spent in trying to find an antiseptic which would kill diseaseproducing organisms in the human body. Experimenters have failed to find any substance which can be placed in the blood in great enough concentration to kill bacteria there, without killing or injuring the patient. The use of all such substances recommended up to the present time is certainly to be discouraged, because not only we do not attain our purpose but decrease the vitality of the patient with strong protoplasmic poisons, and thereby hasten his death.

The symptoms most frequently requiring medication are the fever and throat and heart failure. A moderate degree of fever is conservative and should not be molested, but with a temperature of 102°F. and over, tepid water and dilute alcohol sponging are to be preferred to direct antipyretics; these remedies increase the danger later in the attack and will weaken the heart's action more than the fever, which they are given to control. I am confident that under the old treatment with pure old whisky or French brandy, and the preparations of ammonia, we were more successful in preventing and treating heart failure than with the more recent heart tonics. These alkaloids are highly poisonous and do not invariably produce their expected physiological action, and I am confident many patients are lost by their improper administration. To put into the circulation of a patient whose heart is faltering and struggling from fatigue or bacterial poisoning a hypodermic of digitalin, nitroglycerin or strychnin, is a very dangerous experiment. It is questionable whether you can give strength to a broken-down, paralyzed muscle without first removing the cause. At best digitalis is very slow in action and nauseates. Digitalin is not reliable, and frequently produces delirium. Nitroglycerin should be classed as a heart tonic; it relaxes and dilates the entire cardio-circulatory system, and should never be given except in arterial spasm to remove the vis a fronté and relieve the strain upon the heart, which conditions seldom obtain in pneumonia and other infectious diseases. Strychnia, the safest and surest of all heart tonics, acts directly through the vaso-motor system of nerves upon the cardiovascular system, and at the same time stimulates the respiratory center. But it frequently, instead of slowing, excites the

heart's action, and by increasing the blood pressure will make it wear out quicker than if left alone, and should be used only as a whip to carry the patient over an emergency, until other safer and surer means can be resorted to. The combination of heart tonics placed upon the market and into the hands of physicians by our enterprising manufacturing pharmacists, generally composed of nitroglycerin, digitalin, strychnin, and strophanthus, with some variations as to ingredients, while they may appear upon paper to act as synergists and each assist the other in supporting the heart's action, frequently act very differently when administered to the patient.

A weak heart in all diseases is wanting in systolic power, due either to a degenerate condition of the muscle itself, or insufficient or inefficient innervation. Give one of these patients one of these compound heart tonic preparations. The nitroglycerin produces an immediate effect and increases the condition of relaxation and paralysis, the strychnin next in action, overcomes probably some of the damage done by the nitroglycerin, and by the time the other ingredients arrive upon the scene and make their demands upon the heart it becomes so confused by the conflicting commands that it fails to act

at all.

Opinions differ as to the utility of local application-counter irritants, blisters, poultices, cotton batting, oil silk jackets and the antiphlogistic preparations, but I regard most of these as being useless if not pernicious. Blisters and turpentine stupes are not indicated, and are liable to embarrass the kidney or excite a nephritis. Cold packs are indicated when the temperature is high, but prejudice against them is too strong to stem. I never use a local application except in constant respiratory pain, and then I prefer a hot, moist linseed meal and mustard plaster. This is in no sense a poultice, and is perfectly light and dry, except the moist surface next to the skin. The moist plaster is more soothing and is not only a counterirritant, but it relaxes the peripheral capillaries, which retain more blood than if dry irritation is used.

What of cough mixtures and expectorants once much in use? As a general thing the cough is necessary, and unless very irritating and annoying should not be disturbed. The

cough frees the lung of disturbing poisonous substances, which should be expelled. As a general thing our worse cases are freest from cough.

HINTS ON THE DIAGNOSIS AND TREATMENT OF PNEUMONIA IN YOUNG CHILDREN.*

HERMON HAWKINS, M.D.

JACKSON, TENN.

THIS paper was suggested by recent experiences in the severe epidemic of measles last winter, in which pneumonia was a very common complication. You are familiar with the scientific text-book presentation of the subject, hence I shall only emphasize some practical points in the diagnosis and treatment of the disease as found in young children and infants.

In the examination of infants we should not forget that all symptoms are objective, while a difference in anatomy and a decided modification of physical signs demand a different interpretation from identical exhibitions in the adult. To illustrate. The apex beat of the heart in the adult is normally in the fifth interspace and from one-half inch to one inch to the right of the nipple line. In an infant it is in the fourth interspace, or even slightly to the left of the nipple line, according to authorities quoted by Holt. This certainly is a fact of prime importance; in the diagnosis of a pleuritic effusion, for example. The thorax is cylindrical-antero-posterior and transverse diameters being nearly equal-and not cone-shaped, as at puberty. Its walls are thin, lacking in muscular development, very elastic and yielding, while its capacity is encroached upon by the higher position of the diaphragm, with a relative increase in size of the abdominal cavity. The bronchi are larger, occupying greater space, at the same time the air cells are smaller, filling less space, and the lungs are situated more posteriorly. The respiration is normally about thirtyfive at birth, easily disturbed and irregular, rhythmical respiration not being established until the end of the second year. The stomach lies more obliquely, and the liver is proportionately larger than in the adult. These anatomical facts should *Read before West Tenn. Med. & Surg. Assn., Jackson, May 19-20, 1904.

be remembered in order that changes in physical signs caused by them should be rightly understood; otherwise serious errors in diagnosis are likely to be made. Again. The normal percussion note is somewhat tympanitic, while the normal respiratory murmur is hard to describe accurately, but, roughly speaking, approaches the sound of bronchial breathing in an adult. The signs of pulmonary diseases are usually more distinct in the back, or high in the axilla, and because of the small size of vesicles, "acute congestion may interfere with function almost as completely as consolidation.”

A diagnosis of pneumonia simply is unsatisfactory. True, all pneumonias have a family likeness, but only a superficial study of cause, course, symptoms and termination is necessary to show essential differences, a knowledge of which dictates the particular line to be adopted in caring for a given case. I know we see many puzzling cases of mixed character, but as a rule these can in a short time be classified sufficiently to indicate the proper line of treatment. I do not mean that hard and fast rules must obtain according to the name of the disease on the contrary. But I do mean to say, one must be governed by certain fundamental principles of treatment, fixed by essential differences between the several forms of disease to which we give the general name, pneumonia, modified by special developments, surroundings and individual peculiarities.

This groundwork of hints will find expression in the consideration of lobar and broncho-pneumonia, the two varieties of this disease to which I will confine myself. Lobar pneumonia is not common in children under two years of age, rarely results fatally except in infants or delicate children, is selflimited, and treatment is plain and simple. Yet the onset is frequently violent, the system being so overwhelmed with the shock that I am persuaded the fight is often lost or won in the first thirty-six hours. Here is a case in point:

I was called early one Sunday to see a little girl 3 years of age. I found her in a stupor, respiration superficial, rapid and jerky. Slight cough, pulse feeble, irregular and quick; surface slightly cyanotic, fever 1031°F., but extremities cold. She was up the day before, but had some cold and cough; was

chilly, vomiting frequently, and very restless all night, quieting down toward morning. The mother thought the child was better, until she attempted to give her a dose of oil following calomel given the night before, and found she could not arouse her. I thought I discovered slightly diminished resonance on the right side, with a rather feeble respiratory murmur, but the examination yielded no positive information. This condition continued throughout the day. I finally decided, from the history, peculiar respiration and general condition, that it was a case of lobar pneumonia. Her condition was so alarming I called another physician in consultation. The case seemed hopeless to both of us. Only a faint thrill could be found at the wrist; the surface was cold and clammy, while the stupor was profound. Experience teaches that it pays to fight for a baby's life until death actually takes place, and in this instance I decided to remain with the patient. I used hypodermics of strychnin, atropin, hot mustard baths and packs, high rectal enemata of salt solution, as my judgment dictated. Absolutely no results were obtained until 9 o'clock Monday morning, when permanent reaction was established, and from this time on it was a simple case easily managed. On the fourth day the area of the consolidation was plainly defined, crisis came on the seventh day, and recovery was complete and uneventful.

In this case I found no pleurisy; but, as a rule, it is present in most cases lasting over four or five days, in which there is a considerable area of consolidation. It also impressed me with the correctness of Holt's statement that "consolidation is rarely ever demonstrated before the fourth day, and sometimes later."

If well looked after, an average uncomplicated case of lobar pneumonia in a child will do well without internal medicine. at all. Nevertheless, it requires the exercise of good judgment and watchful care along definite lines. First, the digestion must not be neglected. Holt is right when he says, "No case is hopeless so long as the food taken is properly digested," but the digestion is very apt to be faulty, and this means tympanitic bowels with resulting pressure on a laboring heart and lungs, together with the grave symptoms caused by autointoxication, bad enough in themselves without the pneumonia. Select food carefully, watch stools daily and keep bowels clean by irrigations when indicated. The indefinite