plan of prevention, are the two problems that are up to us 'today for solution. Can we solve them? BIBLIOGRAPHY I. Progressive Medicine, Vol. VI, No. 1, page 152. 3. Jour. A. M. A., July 5, 1902. 4. Jour. A. M. A., August 19, 1899. 5. Jour. A. M. A., June 15, 1901. 6. Progressive Medicine, Vol. VI, No. 1, page 152. 14. Therapeutic Gazette, December 15, 1903, page 795. FOR DISCUSSION SEE PAGE 81 PNEUMONIA: PROBLEMS IN TREATMENT J. B. MCGAUGHEY, M. D. Winona Acute lobar, croupous, or fibrinous pneumonia, to which attention will be limited in this paper, owing to its frequent occurrence and large mortality, presents features of peculiar interest to the general practitioner. It has been charged that the number of deaths from this disease for years past has been constantly increasing, and statistics have been furnished in support of this charge. Death reports, however, are proverbially unreliable. Observation affords abundant evidence that deaths which have resulted from tuberculosis, septicemia, alcoholism, and various other affections have been ascribed to pneumonia. There are no well established grounds on which to base a belief that pneumonia is more fatal now than it was forty years ago, and unfortunately proof is wanting to sustain the assertion that modern methods of treatment, or non-treatment, if you please, have been attended with a larger percentage of recoveries. Pneumonia was formerly regarded as a simple inflammation involving the tissue of the lung or lungs. At the present time it is almost universally believed to be an infectious disease caused by the action of micrococcus lanceolatus, which not only excites the inflammation of the lung, but develops toxines that contribute greatly to the febrile reaction and general disturbance of the system, the effects of which closely resemble those resulting from various septic influences. The first change which takes place in the lung is that of engorgement, speedily followed by the so-called red hepatization, in which the function of the part involved is arrested. This is succeeded by gray hepatization, which in turn in favorable cases gives way to resolution, the stage in which the inflammatory products are absorbed or expelled and the integrity of the lung more or less perfectly restored. It should be borne in mind that frequently, if not usually, in the second and third stages there is a zone, often of considerable extent, outside the hepatized area in which there is active congestion. Here the function of the part is not entirely suspended, but its usefulness is seriously impaired. The various stages are not clearly defined and it is not unusual to find engorgement, red and gray hepatization coexisting in different parts of the same lung. This brief outline of the changes which take place gives a fair exhibit, for practical purposes, of the conditions found in an uncomplicated case of pneumonia. It may be remarked in passing that though the germ of pneumonia from choice seems to select the tissues of the lungs as the field of its work, it not infrequently invades other structures, in some of which its destructive action is pronounced. Recent investigations have shown that the microbe may be generally, if not always, found in the blood of the patient suffering from pneumonia. The lay press has recently given wide publication to a statement alleged to have been made by a prominent physician to the effect that there is no established successful treatment of pneumonia. From the comments made, it is clear that this has been interpreted as implying that treatment avails nothing, and the service of the physician is of no value in this disease. Few or none will assert that specific remedies are known. However lamentable it may be, the fact remains that the number of diseases that can be cured by the exhibition of specifics is very small, but in many of those not amenable to remedies of this class, as in pneumonia, the care and advice of the intelligent physician is often most valuable. The treatment is necessarily symptomatic, but this, properly administered, is frequently attended with as much success as follows securing an artery for the arrest of hemorrhage, which, if neglected, would prove fatal. The service of the medical attendant is often beneficial in preventing the adoption of measures and treatment which would result in injury, if not disaster, to the patient. In this disease, as we have seen, the portion of the lung affected during the second and third stages is functionally useless. Lung tissue beyond this is engorged and capable of performing only a part of its duties. The circulation through the lungs is carried on imperfectly and with difficulty, the supply of oxygen to the blood is diminished, and the general system suffers from poisoning produced by the toxines of the pneumococcus upon which the disease is dependent. These conditions all exist in a typical case, and afford in themselves abundant problems in treatment. Complications frequently occur. Specifics that will meet all requirements may be found, but the discovery can only be made in the future. Pneumonia is a self-limited disease, and in it, like others of its class, we may expect recovery provided the strength of the patient can be maintained and complications avoided Owing to the physical changes in the lung it is clearly apparent that increased work is placed upon the right side of the heart, that there is more or less venous plethora, and a corresponding reduction in the quantity of blood in the arteries. Attempts to correct this want of balance have been made upon two lines, and each seems to have been attended with a degree of success. In the first method adopted, relief of the venous engorgement is attempted by the abstraction of blood. This measure applied early in sthenic cases has much to commend it. The second seeks to accomplish substantially the same result by reducing the force of the heart's action by the aid of depressents, such as veratrum viride, tartar emetic, or aconite. The value of this course is sustained by the testimony of many observers whose honesty and capability command respect, and whose conclusions should not be dismissed without critical examination. The advocates of each system placed their favorite almost, if not quite, in the rank of specifics, and insisted upon an universality of application which time and experience have condemned. In order to properly care for a patient suffering from this disease the attending physician should acquaint himself as fully as possible with the history and habits of the affected person, and the stage, as well as the existence, of pneumonia. Each individual requires special study, as the habits of the patient may, and often do, determine the result. Pneumonia. in an alcoholic subject is always attended with great danger. The prognosis in the immoderate consumer of beer is even more grave than in those who use the stronger alcoholics to excess. Delirium tremens supervening upon pneumonia often proves fatal. Pneumonia appearing in the course of the former disease generally terminates in death. Plethora, if extreme, adds to the perils of the disorder. The same is true of lesions of the kidneys and organic heart changes, though persons suffering from advanced cardiac disease occasionally make surprising recoveries. Rational treatment will be largely influenced by the stage of the affection. That adapted to the early stage of engorgement would be ill fitted to counteract the depression often witnessed at the crisis. There are few general rules applicable to the treatment and these pertain to hygiene rather than to the administration of drugs. The room selected for the patient should be large and well ventilated, the temperature should be maintained at about 70 degrees Fahrenheit. Rest should be enjoined, and all unnecessary attendants, visitors, or other oxygen-consumers should be excluded. Free action of the kidneys should be secured, and while drastic cathartics should be avoided proper evacuation of the bowels is of great importance, as tympanites, or distension of the bowels from any cause, impedes respiration. There is also the additional danger of increased constitutional disturbance from auto-infection or intoxication caused by retained excreta. These measures may be, and often are, all that are required in caring for ordinary cases. Many recover with even less attention than is recommended in the foregoing. |