pneumonia in children we must limit ourselves to a more or less definite age. I am thinking of infants under two years. None of them could say moo, especially when they have pneumonia. They are too sick and too stupid.

I was thinking of the definition of pneumonia and the things I was going to say Dr. Berg stole away from me.

Dr. Freeman and I have been seeing the same cases and we think in harmony. I read between the lines that he is thinking of the kind of cases we see at the Foundling Hospital and at the Presbyterian, and that he also sees at the Nursery and Childs. They are young children, too young to say moo. If they will only keep still and not scream we are thankful.

What is our definition of pneumonia? In my student days when I was working in the laboratory with Drs. Delafield and Prudden, it was the great question, and it seems funny today, whether pneumonia was a local disease with constitutional symptoms or constitutional with a local lesion. What is pneumonia as we

see it in children? It seems that there is a bacteremia, an infection, and whatever the cause of the so-called pneumonia, the infecting agent is certainly in the child. We can have pneumonia in the ear, in the precordium or in the heel.

It seems to me in discussing complications, that empyema is not the most common complication with us. It is commoner in older children especially if not well nourished. I have seen very few empyemas at Presbyterian Hospital but the common complication was in the ear. I have had installed in my observation ward a fifty candle power electric light that they can wheel around to the bed, and every ear must be looked at if the patient has any fever or obscure temperature. There is almost an epidemic of ear trouble. A large number of them have otitis media. It does not go on to mastoid trouble. The ear is the primary complication with me. Dr. Heiman mentioned the intestinal complication. I will take empyema every time for mine rather than a bad gastro-entero-colitis. It is a most discouraging and dreadful complication. The whole bottom drops out of our case when it has a bad diarrhea. It is more and more my way of thinking that it is a bacteremia. It seems more analogous to tubercular meningitis, this dissemination of the lesion by the blood stream to different parts. I am thinking again of children under two years. I believe Dr. Heiman is thinking of older children when he speaks of the diagnosis, prognosis, etc. The temperature chart, Dr. Heiman says, drops in the case of lobar pneumonia by crisis and in bronchopneumonia by lysis. I see many charts that look like sepsis. It is a bacteremia whose toxines give rise to an irregular chart. I learn a great many things from my house staff, though we do not always admit it. The house physicians coming from the adult services find temperatures of pneumonia in children that look like typhoids and sepsis, etc., until they learn more about them.

I don't think so much of the hardening of the muscles. If we have a sore spot anywhere, we are careful of it, but beyond that, I fail to see that the prognosis is any different.

I have been at this job twenty-nine years and I don't care about the apex part. The opisthotonos part Dr. Berg took away from me. The best picture I ever got was a child which stood on his heels and head and he died and had only enterocolitis and marasmus, nothing else.

There are quite a number of very essential things in the prognosis, diagnosis and treatment which are to be thought of especially in the young child which is two years old. To me, the essential and characteristic chart of pneumonia begins when the parenchyma of the lung is involved. A child out in the park with light clothing catches cold in the head, larynx and trachea. So far it is catarrhal inflammation of the larger bronchi which gives fever and cough, but it is not until he has parenchymatous pneumonitis that he begins to have that dopy look, continuous fever and rales of the fine kind heard at the base. It is on these that I prefer to rest the diagnosis in infancy, on the sudden onset and on the fever which gives that dopy prostration. Most of the women would tell you the child began at four o'clock to be dopy. He had a red spot in the face and began to be sick. The disproportionate respiration pulse ratio is because the pneumonia toxins stimulate the respiratory center out of proportion to the pulse center. I think that is the essential feaure of it and one of the valuable features. After that the rales.

In summing up. The sudden onset. The mother will name the quarter of the day when the child was taken sick. It was sick, dopy, and had a fever. The father was photographing the child at twelve o'clock and it was gay and a good subject for photographing and at two o'clock it waked and was cranky, couldn't do anything with it, began to be sick and ran a straight pneumonia.

When the pulse respiration ratio departs. I think O'Dwyer was the one to emphasize this and I like to think when it departs from the ratio of one to four and approximates one to three, the chances are that the disturbance is in the pulmonary tissues, that the lesion is there.

I heard a paper read mentioning a large percentage of cases of pneumonia that had before the development of characteristic pneumonia, ear symptoms. I don't recall how he verified them, whether by looking at the drum or by opening or what.

Blood count and prognosis. In these young children the blood count wobbles around most atrociously. The worst case I ever put out in the sun because it was the last resort for a desperate case, we shovelled away the snow so there was a bank on all sides and we stuck him out there. We said everything is against him, he can hardly keep enough air in his lungs to keep him from being purple. The minute he is anywhere indoors, he is restless and

, 1910

, Vol. V.

toxic and his leucocytes were away down out of sight and my freshly arrived house physician said, "He is gone sure. I have never seen a child that had such a low leucocyte count get well." I said, "Now don't you forget that. You can think again and if they are way down, give up all hope." I rubbed it into his back, front and face. I said, "Write it down. Put it into history and sign your name." The child got well so quick, it was really a brilliant recovery.

Blood count. Our men are hungry to count blood. We have men to count all the blood and keep at it. We keep them busy at it but really it does not help a lot in children. I think children are the funniest things in the world anyhow. They don't do anything they ought to but they have a way of living. When the house physician comes down, I show him a sick child, one of the worst, and say, “Are we to put him on the danger list?" He has him already on the danger list. I see that as I go in. I ask, "When the friends arrived and asked how many chances he had, what did you tell them?" "I told them he was not quite in." I then say, "Tell them when they come again that they couldn't kill him if they tried. You write that down on a little piece of paper."

There are three important things to know a lot of things about. First, summer diarrhea which is incurable. Second, pneumonia, they get well anyhow. Third, obstruction of the bowel and that is my black pest.

It is perfectly obvious from all that has been said that we cannot tuck a nickle in the slot and get a diagnosis of pneumonia in infants right away. I have been very much interested in the three classical papers. The figures of Dr. Hymanson were interesting.

Dr. Freeman's observations of the pneumonia as a general comprehensive proposition I fully endorse. We have worked in the same dead house and have seen the same cases. Dr. Heiman's paper is valuable in the extreme. It does not quite cover the same age. He begins after two years. I want him to say if that is not so. We have these three valuable classical papers. I hope they will be published.

Dr. Louis Fischer said, I will speak on the treatment which is almost as important as making a diagnosis. Considering the papers we have had so far, I think the subject and the symptomatology and diagnosis have been pretty thoroughly covered. There is no use of rehashing.

One word about pneumonia and that is in making the diagnosis of pneumonia in children, we should get away from the text-book symptoms, that is, I am usually asked, "Is it not a fact that pneumonia begins with cough and consolidation and bronchial breathing and dullness on percussion, etc?" As a matter of fact in the large number of cases seen by me, children do not cough in the very beginning. It is a symptom which comes on later in the disease. The early symptoms are high fever, disturbance of the normal pulse ratio and coated tongue, etc., which would make us

believe we are dealing with gastrointestinal indigestion, commonly called spoiled stomach. If dealing with persistent fever after castor oil and rhubarb and soda have been administered and the diet corrected and the fever persists, if throat and ears have been properly inspected and there is nothing to be found, I usually suspect a limited pneumonic process, called a central pneumonia. These are the cases which baffle us early in the disease and it will take two to three days until the diagnosis can be made positively.

In the course of the discussion I said if we have meningeal symptoms and no distinct symptoms of consolidation, it is not unwise to do a puncture because it is a very simple procedure and will help in diagnosis. I have had no less than seventeen cases of cerebrospinal meningitis in children under one year and it was only this last fall that a baby seven weeks old was brought to my service with vomiting and fever for a number of days. I did a puncture which plus the bacteriological findings gave the diagnosis.

An examination of the lung should always be made whether or not the gastric symptoms of an acute infection are present. I make it a routine practice in seeing cases for the first time to invariably go over the thorax. I think it is as important as taking the temperature, because very frequently when we least expect to find a pneumonia, we will find it.

The wandering type of pneumonia is another thing which is very disagreeable. During the present winter I have seen a number of cases of persistent fever of an acute lobar pneumonia and there it was simply a question of an extension from one lobe to another. It was the wandering type. In one case there were three distinct lobar infections in one child which simply took one month to attain its final issue. The temperature came to a crisis, there was a reinfection, a temperature rise to 104 which again persisted for six to seven days and the crisis was followed by a third rise in temperature and again its crisis.

In blood examinations, the leucocyte count is not a very important aid to me in the diag nosis of the obscure fever after pneumonia. I refer to that which has a pseudo-crisis following a normal crisis and suddenly there is a rise in temperature to 101 to 102 and this temperature going up or down which will give the suspicion of a complication. We look after the ears, try to exclude otitis media, palpate the mastoid, then we must not forget the kidneys as a possible source of infection and even in young children I try to get the urine examination at least once. The possibility of the diminution of chlorides is a very valuable aid in the diagnosis of pneumonia. The chlorides are diminished in pneumonia. It is important to examine the blood and I usually watch to see how the leucocytosis behaves. If I see the polynuclear percentage rise and the leucocytosis quite high, 23,000 to 25,000, this with polynuclears 73, 74 or 80, I look for a dull area and if I get any distant breathing and flatness or dullness on percussion, I put my needle in and

try to find pus. During the past week I have seen three empyemas and two of these were fatal. This very winter there has been quite an amount of empyemas.

we

One more word, which is very important. The treatment of lobar pneumonia. I believe in oxygenating the lungs. It is our duty. As pneumonia is a communicable disease, should exclude all useless outsiders. I am not in accord with people who teach that cold winds or south winds are very valuable for very frail and pneumonic children with subnormal vitality. I individually should say I cannot expose a child who is cyanotic in a room filled with cold air. I have seen so many fatal cases following such exposure that I desire to go on record against it. I would not do it with my own child. The effect of such exposure is fatal. When children have been coddled with blankets, etc., one must individualize.

Dr. Walter Lester Carr said, Dr. Freeman made a valuable point in connection with the etiology of pneumonia in well-to-do children as commonly having its origin in influenza infection. I think that is the most ordinary source of the disease of this type. With reference to some of the clinical varieties it is very important that we should realize that a great many men who are good observers and diagnosticians fail to determine pneumonia in an infant or very young child. A common condition is that attention is paid to minor matters with neglect of the lungs, that is, a baby with diarrhea will be treated for diarrhea without examination of the lungs. A case of this kind came under my notice where a very good physician had been treating the patient.

The irregularity of the appearance of symptoms of pneumonia associated with influenza would have to be considered in making the examination, and sometimes these are very acute in their onset; for example, a little boy I saw ten days ago in Brooklyn. This boy had measles, the temperature was normal ten days and ran to 104.5, he had very acute pain and examination of lung showed one area of pneumonia with pleurisy no larger than the stethoscope.

These conditions may be associated with the continued infection of influenza where it is supposed to be cured. A baby I saw today with a physician uptown, 21⁄2 years old, where influenza began just before Christmas with the very mild type of inflammation of the throat, had a slight discharge from one ear. It was supposed after that that the patient was all right. We found pneumonia at the base of each lung.

Another case I saw last winter was that of an Italian physician who had made all arrangements for an operation on his own child in which there was pneumonia at the base.

Some cases simulate typhoid. It is only by blood examinations and examinations of the lung that a mistake is avoided.

A leucocyte count is sometimes useless to go by. I saw a case in Jersey last month where a health officer examined a boy, found a Widal,

It

a leucocyte count of 52,000, and, on the strength of the findings, said it was a very severe case of typhoid complicated with some suppuration. The amount of pneumonia was not great. was the right axilla and in about four days, the boy was perfectly well. So I think all these conditions and associations of pneumonia in childhood should be thought of, and great mistakes may come from failure to examine and reexamine the lung.

The lung in the older children is easily examined but in younger children the condition is easily overlooked.

Dr. Thomas S. Southworth said, I would emphasize the importance of the management rather than the treatment of pneumonia. The treatment is very much overdone. I am inclined to think that a good many of the fatalities are due to excessive treatment and excessive cardiac stimulation.

Of the important things in the management of pneumonia the first is fresh air. I am surprised that Dr. Northrup would talk so long without saying more about fresh air. It is most important where the child is breathing 30 to 50 to the minute, shut up in a close room where the oxygen is removed by the patient's breathing, the lamps and sympathetic friends. I do not believe in exposing bronchopneumonia cases to cold air but I believe in giving lobar cases cold as well as fresh air and fresh air always to the broncho-pneumonia

cases.

An important thing is the food. In the initial stages of any acute infectious disease, digestion is at a low ebb. The food should be cut down and ordinary articles should be cut out and milk should be the diet, not only milk alone but the milk should be diluted. Abdominal distension is one of the serious embarrassments and that can be prevented by proper management of the diet. It embarrasses the heart and the lungs. It should be prevented and not treated.

The third thing is to secure comfort, rest and sleep. Comfort by bathing, comfort by environment. Bathing is also useful for the temperature. Don't sweat the child which has a temperature of 103-4. Allow the child to rest between the treatments some. One has noticed a nurse puttering around the room with all the lights turned on. Secure sleep by drugs if necessary and when we wish a child to sleep, be sure that the room is dark. It is almost impossible for anyone to sleep with a bright glaring light and this fact should be considered more with children than adults.

I have not said anything about treatment as such. I should reserve stimulation toward the end of a pneumonic process. Almost every hospital interne whom I have come in contact with is anxious to put every pneumonia case as soon as it occurs upon some sort of treatment-usually cardiac stimulation. My success in treatment of pneumonia is directly in proportion to my ability to restrain the staff. Don't thrash a tired horse if we want to make a successful journey. The management of

pneumonia is in aiding Nature and the chief aids are easily absorbed food, comfort, rest and sleep and the minimum of medication.

Dr. Henry W. Berg said, a thought occurred to me as I was coming to the meeting tonight that it was almost a presumption for us who are treating children and adults to come here and talk to you or pretend to lecture to you on a subject like pneumonia. I see many members of this association and pneumonia is the one disease which I find is rarely overlooked by the average east side practitioner. They know pneumonias because everyone is likely to lose his clientele if he does not diagnose pneumonia. The clientele is not likely to be satisfied.

What is the use of talking to you about symptoms which are not auscultatory, which cannot be heard? Everyone expects when we talk about pneumonia that we will tell exactly where it is. I remember a case in Fifth street. I suspected pneumonia in one boy who had a temperature. I went over the lung from top to bottom three times a day and couldn't find a sign of the pneumonia. I told the mother and father that we were dealing with a pneumonia according to all the symptoms, the 1 to 3 ratio, the child's voice, etc., but the physical signs were not there. I had Jacobi in consultation and he couldn't find the pneumonia. During the next seven days it was almost a crucifixion to go in there and not locate the pneumonia. The diagnosing of pneumonia consists in simply training the ear to recognize certain physical signs. One of the best pathologists in New York expressed the wish that some day this disease would be known as pneumonitis. Clinically there is no disease which looks so badly as pneumonia and yet there is no disease which has a better prognosis. It has made many successful physicians in New York. It is a disease which looks horrible and yet the crisis occurs and the physician gets the credit. Broncho-pneumonia is more of an insidious disease. I would rather have a child with a lobar pneumonia and a temperature of 105 than a child with a broncho-pneumonia and a temperature of 101 and going on and on and liable to end in tuberculosis.

In lobar pneumonia the disease is limited to one lobe or to one lung. We will not hear a mass of rales all over one side of the chest, not even in all parts of the same lung. They will be limited to one lobe or to one lung.

Secondly, we will find that these lobar pneumonias in the early stage are accompanied by a peculiar grunting breathing. When we enter the room we can tell a lobar pneumonia by the breathing. We cannot do this in broncho-pneumonia. A broncho-pneumonia sits up and plays with toys, a lobar pneumonia never does this. A peculiar flush, the peculiar characteristic drop of crisis, these are characteristic and distinctive things. A presence of a primary disease to which broncho-pneumonia is secondary is important in broncho-pneumonia. If we are called in to see a broncho-pneumonia, and the child has a discharging nostril, take a culture

and we will find probably the Klebs-Loeffler bacillus. That child has diphtheria and has infected the lungs and has diphtheritic bronchopneumonia. If one is not familiar with the sound of breathing over the lung in the presence of a diphtheritic membrane in the larynx, one might say this child has lobar pneumonia over the left lung. What we really hear is bronchial breathing due to transmission of the bronchial breathing from the larynx down the bronchi and into the lung.

In lobar pneumonia cases the prognosis is favorable, and in broncho-pneumonia cases the prognosis is unfavorable and in 70% of cases, we will get recovery and in 30% of cases death. It is important to give a favorable prognosis in lobar pneumonia and an unfavorable prognosis in broncho--pneumonia.

Summing up by Dr. Heiman. I want to thank Dr. Northrup for calling my attention to the ages. I really had more reference to older children.

In reference to the pneumococcus occurring in the ear and when occurring in the lung, we call it pneumonia and in the joint, arthritis, we have the same condition of affairs in rheumatism, if it occurs in muscle tissue we call it rheumatism, if in the tonsil, we call it tonsillitis.

In children up to one year, if the blood count is 15,000 to 20,000, it is still considered normal. In those cases where we have a low white blood count, we must also make a differential count.

In order to get a valuable chloride of sodium estimate in children, we should have a twentyfour hour specimen, and to obtain that in children is extremely difficult.

The real pneumonia occurring in typhoid also gives a low blood count.

Dr. Southworth mentioned the fact that cardiac stimulants are abused. I am very glad he mentioned this. We should not over treat the patients in this particular disease.

The abdominal distension is often due to the toxins due to paralysis of the gut and these are the most difficult cases and almost always fatal.

SURGICAL HINTS.

Persons who have had an arthritis or iritis in the course of gonorrhea are liable to suffer from the same complications during subsequent attacks.

In cases of relapsing epididymitis, even in the absence of a discharge, examination of the prostate should never be omitted.

Urethrotomy should be avoided, if possible, in cases of existing renal disease, so that routine examination of the urine for albumen and casts is a wise precaution before performance of this operation.

Series

PNEUMONIA IN CHILDREN.

BY

LEGRAND KERR, M. D.,

Brooklyn, N. Y.

Professor of Diseases of Children in the Brooklyn Post Graduate Medical School; Visiting Pediatrist to the Methodist Episcopal (Seney), the Williamsburgh, and the Swedish Hospitals in Brooklyn, N. Y., Consulting Pediatrist

to the E. N. Y. Dispensary.

A physician in the active practice of his profession cannot long disregard the subject of pneumonia in children. This is true in part because the disease as it occurs in the immature differs in many particulars from the disease as it occurs in adult life. A disregard of these differences must inevitably lead one into serious error while upon the other hand an appreciation of them will add much to the skill with which the disease is handled.

General appreciation of the finer points of the disease as it occurs during adult life is everywhere evident but not so much can. be said in regard to a general knowledge of the disease in childhood, therefore, I feel justified in subserving possible completeness to a consideration of the more practical points of difference in the disease as it occurs in adults or in those of more tender years. Conciseness demands that only such differences as are of practical value be considered.

Frequency. One of the most interesting questions and one which seems to puzzle the majority of practitioners is that of the relative frequency of lobar and bronchopneumonia. It has been my common experience that lobar pneumonia is considered. by a large proportion of men in general

practice as uncommon in young children and that attitude toward the disease has frequently led to its being overlooked.

There can be no question but that broncho-pneumonia is very common during the earlier and later periods of life and that after the fourth year of life it becomes comparatively an uncommon disease. But this fact should not lead us to the supposition that because a broncho-pneumonia is common during this early period of life that lobar pneumonia must be rare.

Several factors may have contributed to this view and undoubtedly one of the most important has been the infrequency with which the disease is seen post-mortem. The low mortality in children, of course, is mainly accountable for this but in addition there is the fact that when a young child dies it is almost invariably from some complication of the disease and the process in the lung has cleared up.

And, again, broncho-pneumonia is very frequently a fatal complication of lobar pneumonia in children and when death occurs the original process (lobar) has disappeared.

The difficulty has also evidently arisen through an inattention to frequent and thorough examination, to misinterpretation of the physical signs or to both.

But even disregarding these latter factors, a study of the literature would strongly indicate that results in the study of the relative frequency vary at different times and in different places and that no two groups of cases would show similar

results.

My experience has been that at least thirty per cent, of all the pneumonias of infancy are of the lobar type.

My object, however, is to again emphasize the fact that lobar pneumonia is not