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gave us more details along the same line. Koch, Freidland, Leyden and others have gone over the trail, each adding their mite to the theory advanced by Klebs.
Sternberg, by carefully conducted experiments, showed that pneumococci were to be found in the normal human saliva; and as has proven the case with the germ theory in other instances, we must search for some other cause to explain its occasional virulence. Dr. Jacobi has denied in toto that pneumonia must necessarily be a bacteric process.
For me to give a complete description of a disease like pneumonia, I would take up much time that properly belongs to others, for it is not possible to do so within the limits of a paper like this. I look on pneumonia as a self-limited disease; but should be helped over the severe places by the skilled physician. He should conserve the strength; guard carefully the heart, and by every possible means endeavor to diminish the toxins.
Pneumonia generally begins in the lower portion of the lung (not the bottom), but below the upper half and spreads both ways; it may cccupy one lobe only, or it may pass the septum and occupy a second lobe, or it may invade the whole lung. The right lung is most frequently involved; the ratio being, perhaps, about 1 to 3. The disease is more prevalent among males than females, and it appears that those between the ages of 36 and 40 are more susceptible to the malady. The months of December, January and March are apparently most favorable for the development of the disease, with May and June next in order. While it occurs at all seasons of the year, it is most certainly more common in the colder months. It behooves the physician to be on guard when it comes to pronouncing pneumonia of a special type, unless he has experience back of his opinion. An examination, a thorough one at that, both as regards objective and subjective symptoms, must be made, for remember that no sharp line exists between the ending of a bronchitis and the beginning of capillary or catarrhal pneumonia. Depend always on a physical examination as being of
the most importance. Children as a rule, under six years of age, have capillary or catarrhal pneumonia-from six to sixteen it is generally croupous, whilst with the adult is it usually lobar. I have already defined pneumonia, and now will give you, in brief, the symptoms. There are a few points that perhaps I may bring out in this paper that are not common (?) with the standard textbooks; I am familiar with them and know they are correct; for that reason I will not apologize for my position.
One of the first physical signs in pneumonia is a fine crepitation, the same that is found in the smaller bronchial tubes in bronchitis. Now, understand me, at this point I can not, neither can you at this stage, make a distinction between bronchitis and pneumonia. Some of you may dispute this point with me, but that will not change my opinion in the least. The physical signs are not distinct enough for me to be positive, so I will use caution; the process of filling the air cells is steadily going on, and will continue for a day, or perhaps a day and a half; and during this time until the cell is filled (at which time the air is excluded entirely) you will continue to have this crepitation; you will get this crepitation only on inspiration, and you may have to tell your patient to cough and then listen to the inspiration before the cough, which will be a deep one. Now, you will understand that after the cell is filled with fibrinous material, no more air can enter; therefore, no more crepitation, unless we have an accompanying bronchitis; but you get another sound-a breath sound, and also a voice sound. If any of you have ever heard Dr. Loomis, or Dr. Stephen S. Burt, of New York, lecture on physical diagnosis, you will recall their description of those sounds, and their importance their descriptions were identical, for Burt was a student of Professor Loomis. Both of these sounds are readily detected. Two things now must be borne in mind, for an opinion is being given—perhaps to a circle of anxious friends. The crepitant rale in pneumonia and the crepitant rale in bronchitis may mislead, and give a very uneven road to make the return trip over, for sometimes these return trips are not at all pleasant. Quite often I have made my return from impor
tant cases of this sort and found the traditional maiden with her song and tambourine conspicuous by her absence. But if one is guided by this one rule, he may consider himself reasonably safe. The crepitant rale in pneumonia occurs only in one lung, at first at any rate, for should we have double pneumonia, it will not begin in both lungs at the same time. If double, it will develop in one lung a day or two before it occurs in the other. The crepitant rale in bronchitis is always double. There is resonance on percussion in bronchitis, but no dullness. A cough is not only almost constant, but it is generally one of the earliest symptoms, and among the aged bronchitis commonly precedes pneumonia. The respiration in pneumonia is always out of harmony with the pulse rate. Often a patient will present the symptoms of an engorged lung; sluggish brain; dull intellect, etc., with a pulse rate of less than 100, and a respiration of 50 or 60, or more per minute, and exceedingly shallow. Sputa is generally an early symptom, but not always-cases occur where there is little or none until the disease is well advanced. When the disease is in the apex of the lung, expectoration is scant compared to that at the base of the organ. Children under six years of age rarely expectorate, and with the adult it often ceases when approaching a fatal termination.
The circulatory system must receive direct attention, for I have not what is commonly called a weak heart, but an engorged heart; and when the pulse rate steadily advances with the disease, it bodes no good, especially if it reaches 130 or upward in the adult. A high rate, 140 or 160, with children is not so dangerous, but it means much with the patient who has reached the adult age.
The mortality in pneumonia is much gerater some years than in others. Why, I am not prepared to say. The mortality for the State of New York, during the year 1878 I believe, was one death out of every fourteen from all other causes; and these figures will hold good generally for nearly all New England.
It is the opinion of the writer, though I may not be able to prove it at present, that atmospheric influences cause a catarrhal hyperemia of the bronchial mucous membranes that is preparatory
for the poison of pneumonia, and that there is no pneumonia without this preparatory condition. Pneumonia is not due to weather influences alone, but they have a decided influence in the origination of the disease.
In mild, uncomplicated cases, I do but very little. I let the patient alone as far as possible; conserve the strength; guard the heart and endeavor to hold the temperature within the bounds of reason; try to make the patient as comfortable as possible; see that the room is well ventilated, so that the patient can get an abundance of pure, fresh air. In order to keep the air as pure and free from contamination as far as possible, see that the number of attendants are as few as possible; endeavor to keep the temperature as uniform as possible about 70 degrees; give the patient plenty of pure cold water, which serves to quench the thirst, flush out the organs of elimination, and reduce temperature. A calomel purge in the beginning of the disease, followed by a saline, if necessary. If there is much pain or the patient is restless or suffering from sick stomach, I usually give morphine hypodermically.
In the great majority of cases, the above is about all I give. I meet with cases, however, where the treatment is not so simple: For instance, a patient previously strong and robust is suddenly attacked with the disease and attended with high fever. I find a strong, full and bounding pulse, with rapid breathing, may be attended with wild delirium. In this type of the disease, I have found nothing better than Norwood's Tincture Veratrum Viride. I give the drug for its effect, which is shown by a reduction of the pulse rate and respirations. Veratrum acts as nothing else in this world will; it relaxes and produces dilatation of the entire arterial system, and in this way favors the easy flow of blood into the dilated blood vessels, and in a great measure relieves the engorgement of the lung tissue and heart, and frees the latter of a great portion of its burden. Veratrum not only accomplishes this most happy result, but it reduces the fever. I have used veratrum hun
dreds of times since I began the practice of medicine, and I have never had the drug to disappoint me in a single instance. I have never seen any dangerous symptoms attending its use. I have used ice locally to great advantage in this class of cases. Cough syrups I rarely ever use, because in my opinion, by upsetting the stomach, they do quite as much harm as good; also the different preparations of ammonia.
Stimulants are required in most cases, I think, but should not be given too early in the disease. If the pulse is weak and fast-the patient approaching the danger line-stimulants should be given, but the kind of a stimulant is a matter of choice with every physician. Some excellent authorities claim digitalis to be almost a specific in the treatment of pneumonia. I believe the drug is used by the majority of physicians everywhere, but in my opinion this drug is responsible for a great amount of harm. I used the drug for many years in the treatment of pneumonia, and I watched its effects closely, and to me it has been a bitter disappointment. Digitalis is a powerful heart stimulant, no one will deny, but while it stimulates the heart to more vigorous action it also, through stimulation of the vaso-motor ganglia in the medulla, causes contraction of all the arterioles throughout the body. It is known that the heart bears the brunt in pneumonia. The obstruction in the lung tissue vastly increases the labor of the heart, and if it be true that digitalis or any other drug diminishes the caliber of the blood vessels, is it not reasonable and plain that it increases the resistance which the heart has to overcome to pump the blood through them? You do not want to whip an overloaded horse; the thing to do is to take part of the load off.
Now, in cases like the above, with rapid breathing, great cyanosis, and rapidly failing heart, one has a condition of great danger and unless the heart can be relieved of some of its burden, soon a cessation of the play of its valves and the rhythm of its throb will inform us that the wheels of life have stood still. It is not the motive power that is at fault altogether, but the hindrance which the blood finds in circulating through the capillaries. The proper