey to another the impression made uponthe observer either of the dangers threatenedor the relief afforded ; while statistics, includ-ing as they do casesof great variety in causa-tion, course, complications, environment,including season and weather, to say nothingof age, sex, temperament, personal idiosyn-crasy and the like, are utterly without valueto the thinking mind.

However, it is in the smallest proportion ofcases of lung fever that venesection will findan appropriate place. In the majority ofcases other measures will be more rational ormore successful. I do not agree with myfriend, the distinguished teacher, who in hisgreat treatise on the practice of medicine in-timatesthat the mortality of pneumonia, takenby and large, is at all events not diminishedby any method of treatment hitherto em-

ployed. Nevertheless, I believe that we can

trust much to nature—that is to say, to theinherent recuperative tendencies of the humanorganism; seeking to discover the coursewhich these take and interfering only whenthat course seems to be departed from in theindividual case. On the other hand, if byany means in our power we can facilitatethe natural evolution of the disease towardrecovery, such measures are eminently ap-propriate.

The febrile temperature is one of the mostimportant indications in this connection.When, in acute infective pneumonia, thetemperature is low, the usual inference is thatintoxication is profound and vital reactionimperfect; while, on the other hand, an ex-cessively high temperature indicates a severeinfection with violent reaction and corre-sponding danger. Both extremes, therefore,awaken solicitude on the part of the physi-

cian. An average temperature of 102.50 to104° F. is the most favorable.

Cases with what we may call the tempera-ture of depression, need more than usuallycareful watching in respect to diet and togeneral environment, and call for the ad-ministration of supporting and stimulatingremedies, such as strychnin, camphor, am-monia, and in some instances alcohol, to-gether with the early and sufficient use of

' oxygen by inhalation, and the most scrupu-lous avoidance of those sudden changes ofposture and the like which are likely toadd to the disturbance of the vascular equi-librium. In the aged, the application ofexternal heat is sometimes useful—not merelyto raise temperature, but to counteract thedepressing effects of the causes of lowertemperature. In cases showing violent tem-perature, cooling applications may be neces-sary to counteract the effects of excessiveheat upon the nervous system; and thesemay take the form of the cold bath, the wetpack, the ice pack to the chest, frequent coldsponging or cold compresses, as advised byDr. Baruch, according to the circumstancesof the case and of the nursing.

In the moderate cases my own preferenceis—apart from the necessary sponging forcleanliness and stimulation of the skin—forthe external application of heat and moistureover the chest, as accomplished by the old-fashioned jacket poultice, although in thesecases, the compresses advised by Dr. Baruchalso seem to serve the purpose admirably.This purpose is neither the elevation nor thereduction of temperature, but action uponthe vascular system—upon the “skin heart”—relaxing the opposition to cardiac action,increasing the tone—not the tension—ofthe vessels both by local and reflex effectand thus directly or indirectlyrelieving a por-tion of the mechanical difficulty ofcirculation.In these cases, also, the internal administra-tion of strychnin is useful, though alcohol israrely necessary.

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In all cases, careful attention to the excre-tions is required. Free diuresis, diaphoresis,and purgation are to be encouraged, if neces-sary, by the use of calomel, of saline cathar-tics and diuretics and by external applica-tions to the skin, the nature of which is to bedetermined by considerations previously re-ferred to—that is to say, warm or cold spong-ing, poultices, or moist compresses.

I am in the habit of administering a stimu-lant expectorant mixture in somewhat of a

routine fashion to most patients with pneu-monia, and I think the practice is a goodone, though rather on empiric, than scientificgrounds. In other words, observation showsthe practice to have good effect, though Icannot frame a theory to explain this effectcapable of successful defense against all as-saults. By experience I refer not to my in-dividual experience only, but to the tradi-tions of the profession. The formula I usemost frequently is about as follows:

Ammonium chlorid .,

. .10 grains.Ammonium carbonate

... 5 grains.Ammonium salicylate ... 5 grains.Fluid extract of coca .

. .. 1 fluidram.

Essence of pepsin ..... 1 fluidram.Sirup of tolu I fluidram.Water I fluidram.

Mix.To make a tablespoonful,which is to be given with

or without water every second to fourth hour.

The object of the coca is to disguise thetaste, of the pepsin to prevent nausea, of thesirup to render the dose a little more smoothand palatable ; and any of these, therefore,can be substituted by whatever individualfancy or experience may suggest. Licorice,as all know, is often an acceptable meansof disguising the taste of the ammoniumsalts and acacia frequently serves better thansirup. Coca has, however, some actionupon the heart and kidneys, which is addi-tionally useful; and spirit of nitrous ethermay be added for diuretic effect if deemedneedful. One can, if he chooses, add nuxvomica and digitalis to this mixture, thoughas regards the former drug I prefer to give

strychnin separately, so that the size and fre-quency of doses may be varied according tocircumstances; and as regards the latterdrug, I seldom use it in the treatment ofpneumonia. There are cases, however, inwhich it is useful as a cardiac tonic, espe-cially in the middle period of the disease andagain after resolution has occurred.

Of drugs designed to act upon the heart Ipreferaconite and nitroglycerin ; the first hasusefulness only before consolidation, as in-dicated by bronchial breathing, has takenplace. It is, however, undoubtedly usefulduring the preliminary stage of congestionin which the crepitant rale is heard. Itprobably acts mechanically. Nitroglycerinfinds its use during the stage of hepatization,to relax the vascular channel generally, bothpulmonary and systemic, and in that way,in some measure obviates the necessity ofvenesection. It should be given as spirit ofglonoin in drop doses every hour at first,until the patient’s susceptibility is ascertained,when the size of the doses and the intervalsshouldbe regulated accordingly. One judgesby the effect upon the tension, force andfrequency of the pulse, and by the conditionof the right heart.

I have referred to the use of oxygen by-inhalation. Let me now repeat and empha-size the recommendation. It undoubtedlysaves life in many cases; but to do this itmust be given promptly and persistently. Towait until a patient is moribund and thenattempt to revive him with a few cubicfeet of oxygen forced into his lungs wouldbe ludicrous, were it not so serious. Oxygento be useful must be given so soon as thethought that it may be necessary enters thephysician’s mind. That thought will besuggested by the respiratory distress, and bythe extent of local lesion as demonstrated byphysical signs. Observe, please, that theseare not identical conditions, nor conditionsinvariably associated. It is true that exten-sive lesion will usually cause great embarrass-

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ment of breathing j but frequently there is adyspnea of nervous origin, with comparativelyrestricted local lesion. Often after the crisis,resolution not having occurred, local lesionremaining, extensive dyspnea will have van-ished ; an evident proof that it was not ofmerely mechanical origin.

Now either condition, whether severenervous dyspnea—pneumoparesis—which isespecially associated with the pneumonia ofinfluenza, or great mechanical difficulty ofbreathing, or their combination, calls for thetimely and sufficient use of oxygen.

The air-current, doubly necessary in acondition of intoxication, is diminished, oxy-gen is not supplied in necessary quantity, thenecessity for a more concentrated respiratorypabulum is manifest. Pure oxygen is usuallybest ] in some cases its combination with asmall proportion of nitrous oxide answers.It has been advised to heat the oxygen, butpersonally I have seen no better results withthe heated gas than with the unheated gas.Recently-evolved oxygen is preferable tostored oxygen, and there are in the marketsome quite readily available forms ofapparatusfor its production, of which Wallian's seemsthe most convenient. The compressed gas,however, is usually better managed by nurses,and will serve the purposepn most cases.

In the apparatus that I employ, the gas,which is chemically pure, but diluted withabout 5 per cent, of air, owing to the methodof storage, is furnished in cylinders contain-ing i oo gallons. From the cylinder outlet,which is controlled by a key, it passes to asmall rubber bag and from this to a quartwash-bottle, about one-third filled with water.Bubbling continuously through the water,as it overflows the bag, it passes through rub-ber hose and hard-rubber mouth- or nose-piece into the patient’s throat, by way ofthe mouth or nasal chamber. When thepatient is comparatively strong the pressureis so adjusted tnat a Slight inspiratory effortis necessary to bring the oxygen over, anddaring expiration the current ceases. But

in the vast majority of cases, the gas is al-lowed to flow over gently but continuously,no attempt being made to check the currentsynchronously with expiration. Oxygen isthus wasted, but life is often saved.

The administration of oxygen is kept upfor from ten minutes to thirty-six hours ormore, uninterruptedly, according to circum-stances. If begun in time, it will usually befound that one-half hour’s continuous inhala-tion, repeated every second hour, will suffice.I have known it to be ordered for 10 minutesat a time, three times daily, or perhaps everyfourth hour, in a serious case. This issimply tomfoolery. In a desperate case theoxygen must be given as nearly continuouslyas possible until relief is manifest. Whenthe patient is unconscious, nasal delivery isusually the better method. Hard-rubbernozzles are preferred to avoid danger ofbreakage by unconscious movements of thepatient. The apparatus shouldbe thoroughlydisinfected after each case, so that it goesnot only mechanically, but medically cleanto the next case.

Conjointly with the inhalations ot oxygenin severe cases, it is usually necessary to givestrychnin nitrate hypodermati ally. say -jLgrain, every second to sixth hour, accordingto results. These cases,too,usually call for thesufficient use of nitroglycerin or amyl nitrite.Not rarely I use a mixture containing am-monium carbonate five grains, with amyl ni-trite three drops, in a fluidram each of gly-cerin and alcohol, every second or thirdhour, as suggested by B. W. Richardson.In these bad cases, too, time for natural re-covery is sometimes gained by temporarystimulation of the heart, as with cocain,musk or camphor, preferably under the skin.

In regard to the various complications thatmay occur in pneumonia it suffices to saythat they are to be met, as they arise, ongeneral principles. That means that there isto be no unnecessary interference ; but wheninterference is needed it is to be prompt andbold.