Page images
[blocks in formation]

ETIOLOGY. It is generally conceded that croupous pneumonia is an infectious disease and the product of the Pneumococcus Lanceolatus. As to this germ being the only factor in its production, I am not willing to admit. The lungs are exceedingly vulnerable organs and easy of access to all disease-producing germs.

We have several inflammatory conditions of the throat and tonsils that bear such a close resemblance to each other that they cannot be clinically differentiated, mixed infections in which different microorganisms are found and in which it is a matter of doubt to which class the disease belongs, so again in the acute eruptive skin diseases, we have conditions which so closely simulate each other that they cannot be classified, except as hybrid or of unknown origin. So in pneumonia we may have it close to several causes-as the pneumococcus lanceolatus, the streptococcus, the lagrippe bacillus, or other organisms, either in pure or mixed type.

Exposure to cold, fatigue, etc., which were so long considered as the sole causes, are now known to be only predis

*Read before West Tenn. Med. and Surg. Assn., Jackson, May 19-20, 1904. 393

Vol. 24-29

posing, rather than active causes. By lowering vitality and body resistance and at the same time checking elimination and deranging metabolism they place the system in the best possible condition for bacterial invasion.

TYPES. The types of pneumonia might be classified: 1. According to its cause or its bacteriology. 2. According to the effect of the cause upon the individual, which may vary according to the malignancy of the cause or the constitutional condition of the patient, which may be either inherited or acquired. 3. The type may be due to some concurrent or intercurrent disease or some deranged or insufficient organic action. 4. Or the type, as in the adynamic or asthenic cases in which we have the constitutional symptoms several days before any indications of pneumonia manifest themselves, may be due to a primary bacteriemia. The interesting question, whether lobar pneumonia is the primary result of a direct local infection of the lung, or a secondary localization of a primary blood invasion, is yet undecided, but a certain class of cases called typhoid-asthenic, adynamic, latent, etc., might be properly called toxemic,-in which we have a primary blcod invasion. The constitutional condition of the patient is the great factor in developing the type and in guiding our course of treatment of this disease. Age has also a marked influence on the type which this disease assumes. Senile pneumonia is the great plague of the aged. More old people succumb to this disease than any other-almost all others combined. It matters not what other disease the aged patient has, whenever he is reduced to a low state of vitality or resistance, pneumonia is liable to supervene and claim its victim. To discuss the pneumonia of infancy and childhood would make this paper too long; it frequently bears the mask of other disease, with symptoms and pain deflected to other organs, especially the abdominal and cerebral. All inflammatory conditions of the lungs in children extending beyond the larger bronchi should be called pneumonia. It is frequently impossible to make a diagnosis between lobar pneumonia and catarrhal pneumonia or capillary bronchitis, and even if a pathological distinction does exist the tendency is the same toward lobular collapse and asphyxia.


Prophylaxis, if possible, is certainly better than treatment or even cure if effected. But it is a thankless task, and brings no revenue; who but physicians would advocate such procedure? Knowing that pneumonia is infectious or contagious, and that the microorganisms are eliminated from the infected individual by and in the expectoration, and gain access to the victim's lungs by the dried and dust-borne sputa, it devolves upon us to use every known means to limit the extension and check the ravages of this disease if possible. It is needless to enumerate the methods of disinfecting the sputa and surroundings of the patient. Not only disinfection should be enforced, but no feeble nor aged person should be allowed to come in contact with the patient, and if so they should be kept well nourished, observe regular hours of rest and sleep, and take sufficient exercise in the open air and sunshine. Pneumonia is a house disease, and the aged and feeble should avoid overheated and crowded gatherings.

All the rules of prophylaxis used in nursing a case of typhoid fever or any other infectious disease should be observed in pneumonia, and after the termination of the case a rigid course of house disinfection should be required.

TREATMENT. With all the advancement in other branches. of medicine, with almost perfect knowledge of its etiology and pathology, still the mortality from this disease has increased until it has become alarming to our most advanced medical thinkers. Why this great increase in mortality? Is the disease more malignant or have our patients less vitality, or are we as physicians less skillful in its management? All these causes obtain probably to a certain extent. The population of our towns and cities is rapidly increasing, and there are more persons engaged in indoor occupations than ever before, which both lessen the vitality of the patient and increase the malignancy of the disease. I am confident that the course of treatment found most successful in cities and hospitals, in treating their asthenic or toxemic type of patients is not applicable to a large class of our well-nourished country patients. Our patients as a class are more sthenic, the pneumonia is more frequently a primary invasion, and the tendency to death is more toward asphyxia than asthenia or toxemia, and con

sequently require a more active course of treatment to limit the extension of lung involvement. The decree has gone forth that this is a self-limited disease and needs no treatment, and frequently valuable time is lost, the disease allowed to overrun the lung, and the patient become profoundly poisoned before active treatment is commenced. In no other disease is it so important to lose sight of the name of the disease and treat the patient, as in this.

After placing our patient in the most favorable condition. so far as surroundings, room, and the procuring if possible the services of a trained nurse, we may give our attention to his physical condition, treat individual symptoms, and combat complications as they may threaten or arise.

A great deal has been said about the use of heart sedatives, especially the use of aconite and veratrum, in the treatment of pneumonia. Some few have given them faint-hearted praise but the leaders have consigned any practitioner to the "demnition bowwows," who uses them. These remedies which are classed as physiological synergists, and used interchangeably to produce like effects, I consider very unlike. Aconite is very poisonous and acts by paralyzing the heart muscle, and will and has produced death in numerous instances. Veratrum does not paralyze the heart but reduces the heart's action by its action upon the inhibitory nerves. It is not a poison; no known case of death has been accredited to it. I have given it in fifteen and twenty drop doses hypodermically to eclamptic children with favorable results, when all other means had failed. It not only does not paralyze the heart but by restraining abdominal action conserves its strength. I have found by experience not only in pneumonia but in all other conditions in which you have an active inflammation with a full strong pulse, that it is the remedy par excellence. It is only to be used in the first and advancing stage of a sthenic pneumonia, that class in which the tendency to death is by asphyxia. In this stage, with full pulse, acute pain and humid respiration, there is no remedy that can take its place. These are the cases that country doctors abort or check. It is not claimed that veratrum will modify or change the effusion which has already taken place, but the pneumonic inflam

mation spreads by contiguity along and with the collateral congestion. It is axiomatic that where there is an irritation there you will have an afflux of blood.

Veratrum not only limits the supply of blood to the inflamed area, but reduces arterial tension and relieves the pressure upon the tender, inflamed nerves, and by so doing lessens the irritation and afflux of blood to the inflamed lung. Consequently the disease is limited to its first point of invasion, crisis quickly supervenes, the absorbents readily remove the limited effusion and your patient is well. But why not bleed your patient? It is certainly indicated in this condition. My objection to bleeding is that it devitalizes the patient, reduces his power of resistance, gives only temporary relief, makes his convalescence longer, and does irreparable harm if no good, while veratrum does all that could be expected from bleeding with none of its objections. There are other things to be done in the first stage if indicated. If pain is severe and respiration rapid, a hypodermic of morphin and atropin is indicated, not only as an analgesic, but as a curative means, by relieving irritation and reducing congestion, the atropin diverting the blood to the cutaneous capillaries; as to morphin it should be confined to the early stage and to relieve especially pleuritic pain; in the second stage when the patient is delirious with blood surcharged with carbon dioxide, it will benumb the respiratory center and hasten his demise.

Another class of patients, the adynamic or toxemic class, require a different course of treatment from the beginning. Under no circumstances is veratrum or the arterial sedatives indicated when we have a primary toxemia. Their strength should be rigidly conserved; they should not be allowed to raise themselves or sit up in bed, nor make any muscular exertion whatever. Every organic function should be closely watched, especially the heart and kidneys. There is no specific course of treatment, neither antitoxic nor antiseptic. Even if the anti-pneumococcic serum had proven successful, to use it rationally we must first determine that our patient is suffering from a pneumococcus pneumonia, otherwise we would add a toxin instead of an antitoxin to the existing evils. Ever since antiseptics were first discovered much labor has been

« PreviousContinue »