complicating diseases (cardiac especially), or from asphyxia. In some
cases death seems to come from the overwhelming of the system with a
poison which acts primarily and principally upon the nervous system. In
a few cases fatal collapse has followed an apparently regular,
well-marked crisis.
TREATMENT.--The treatment of croupous pneumonia involves not only many
unsettled questions in modern therapeutics, but it embraces a history
of the therapeutics of inflammation. An heroic, antiphlogistic plan of
one period gave place to the rational plan of another, and that in turn
to the expectant plan of a later period, while to-day an antiseptic
method finds many advocates.
Regarding it as a general disease with characteristic local lesions,
and not a local inflammation with constitutional symptoms, its
treatment must vary with the constitutional condition of the patient
and the type of the disease. When uncomplicated and occurring at
certain periods and in certain conditions of life, it will terminate
spontaneously in recovery. But when certain complications exist and
certain conditions are present, and at certain ages, it is almost
necessarily fatal. Any plan of treatment in such a disease, if resorted
to indiscriminately, must needs be unreliable and unsatisfactory.
Although there is no doubt that a large percentage of cases of croupous
pneumonia will recover without treatment, there is also little doubt
but that well-directed therapeutical efforts can save lives and render
convalescence less tedious. If it is remembered in the treatment of
pneumonia that the pneumonic lung no more requires treatment than do
the intestinal ulcers in typhoid fever, and that we are to be governed
by the patient's general condition, and not by the physical changes in
the lung as indicated by the physical signs, it is evident that all
those measures which have been employed for the arrest of a local
inflammatory process have no place in our therapeutics. It is for this
reason that venesection, which at one time had its stronghold in {346}
the treatment of pneumonia, has now fallen into disuse. A summary of
the arguments against its practice seems to be conclusive, and the
numerous discussions that have so often distracted the most careful and
truthful observers are well expressed in the following terms:[49] 1st.
That indiscriminate bleeding immensely increases the mortality of the
disease. 2d. That it is specially fatal in old people and in young
children, in patients of exhausted constitutions, and in those
suffering from chronic diseases, and particularly from Bright's
disease. 3d. That it is absolutely unnecessary in the majority of cases
of young adults and also young children. 4th. That in the majority of
cases it has no influence whatever either in cutting short the disease,
in lessening its duration, or in diminishing the pyrexia, but that
occasionally these results appear to follow from its use when practised
early. 5th. That in the majority of cases it hinders the critical fall
of temperature and delays convalescence. 6th. That in the majority of
cases, as shown especially by Bennett's and Didel's data, recovery is
equally if not more rapid when it is not practised as when it is
resorted to. 7th. That in a few cases a moderate venesection may be
necessary in the early stages to avert immediate danger of death from
asphyxia.
[Footnote 49: Wilson Fox, _Reynolds's System of Medicine_.]
Not only does indiscriminate bleeding increase the death-rate and have
no influence over the progress, course, or severity of pneumonia, but
it postpones crisis and convalescence, and in the old, young, and
enfeebled is very often nothing less than a fatal procedure. In a
robust, vigorous individual, in spite of the fact that a free bleeding
at the very onset will temporarily relieve the urgency of some
symptoms, it nevertheless diminishes by so much the chances of
recovery, lessens the power to fight against the disease, and makes the
patient far more pregnable to subsequent dangers and complications.
Venesection has no influence upon the temperature. It may sometimes
postpone imminent death from asphyxia; and the fact that there is one
condition in which bleeding may be practised is no contradiction to the
foregoing statements, for venesection is then resorted to on account of
conditions that must be treated independently of the coexistent
pneumonia, such as sudden engorgement of the heart with blood, attended
with all the signs of sudden and extensive pulmonary oedema and
congestion. When the patient is vigorous and the above-mentioned
emergencies exist, free bleeding gives prompt relief. In no case should
more than ten ounces of blood be taken.
A careful study of the pathology of pneumonia not only leads one to the
conviction that venesection must do harm, but it strongly
contraindicates the employment of all those remedial agents which have
been used to arrest a simple pulmonary inflammation. Hence tartar
emetic, veratrum viride, aconite, and all other cardiac sedatives which
at one time were used so extensively have now fallen almost entirely
into disuse, as by their effects they can only add to the burden of a
heart already overtaxed by the venous stasis and the lack of arterial
blood. They may for a time lower the temperature and diminish the
pulse-rate, but they will accomplish this at the expense of
heart-power, and will almost certainly favor the earlier and more
certain development of that heart-insufficiency which must be regarded
as the most powerful death-producing agent in pneumonia. Dangerous
collapse has frequently followed the free use of these drugs.
Veratria is claimed to be a cardiac depressant; and this fact should
make us hesitate before we administer it in pneumonia. It acts promptly
in slowing the pulse, but its effects are only temporary, and when used
for a couple of days the larger doses that are necessary to bring about
the desired results interfere with the nutrition of the patient, often
causing vomiting and diarrhoea. Aconite is also a cardiac sedative, but
my experience with it has {347} convinced me that it is in all respects
inferior to veratria. Digitalis, which may be regarded as a cardiac
stimulant, is to be preferred to either veratria or aconite. It not
only lowers the temperature, but lessens the frequency of the pulse,
steadies it, and produces in the majority of cases its well-known tonic
action upon the heart. Its use in children is sometimes followed by an
intermittent pulse, but it is a symptom of no dangerous import.
Calomel and antimony have been almost entirely discarded from the
therapeutics of pneumonia: there is no evidence that the former has any
influence either upon the progress of the disease or the absorption of
the pneumonic exudation. Those who advocated its use believed it to be
most advantageous after the patient had been freely bled and large
doses of tartar emetic had been given. The latter was also a part of
the treatment where bleeding was practised. It exercises a depressant
effect upon the heart, and hence, although it may diminish the
frequency of the pulse and lower the temperature temporarily, it is an
exceedingly dangerous relief, as it is obtained at the expense of vital
power. It is absurd, with our present knowledge of the pneumonic
process, to discuss what was once claimed for tartar emetic--namely,
that it had the power of arresting the pneumonic process as well as
preventing pulmonary congestion in the unaffected portion of lung.
These drugs, while they at best afford only temporary relief, require
most careful watching to guard against their dangerous and prostrating
effects.
Expectorants have no place in the treatment of pneumonia, as only a
very small portion of the exudative matter in the lung is removed by
expectoration. If mucus or other secretions accumulate in the bronchial
tubes in sufficient quantities to cause inconvenience, it is in
consequence of the exhaustion and a loss of muscular power which attend
the disease, for which expectorants will afford no relief.
Counter-irritation, by blisters or other irritants applied to the
surface of the chest in the earlier stages of pneumonia, is of
questionable utility. Occasionally, blisters may be applied during the
third stage to hasten the process of resolution and promote the
absorption of plastic exudation. The application of leeches, followed
by a linseed poultice or some other soothing fomentation, will often
relieve the pain in the side which is so urgent at the onset of a
pneumonia. If extensive pulmonary oedema occurs, dry cups applied to
the chest will afford relief to the dyspnoea and temporarily remove the
oedema.
It has come to be a quite universal practice in this city to encase the
chest in a layer of cotton batting or flannel covered with an oil-silk
jacket. While this procedure has no direct influence on the course of
the pneumonia, it promotes diaphoresis and protects the surface from
sudden changes of temperature, and is always grateful to the patient.
It is especially serviceable in children.
A pneumonic patient should be kept in bed, as nearly as possible in a
horizontal position. Every appliance for promoting rest should be
employed. He should be cautiously moved for the necessary examinations
of the chest, and should be kept as short a time as possible in a
constrained position. If there are evidences of heart-failure, the
sitting posture should be avoided and talking should be prohibited. The
sick-room should be large, cheerful, and well ventilated, and its
temperature should range between 65° and 70° F. In acute febrile
disease there is no danger of catching cold from draughts, and the idea
of the laity that the moment a person is sick or has a fever he must be
put in a dark, close room is one of the superstitions of ignorance.
Pneumonic patients always demand air, and the cooler the more grateful
it is. Pure fresh air has a marked antipyretic power. It is a good rule
to allow adults to regulate the temperature of the sick-room to suit
their feelings.
One of the most important things in the successful treatment of
pneumonia is a carefully-regulated diet. The food should be fluid or
semi-fluid and {348} highly nutritious, such as milk, eggs, beef-tea,
and concentrated meat-broths. Milk is to be preferred to all other
forms of nutrition. It should be given in small quantities at short
intervals.
When not contraindicated wine may always be administered with milk.
Such administration of wine is not a part of the stimulating plan of
treatment hereafter to be considered, but it is a means of increasing
the digestive power of a feeble stomach.
If expectoration becomes difficult, it may be from a loss of muscular
power in the bronchial tubes, when stimulants are indicated; or from
extreme viscidity of the sputa, when alkalies will be of service. Just
here it may be mentioned that alkalies and neutral salines possess a
diuretic and diaphoretic power which often affords relief from the
pungently hot skin, and may aid the elimination of effete material by
the kidneys.
It should be remembered that in the treatment of croupous pneumonia we
have to do with a self-limited, acute febrile disease, which usually
runs a cyclical course.[50] Routine treatment is therefore always
harmful.
[Footnote 50: Fernet ("De la Pneumo. franche aigue," etc. _Arch. gén.
de Méd._, 1881, pp. 5-155) has demonstrated the regular and cyclical
course of pneumonia. The evolution of the malady is represented by the
march of the fever and is figured by the thermometric curve.]
The nervous shock which attends the ushering in of a severe croupous
pneumonia is greater than in any other acute disease, unless it may be
peritonitis, and the important question presents itself at its very
onset, What measures shall be employed to overcome or mitigate the
impression made upon the nerve-centres by the morbific agent which is
operating to produce the pneumonia? The experience of the last few
years leads me to the conclusion that during the developing period of
the disease, when the pneumonic blow is first struck, and until the
pneumonic infiltration is completed (usually for the first four days of
the disease), if the patient is brought under the full influence of
opium, and held in a condition of comparative comfort by hypodermic
injections of morphia repeated at regular intervals, he is placed in
the best condition not only for resisting the shock, but also for
combating the activity of the pneumonia. Opium does not, when thus
administered, interfere with a stimulating or antipyretic plan of
treatment which may be demanded, but it does very greatly diminish the
chances of heart-failure, cases often recovering under its use which
from age and condition of life seemed hopeless. Then the great relief
and comfort which it gives to the sufferer in the first four days of
his struggles are sufficient to commend it, especially in those cases
where pain is severe and the restlessness of the patient is exhausting.
After the pneumonic infiltration is completed opium should be
administered with great caution, for paralysis of the bronchi (which it
induces), and the consequent accumulation of secretion in the bronchial
tubes, may greatly increase the already existing difficulty of
respiration.
In all severe types of croupous pneumonia there are two prominent
sources of danger: heart-insufficiency and high temperature. There are
consequently two prominent indications for treatment--viz. to sustain
the heart and reduce temperature.
A large proportion of deaths from pneumonia result directly or
indirectly from heart-failure. Alcoholic stimulants, judiciously
employed, are the most efficient means which we possess for sustaining
a flagging heart, but their indiscriminate use is more dangerous than
indiscriminate venesection. It may be that only a few ounces of brandy
will be required to carry a pneumonia patient through a critical
period, or it may be that its free administration will be required to
save life. In the old and feeble, and in those who have been accustomed
to the use of alcohol, stimulants may be indicated from the
commencement of the attack, and their free use required throughout the
whole course of the disease. Each case demands careful study. In no
{349} other disease is so much discretion and judgment required in the
administration of stimulants as in croupous pneumonia. The pulse, being
the indicator of the condition of the heart, must be carefully studied.
A frequent, feeble, irregular, or intermittent pulse always indicates
heart-insufficiency. The quantity of stimulants to be administered in
any case must be determined by their effect upon the pulse. It is
advisable to commence their use in small quantities, and carefully
watch their effects. If the effect is beneficial, a favorable result
will follow within a few hours, and then the quantity to be
administered can be increased according to the necessities of each
case. It is seldom necessary to give more than six or eight ounces of
brandy in twenty-four hours, yet if the necessity of the case demands
it may be given in much larger quantity, twelve or twenty-four ounces
often being required in twenty-four hours. A dicrotic pulse is a
certain indication for the administration of stimulants.
The period immediately following the crisis is the one in which
stimulants are usually most serviceable. Delirium is a symptom which
calls for their administration, whether it is due to asthenia, pyrexia,
or is an expression of blood-poisoning. When muscular tremor and
subsultus tendinum are present, alcohol may usually be freely given. A
critical collapse in the aged and weak, attended by great prostration
and a subnormal temperature, is a condition in which alcohol shows its
best effects, and the amount of asthenia will determine the amount of
stimulation required.
It has been claimed that carbonate of ammonium in large doses
stimulates the heart and prevents the formation of heart-clots by its
action on the blood. The cause of heart-clot is the heart-failure, and
there is no evidence that carbonate of ammonium prevents the
coagulation of the blood when the blood-current is slowed. Besides,
large doses of carbonate of ammonium irritate the stomach, and on this
account interfere with nutrition, and thus diminish the chances of
recovery. As a diffusible stimulant it is inferior to champagne.
Moreover, champagne can be administered for a much longer period
without causing gastric disturbances.
Camphor and musk have been highly recommended as cardiac stimulants,
but they are inferior to alcohol.
Digitalis of late years has been extensively used to counteract
heart-insufficiency, but it is very uncertain in its action in the
heart-insufficiency of pneumonia, and has seemed to me more frequently
to do harm than good. The nervous element of the heart-failure
contraindicates its use.
The second important indication in the treatment of croupous pneumonia
is to lower the temperature. The plan of applying cold compresses to
the chest in pneumonia, though far from being a new one, still has its
strongest advocates in the modern school of therapeutics. It is
proposed to apply thick compresses wet in ice-water over the seat of
the inflammation, changed every five minutes. Some use the Esmarch
ice-bag for the same purpose. Patients who were moribund have, it is
said, been revived by immersion in a cold bath. The advocates of this
treatment claim that the temperature is lowered; that the patient
experiences a feeling of relief during the bath; that the pain,
dyspnoea, pulse-rate, restlessness, and severity of the attack are all
ameliorated; and that the duration of the disease has been cut short by
the continued use of cold baths or cold packs.[51]
[Footnote 51: Rules for the employment of cold as an antipyretic in
pneumonia:
Cold Bath.--As soon as the axillary temperature in the evening rises
above 103° F., place the patient at full length in a bath with a
temperature of 70° F. or 80° F. Gradually lower the temperature of the
bath by the addition of cold water or ice until the temperature of the
patient begins to fall. It may be necessary to lower the temperature of
the bath to 60° F. before the temperature of the patient is affected.
After the temperature begins to fall, thermometrical observations must
be taken every two or three minutes; the rectal temperature only can be
relied upon. If the temperature falls {350} rapidly--that is, two or
three degrees in five or six minutes--as soon as the fall reaches 102°
F. the patient should be removed from the bath; if it falls slowly, as
soon as it reaches 101° F. he should be removed and immediately placed
in bed. The patient should never be kept in the bath until the
temperature reaches the normal, for it continues to fall for some time
after his removal from the bath, and he may pass from a condition of
fever into a state of collapse. The duration of the bath should rarely
exceed fifteen minutes. While the patient is in the bath cold should be
applied to the head by means of a sponge or by an ice-bag.
In the young, the feeble, and the aged the duration of the bath should
never exceed five minutes. Once commenced, the baths must be persisted
in until the crisis is reached.
Cold Pack.--This is much less effective than the bath, but if the
patient is too feeble to be moved it may be employed. The patient
should be wrapped in a sheet wrung out of tepid water, and over this a
sheet should be applied wrung out of ice-cold water; the latter may be
removed as often as it becomes warm. Its application and removal may be
continued until the desired fall in temperature shall be obtained.
Cold Compresses.--The method of applying cold compresses in pneumonia
is as follows: A cloth of some thickness is to be wrung from ice-cold
water and applied every five minutes to the affected side, or an
ice-bag is employed instead of the compresses. It is claimed for this
method that it not only relieves the local symptoms, but lowers the
temperature and hastens the day of crisis.
If cold is to be applied to the chest, either moist or dry, all the
disadvantages arising from repeated exposure and frequent changes of
temperature can be avoided by the use of the rubber coil, and it should
always be employed in preference to wet compresses.]
The experience of American practitioners, so far as I have learned, is
against this plan of treatment. It is found that under it pneumonia is
more liable to extend; that the shock of the cold to the surface causes
a nervous depression from which the old and feeble do not rally; that
although a reduction of temperature may be effected,
heart-insufficiency is more rapidly reached and is more difficult to
overcome. Besides, the statistical results of this plan of treatment
are decidedly against its use. The above statements do not prohibit
cold sponging of the limbs and face if it is grateful to the patient.
If the high temperature in pneumonia is due to rapid
tissue-metamorphosis, the result of the action of some morbific agent
in the blood, it follows that we must look for an antipyretic which can
check this rapid tissue-change. It is claimed with reason that the
sulphate of quinia is a sedative to the arterial system, and has a
stimulating effect, sui generis, upon the capillary circulation; that
it can arrest cell-development, and also check the amoeboid movements
of the white corpuscles. Theoretically, therefore, it is a remedy par
excellence for the lowering of the temperature in this disease; and
clinically and empirically it has been found to reduce temperature more
permanently and with greater certainty than any other agent. None of
the objections brought against the other antipyretics can be urged
against this one, for it possesses the twofold power of reducing
temperature and sustaining the heart-power from its action on the
nervous system. To act antipyretically, quinia must be given in large
doses. From twenty to forty grains must be given within two hours, or
the whole quantity may be given at a single dose. The greatest
reduction of temperature will be reached in about seven hours after the
quinia is taken.[52]
[Footnote 52: When quinia is employed as an antipyretic in pneumonia it
must be given in large doses. The administration of two grains every
two hours, or a larger quantity administered in divided doses within a
period of twenty-four hours, will not act as an antipyretic; but from
twenty to forty grains must be administered within a period of two
hours. If the stomach is irritable, ten grains may be given every half
hour until the desired quantity has been administered. Usually in from
four to six hours after the antipyretic dose has been taken the fall of
temperature will begin, and in about twelve hours it will reach its
minimum height; then it will remain stationary from twelve to
twenty-four hours. After the temperature has once been reduced by the
quinia, its administration may be discontinued until the temperature
shall again rise to 105°. As a rule, the temperature does not reach as
high a point as before the quinia was administered. This mode of
administering quinia rarely produces any symptom of cinchonism {351}
other than transient deafness after the first dose. In a large
proportion of cases the temperature by this method can readily be kept
below 103° F.
In Ringer and Gill's experiments with quinia on temperature it took at
least twenty grains to produce a fall of a degree. From fifty to eighty
minutes were required before the fall occurred, and the effects lasted
from forty-five minutes to three hours. Ringer states that in pneumonia
the quinia does not readily pass out with the urine, but is delayed in
the system for a considerable time.