Selected Articles THE PRESENT TREATMENT OF PNEUMONIA AS BY HENRY R. LOOMIS, M.D. (Professor of Therapeutics and Clinical Medicine in the Cornell University Medical College; Visiting Physician to Bellvue and the New York Hospitals.) THE fact that pneumonia to-day occupies first place in mortality statistics as the cause of death arrests our attention. In New York the statistics of the Board of Health show that the mortality curve of pneumonia has passed that of tuberculosis, and more people die from penumonia every year in Greater New York than from consumption, which until the last few years has always been considered as the great scourge. A satisfactory explanation of the increase of pneumonia is very difficult. Has the type of the disease increased in severity? Have the local conditions favoring its development become worse, or has the treatment of this disease known no advance? These are questions that must interest every medical man. Personally I believe the treatment of pneumonia at the present day is the least satisfactory of that of any of the acute diseases. In our large metropolitan hospitals we may look more than anywhere else for the most advanced methods of treatment, as here every new suggestion in therapeutics is tried, weighed, discarded, or adopted. Accurate statistics are kept, thus furnishing data for approximately reliable and impartial conclusions, and all under the critical eye of the young and enthusiastic members of the house staff, who before their two years are up are well able to determine the treatment producing uniformly the best results. Therefore, in the large hospitals I should say we can find, if not the best plan of treatment, certainly the one that is accepted by the majority of the profession as giving the best results. I have taken for comparison four of the largest hospitals in New Yorkthe Presbyterian, Roosevelt, New York, and Bellevue. On the visiting staff of these four institutions are some of the ablest men in the profession, certainly men with large practical experience. As the medical service in all these hospitals rotates, the criticism might be offered that the treatment would change as each new visiting staff comes on duty, in accordance with their personal ideas. This I have found not to be the case to any extent. After a talk with the present house staffs of all these hospitals, I find that there is in each institution what might be called a routine treatment for most of the common diseases, based upon past experience and drawn from the most effective suggestions of the various visiting physicians. The hospital treatment which I shall speak of may differ somewhat from the treatment we each might carry out, but it will certainly represent the prescribed treatment of the majority. To obtain the details of treatment from the different hospitals, I had typewritten a careful series of questions; these were answered in writing by the different house physicians. Then personal interviews with the medical staff of each hospital were had, and I found that in many instances one or more of the visiting staff had verified the answer to the questions and had added elaborations of their own. I was surprised to find after investigation what a uniformity there was in the treatment of pneumonia in the different hospitals. This is not seen in any other disease, with possibly the exception of acute rheumatism. I will give briefly the general hospital treatment of pneumonia and note the exceptions as I go along. Cathartics. When a patient enters any one of these four hospitals suffering from pneumonia, he is given calomel, usually in small doses, often repeated, and this is followed by a saline the following morning, generally Epsom salts. The calomel is re peated during the course of the disease if necessary. This is as a routine treatment. Local Applications to the Chest.-All the hospitals at the present time apply local measures to the chest over the affected lung only when the pain and distress is intense. They make no local application as a routine practice. When applications are made large flaxseed poultices enveloping the chest are applied, although at the New York Hospital and on the first division of Bellevue Hospital ice poultices are sometimes used. The old-fashioned pneumonia jacket, made by covering flannel with oiled silk, is used in none of the hospitals at the present time for adults suffering from pneumonia. At the New York and Bellevue its use is confined to children. Diet.-All the four medical divisions of Bellevue Hospital put their patients during the heighth of the disease on an exclusive milk diet, giivng the milk plain or modified. The other hospitals make milk the principal article of diet, and alternate it with broths and egg-albumen. Roosevelt Hospital adds eggs and crackers, and there the patients are urged to drink a very large quantity of water. Fever. The treatment of the fever of pneumonia in the different hospitals varies more than anything else. A temperature of 104 degrees and over is not necessarily an indication for special treatment unless it is accompanied by nervous symptoms, marked restlessness, or delirium; then it is treated as follows in the different hospitals: Presbyterian Hospital: They use either cold packs to the anterior portion of the chest, the technique of which consists in enveloping the chest with sheets wrung out of water at a temperature of 50 degrees and repeating the applications for ten minutes, or by making use of what is known as an "anterior pack." This consists in covering the patient with a sheet and sprinkling with water from a sprinkler, or by a brush wet with water; the temperature of the water is just as it comes from the hydrant, about 85 degrees. This method of reducing the temperature is also used at Roosevelt Hospital. At the New York Hospital the temperature is controlled by alcohol sponges, and if these are not effective, with a cold pack. At Bellevue Hospital tepid sponges are used to reduce the temperature, the water being from 80 degrees to 85 degrees. At Roosevelt Hospital alcohol sponges or "anterior packs" are used. I made inquiries to ascertain if tub baths are given in pneumonia in the various hospitals, and found that Bellevue and Roosevelt never use them; the New York very seldom, and only in cases with toxemic pyrexia. At the Presbyterian they are used in alcoholic cases when nervous symptoms are present. Cough. When cough is a distressing symptom, all the hospitals give codeine. Ordinarily it is the only drug they use. When it is commenced it is given in regular doses of one-quarter of a grain every four hours. All the hospitals, with the exception of Bellevue Hospital, at times use heroin in one-twelfth-grain doses. The third division of Bellevue prefers morphine. At times Roosevelt Hospital gives morphine to aid a distressing cough. Insomnia. For insomnia, which is often a distressing symptom, the three drugs most used are trional ten grains, veronal ten grains, codeine one-quarter of a grain. The Presbyterian uses any one of these indiscriminately. The New York and Bellevue generally uses trional. Roosevelt only veronal and codeine. Pulmonary Edema.-Pulmonary edema is treated at the Presbyterian and Bellevue Hospitals by hypodermic injections of adrenalin; fifteen to thirty minims of one in a thousand solution is given every fifteen minutes, for five doses, then every half-hour for four doses. Atropine hypodermically, one one-hundredth of a grain, is also used at these hospitals. They all cup the chest for pulmonary edema; however, at the New York and Bellevue Hospitals greater reliance is placed upon increased stimulation. Oxygen is not given as much as formerly in any of the hospitals. It is only used in cases of dyspnea and cyanosis. The oxygen tank seems to still hold its place as the actual forerunner of the end. Cardiac Failure. As we all know, the critical period in a case of pneumonia begins with the evidence of cardiac failure. The first indication of systolic weakness and failure of arterial tonicity leads to the administration of cardiac stimulants. The three cardiac stimulants which are used in all the hospitals are alcohol, strychnine, and digitalis. I find the use of these drugs varies a good deal in the different institutions. (a) Alcohol. The cardiac stimulant which occupies first place and upon which the greatest reliance is placed is alcohol. Whisky is the form used, in doses of half an ounce, the time of its administration varying from every hour to every four hours, according to indications. These indications are a small, incompressible, rapid, feeble, and often irregular or intermittent pulse, associated with the absence of the first sound of a diminution in the apex heat. At the Presbyterian Hospital alcohol is not commenced until there are absolute indications, such as cardiac insufficiency and marked constitutional symptoms-nervous symptoms, dryness of the tongue, etc. I find that alcohol is less used in this hospital than in any of the other institutions. At the New York Hospital it is used especially in alcoholic pneumonias. Inquiries at the different hospitals show, with the exception of the Presbyterian, that alcohol is used to-day as much in pneumonia as it was two or three years ago. It is used at the Presbyterian less generally than it was. (b) Strychnine. There has been a peculiar thing about the use of the second drug in pneumonia-strychnine. Most of us can remember when we first began the practice of medicine that strychnine was seldom, if ever, given as a cardiac stimulant in pneumonia; now it is universally used. Clinical experience has confirmed what physiological experimentation has long ago proven. When we remember the physiological action of this drug, how it stimulates the heart and tones up the arterial system by its direct stimulant action on the vasomotor centers, and not like alcohol and digitalis by its action on the heart muscle and the arterial wall, we find an explanation of its effectiveness; it whips up the heart, one might say, from its powerful nerve center. Strychnine is never followed by the secondary depression so often seen after alcohol. I find this drug universally used in the hospitals. In |