EARLY SYMPTOMS OF IMPENDING PNEUMONIA NOT USUALLY OBSERVED.

BY DR. H. M. NEALE, UPPER LEHIGH,

READ NOVEMBER 19, 1902.

During the past nineteen years, while living in a region where acute diseases of the respiratory tract are exceedingly prevalent during the fall and winter months (and I might add that it is not uncommon to see diseases of this character in summer), I have attended a great many cases of pneumonia. The early history of two or three cases that came under my observation, is responsible for a series of questions that I have asked all my pneumonia cases, for the past six or seven years. I will give you from some clinical notes in my possession the history of two cases.

In February, 1895, J. D. H., age 42, a lawyer by profession, called at my office, presenting the following symptoms: A peculiar hyper-sensitiveness to the slightest cold, momentary in character, but occurring every time he stepped out of doors, or took a cold object in his hand, such as a paper weight or cane or umbrella. He would notice a slight shiver pass over him, and at the same time experienced a slight metallic taste, sometimes very slight, and seemingly confined to the base of the tongue. Otherwise he felt as well as usual, with possibly a slight falling off in desire to take food. He stated that he had a good appetite for only one meal a day and that was followed by an uncomfortable feeling in the stomach, with an occasional twinge of pain. After a thorough examination I could detect no objective symptoms. Temperature normal and no physical signs of any trouble whatever. I prescribed quinine, two grain. doses every four (4) hours, and advised ten (10) grains of dover powder at bedtime. I thonght nothing more about the case till four days later when he again called to see me with the same story, and also complaining of intense pains, at times in the pit of the stomach. He stated that he had felt better for a couple of days after beginning the use of quinine, but at

no time had this peculiar chilliness left when touching anything cold. I looked him over very carefully this time, made an examination of his urine with negative results except that the specific gravity was rather high: 1026. This time the tongue was coated and the breath heavy; I advised him to remain in doors and take an occasional hot whiskey in addition to the quinine, which was continued in increased doses, til! he felt a ringing in the ear. He however told me that it was absolutely necessary for him to go to Philadelphia on the following morning to attend the Supreme Court then sitting at that place. As he had no fever and promised to be carefu! I told him to go. At that time, while nothing serious was to be seen, I had vague suspicions that something was going to develop. As he was constipated I gave him a pill of blue mass and aloin, to be followed by citrate of magnesia. He was away two days and upon his arrival home he sent for me. I found him with a dry cough, tongue dry and brown, with a temperature of 104 F., with slight dullness over base of left lung. He was very seriously ill for four weeks and finally made a slow but satisfactory recovery. He noticed no decided chill, but while in the city, the weather was cold and damp, and he was obliged to take hot whiskey very often in order to be able to attend to his business, according to his statement. fact, when I saw him upon his return he had taken about all he could carry. I mention the foregoing to illustrate these symptoms, viz: slight creeping chills upon the slightest exposure to cold in any form. Metallic taste, fleeting or momentary, just a flash, as it were, and pain in the pit of the stomach.

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I will now give the history of another case with the same premonitory symptoms, but not followed by pneumonia, after which I will endeavor to explain, from my point of reasoning, what these symptoms meant. Harry J. K., age about 30, clerk in a store, called to see me on the 8th of March, 1902. He complained with the same symptoms described in the preceding case. I immediately ordered him to bed and gave free diaphoresis laxatives; as no fever was present I gave no antipyretics. The feeling of chilliness upon touching cold objects, such as taking a glass of water in his hand, or touch

ing the headboard of the bed, persisted for four days, when feeling considerably better I allowed him to get up. He stayed in the house for two days longer and then returned to his work. He said that he felt a little weak and shaky for a few days, and had a slight bronchial cough, which, however, only lasted a short time. He looked pale for two weeks or more, but gradually returned to his normal condition. As it is not often that one consults a physician in the stage of vague premonitory symptoms of any disease, it has not been my fortune to note personally many of the early symptoms referred to. Still, in nearly all the patients who have had pneumonia in which I have questioned them about their feelings prior to the onset of the disease, I have gotten from them a history of slight chills, persisting in many cases for two or three weeks. In some the peculiar metallic taste, and in others pain in the pit of the stomach, and in many cases all three symptoms have been present in varying degrees of intensity. Now what is to be learned from this? Can it be explained to your satisfaction or will you say in the language of the late Josh Billings, "Some folks know a great deal, but what they know ain't so."

It is not necessary to say that pneumonia is now classed as an infectious disease. And as such must conform to the laws governing all diseases of this character. We may safely assume that among the predisposing causes of throwing into activity the germs of pneumonia in an infected person are: first, age; second, malaria; third, exposure to cold, by which the secretions and excretions are temporarily locked up; fourth, alcoholism. These causes, while totally different from each other, nevertheless, under certain conditions, are productive of the same result. Each may produce congestion of the capillaries by different mode of action. They do not, in themselves, produce pneumonia, properly so called, but work such structural changes in the body that upon further disturbance of the general system a congestion of the pulmonary capillaries is likely to occur, a wound or an injury to the lung may produce inflammation and consolidation, but not a croupous pneumonia. A disease, which is stated by Whittaker, to cause 6 per cent. of all deaths and 12 per cent. of the mortality of

all internal affections, is a formidable disease, upon which one cannot expend too much thought in endeavoring to ameliorate its ravages. Whittaker further states, "That with the recognition of pneumonia as an infectious disease came the correction of many errors which, like the enveloping of a veiled statue, so obscured the figure that only its rough outlines could be seen." The recognition of the fact that pneumonia is commonly epidemic in character, dealt a death blow to the old theory that it was invariably caused by exposure to cold. Over 80 per cent., according to general observation, could recall no unusual exposure. Another error, that pneumonia attacks only the robust and healthy, was corrected by the observations of a French writer, who states that only 18 per cent. of cases under his observation were previously healthy. Ricketts, alcoholism, tuberculosis, malaria and previous infection furnish the victims of pneumonia. Not the outdoor but the indoor life is more liable to attack. Soldiers are more often attacked in barracks than in camps. Seventeen per cent. is the appalling percentage among nuns in the Paris convents. While three per cent. is the percentage among the washerwomen of the same city, and according to the same author (Parent du Chantilet).

Now, having shown or tried to show that the disease has temporal as well as causal relations, I would again call to mind the cases referred to at the beginning. The disease being infectious, two persons were similarly infected at different times, one went about his business and endeavored to brace himself up by the use of alcoholic stimulants. He narrowly escaped death from an especially virulent attack of pneumonia. The cause was either alcoholism or exposure to cold, or possibly both. The second case went to bed; was not exposed to any further predisposing cause, but by good feeding, rest and warmth he escaped, the germs apparently being eliminated without accomplishing their mission. By rest and good nourishment the line of resistance was strengthened and the patient kept up till the germs had lost their virility or were eliminated. While it is not to be presumed that many will have an opportunity to see their pneumonia cases in the prodromal stage, it

would be advisable, in case it should so happen, to put them to bed, or at least keep them in doors, and by rest, warmth and good nourishing food, try to improve the general strength of the patient, and while pneumonia may not be averted the case is more likely to recover than if allowed further exposure, for I have observed that while many insidious cases are often among the worst, they usually occur in people whose previous health was broken down from other causes. The comparatively healthy patient may suffer for weeks with slight prodromes, such as have been described, and the disease may be prevented in some cases; its dangers lessened in all if recognized as impending or threatened by the symptoms I have mentioned.

PURPURA HAEMORAGICA.

BY DR. W. B. FOSS, ASHLEY, PA.

READ DECEMBER 3, 1902.

On September 1, 1900, a man brought a girl about 5 years old, into my office and called my attention to two or three what appeared to be bruised spots on the shins, saying they had made their appearance during that day and that they were not due to injury. These were all the spots that could be seen. I did not think them of much moment and sent the child home telling the father to keep watch of them, and to bring her back again on the following day. The next morning about 5 o'clock I was awakened by the same man telling me to hasten to his house as the little girl was bleeding from the nose and that they could not stop it.

When I reached the house I found blood everywhere, piles of clothes about the room soaked in blood and the bleeding