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thing to do is to administer remedies that will have a tendency to dilate the arteries and favor the onward flow of the blood. Is there such a remedy? Nitro-glycerine will do it, but its action is too evanescent, and the drug can not be repeated as often as necessary. Alcoholic stimulants, in my opinion, answer the purpose better than any other remedy. I give them for the effect and not with a sparing hand. Alcohol is especially valuable with old people, and children stand it remarkably well. Alcohol undoubtedly has, to some extent, an antidotal effect in all septic cases, and, no doubt, in my mind, does great good in pneumonia in this way. Strychnine is a good heart stimulant in pneumonia, provided it has not been used too long before the danger point. I have used carbonate of creosote in some cases, but I can not say that is has cut the disease short in any single instance.
I watch the stomach carefully; keep the mouth and teeth clean, and see that the patient gets plenty of sleep. Sulfonal is an excellent remedy to produce sleep in pneumonia. I believe we frequently over-feed in pneumonia. A surplus of food often serves to produce flatulency and diarrhea. I am partial to buttermilk, where it is liked and agrees with the patient. Beef juice is fine when properly made. I like Ducrow's Elixir very much as a food in pneumonia. I think the proper thing to do is to let the patient alone as far as possible, and treat everyone on the expectant plan.
DR. F. D. GARRETT, Gainesville: One point I want to make: the doctor, in speaking of the differential diagnosis between pneumonia and acute bronchitis, says: "I do not think any one would be able to distinguish a case of acute bronchitis from beginning lobar pneumonia." I believe it is possible to make a distinction between the two. Acute bronchitis involves the bronchial tubes of both lungs; lobar pneumonia is different, it is confined to one or more lobes.
DR. S. C. RED, Houston: I have seen a good deal of pneumonia; I have written about it; I read a paper, you doubtless recall, on Pneumonia, at the last meeting. How the doctor is able now, in the light of present knowledge on bacteria, to say that the etiology of pneumonia is shrouded
in mystery is beyond my ken. It seems that the pneumococcus, in a large majority of cases, is responsible for pneumonia; that there are other organisms that will produce the same results is certain, but that pneumonia is decidedly a germ disease is settled.
In regard to the use of the various drugs for the stimulation of the heart, it occurs to me that it is absolutely unnecessary, and is often contraindicated until there is evidence shown that the pulmonic second sound of the heart is discovered to be losing in its strength or volume; unless this arises, the use of cardiac stimulation should be left off.
At the last meeting I read a paper and spoke of the use of creosote. It was just then beginning to be extensively used. Since then I have seen a good many cases of pneumonia, especially of the croupous variety. In a large per cent of them, i. e., in a number of the cases, I did not use creosote. When I found, however, that those cases were not doing well I put them on creosote, and they immediately began to improve. This did not occur in one, two, three or four cases; but it occurred in dozens of cases, and in every instance there was an improvement in many of the symptoms. Some of my cases died. This negatives creosote as a specific, yet places it very near being one. By what means it accomplishes this result I am unable to say.
DR. T. P. WEAVER, De Leon: The doctors who have gone before me misunderstood the doctor who read the paper. I am sure he did not say absolutely that he did not believe that the disease was influenced or caused by the pneumococcus; but, because of the fact that the pneumococcus is frequently found in normal sputum, and that on microscopical examination we frequently find other germs in the broken down tissue of the lungs, he meant that it was possible that there might be some other agent. Suppose you have a specimen and find the staphylococcus or the streptococcus in it, is it right to say that it was the cause of the disease or the agent producing it? The consensus of opinion is that it is not, but secondary to the ravages of the pneumococcus. As to giving tr. veratrum in pneumonia, I give it in the beginning, or inflammatory stage, especially in full bounding pulse.
Now, I want to say that this subject has a great interest to me, as I live where we have a great deal of the various forms of pneumonia, and I say, fortunately for the people, that it is less fatal in our part of the State, in my judgment, than in some other localities, for the reason that we have very little malaria. As stated above, in the inflammatory or beginning stage of pneumonia we use veratrum; we do not know just exactly what it does, it is all a good deal of theorizing; but we believe it lowers blood pressure in the inflamed areas. We do not use veratrum as the heart gets
weak; then we should leave off veratrum and give the patient rest. As to digitalis, strychnia and whisky, I believe that in the latter stages I would give them, because I believe that in heart weakness we have got to hold it up; but I do not believe in giving heart stimulants at all until the heart needs them.
DR. M. M. SMITH, Austin: One point I should like to make. It is the experience of some of the physicians who live in malarial sections of the country, and I have noticed that in the highly acute and epidemic form of pneumonia in Texas that invariably my serious cases, with very few exceptions, existed wholly among patients who were saturated with malaria or who had previously had malarial fever. It has occurred to me that there must be something with reference to the malaria that causes a more unfavorable prognosis in a case of pneumonia. Doubtless some of the members here, and particularly Mr. Moore, are familiar with that phase of the question. I merely introduce it to get the expression from this Association.
DR. FRANK PASCHAL, San Antonio: I wish to say that it does not require an experience of twenty-five or thirty years to make one aware of the fact that pneumonia can not be treated by this or that method. You can not treat any disease in that way. You treat the case. You have to use common sense in the treatment of this disease, as you do in everything else. In regard to the use of stimulants, I do not think they are always indicated. The disease at different times will manifest peculiar conditions. For instance: during a practive of nineteen years in a district of over 4000 feet above the sea level, and entirely free from malaria, there were some years in which pneumonia was very benign; then again, during other years, pneumonia would be virulent, asthenic, and from the beginning one would have to employ stimulants, so one can not employ the same treatment in all cases of this disease. My experience has been that when properly treated, the mortality from pneumonia should be small. I have seen doctors keep their patients on the flat of their backs for weeks at a time, and never have them turned on their sides; you are bound in this way to get hypostatic pneumonia. I always instruct the nurses to keep their patients off their backs as much as possible. Proper nourishment with common-sense treatment must apply to this as to all other acute dis
[The following remarks upon the treatment of croupous pneumonia were made at a meeting of the West Texas Medical Association at San Antonio, October 23, 1902, and subsequently published in the January, 1903, number of Merck's Archives. As this is essentially what I intended to say in discussing the paper of Dr. Evans—and the subject is one of such great importance and practical interest to my friends, the members of the Association
-I may be excused for presenting the same for publication in the proceedings, especially as I was prevented from completing my discussion at the time.]
DR. H. A. WEST, Galveston: Having had the opportunity of participating in a discussion on croupous pneumonia before the Section on General Medicine of the American Medical Association, at Saratoga last June, I was impressed with the fact that there were various questions in regard to this disease which were very far from settlement, in spite of the immense progress made in the past few decades in the knowledge of the natural history, pathology and therapeutics of pneumonia. Illustrative of such questions the following may be mentioned:
(a) Has a better knowledge of the disease and a more rational treatment resulted in any decided decrease in mortality?
(b) What, if any, satisfactory explanation may be given of the high mortality which continues to prevail?
(c) Is there any specific treatment?
(d) Has the use of anti-pneumococcus serum yielded satisfactory results?
(e) Are the coal tar antipyretics contra-indicated?
(f) What measures, if any, are justifiable for the control of temperature?
Under what circumstances are cardiac stimulants required?
(i) Are the enormous doses of digitalis, as used by Petrusco and his followers, rational and justifiable?
(j) Are blisters and counter-irritants indicated?
(k) Should poultices and other hot applications be used?
This is by no means a complete list of such questions, but will afford a text for the present unpretentious discussion.
Has a more rational therapy, based upon a more thorough understanding of croupous pneumonia, resulted in any decided decreased mortality? Such a question would hardly be necessary if the figures in the mortuary reports did not appear to give a negative reply. Those who listened to the discussion at Saratoga, or who have read Dr. Osler's views upon this subject, can not fail to have been impressed with their pessimistic tendency. In fact, he regards the treatment of the disease under consideration as a matter of professional opprobrium. I do not altogether take this view. In spite of what the figures of the mortuary reports may indicate, it does not appear to me as reasonable that the Sangrado method of purging, puking, blistering and bleeding, which was the practice of our forebears, in a disease where the tendency to death was from cardiac depression, did not turn the scale against the patient in a great many instances. Who can call to
mind the barbarisms of the antiphlogistic plan of treatment without a shudder and without thanking the Lord he was not a patient in those days? The enormous doses of calomel, the excessive purgation, the salivation, the poisoning with tartar emetic, the excessive nausea, the irritation from large blisters, the exhaustion from excessive blood letting! How any of these patients recovered excites our wonder and admiration for a constitution that could withstand such heroic treatment.
I must conclude that the rational symptomatic treatment of the present time will produce better results in spite of what the figures seem to teach. In other words, there must be something wrong with statistics which would convey a lesson so irrational. The mortality rate of croupous pneumonia varies under many different circumstances, entirely irrespective of the treatment. It will in the future, as in the past, occupy a foremost place as a cause of death. It is the terminal event and complicating factor in many other morbid processes, e. g., in acute infections, such as cerebrospinal meningitis, malarial, enteric, typhus and relapsing fevers, epidemic influenza, measles, scarlet fever, dysentery, pleurisy, pericarditis, malignant endocarditis. It is a very common cause of death in alcoholism, old age, tuberculosis, chronic Bright's disease, arteriosclerosis and in many other conditions where vitality is impaired and the resisting powers of the individual diminished in consequence of exposure, want, uncleanliness, overcrowding and unhygienic surroundings. The pneumococcus is a frequent inhabitant of the mouth, occurring there in the virulent state in 15 to 20 per cent of healthy adults; and on account of the anatomical relations of the lungs and the frequency with which a germ-laden atmosphere is inhaled, infection and inflammation of them is of frequent occurrence; and there is no wonder that croupous pneumonia should furnish 7 per cent of the entire mortality. A disease so widespread in its prevalence will attack many persons with lowered resisting powers as a result of pre-existing acute or chronic disease, and consequently will always be attended by a heavy mortality rate in spite of the best and most rational therapeutic measures.
Now, as to the question of specific treatment. Is any method of treatment known by which this disease may be aborted, or its duration shortened? The only reply I can give to this question is in the negative. Venesection, mercurialization, tartar emetic and blisters may be dismissed with a word: "Tried and found wanting," and the same may be said, in my opinion, of quinine, veratrum viride, aconite, digitalis, creosote and the anti-pneumococcus serum. Osler says: "Pneumonia is a self-limited disease which can neither be aborted nor cut short by any measures at our command. There is no specific for it." The facts in sppport of this position are so numerous and have been so often repeated that it is unnecessary for me to recapitulate them here.