ture has been normal; and to this, and this alone, do I attribute the remarkable exemption from bowel trouble and ulcerative disaster that I have experienced.

Three or four years ago a long and very interesting article appeared in one of the leading journals giving the record, treatment, diet, and mortality-rate of this disease in the hospitals of Philadelphia, New York, and Montreal, and I convinced myself, in reading it, that the diet was excessive in them all, and that the bowel complications and death-rate were in proportion to this excess, and probably attributable to it more than to any special features of remedial treatment. Why should a patient have an atom more of food in such a disease than will barely help him live through it; and why should not everything possible be kept out of the alimentary canal? In the earlier years of my experience in treating this disease, I always carried with me a mixture of extract of coto-bark rubbed up in mucilage (because it is of little effect in any other form), and depended on it, almost without disappointment, in every relaxation of the bowels. The bismuth I usually added to it may have been of some avail, though I often doubted if it was. A stricter discipline as to diet in latter years has given me very much less occasion to use either of them.

Perhaps the greatest triumphs in the management of severe forms of typhoid fever are those achieved toward the far-off end of the disease, when a very feeble and rapidly failing heart, that may not even have been poisoned by antipyretics, warns us how close a place the patient has to pass through yet to escape. I need not repeat to you that it is now that stimulants, and nux vomica, and quiet, and no mistakes, can come so nearly performing a miracle. It is now that you can single-handedly fight away the grim monster, if only the bowels are not harassing the victim. There are those practitioners, and there are very many of them, who give stimulants long before the heart fails; but I desire to express a strong doubt as to the wisdom of the method. The human system longs for alcohol as it does for nothing else when the proper time has come, and utilizes its every element; but I offer it as a demonstration of this law, that whenever the physician can discover the odor of alcohol in the

breath of his patient, no matter what the disease or what its stage, he may safely accept it as a reminder that the prescribing of it was a mistake.

I need not say that once a normal temperature has been touched, nutritious fluids may be gently added to the patient's diet; nor need I say how long he should still lie absolutely quiet, except to add that I have never seen but a single case of relapse of the fever that was not certainly due to exertion or excess of food, and I have but little faith in calling any condition a true recurrence of the original disease.

I have said nothing of all the other complications that may come all along the way, nor need I allude again to the horrors of the discovery about this time that the case never was one of enteric disease. All these are emergencies in which the skillful and cunning practitioner knows what best to do. And then come all the sequelæ, which will, I believe, be serious or numerous, or absolutely wanting, in exact proportion, or well-nigh exact proportion, to the wisdom and caution with which the case has been managed from the onset of the disease.

In conclusion I may add that this paper has been written that I may learn some useful lesson from its discussion, and that I may have an opportunity after much experience. of emphasizing as strongly as words may do it, my strong conviction that errors in diet are the most common and the most deadly in the management of enteric fever. If I should to-morrow suspect myself the victim of the typhoid contagion, I would select my surroundings and my nurse with all speed and the utmost care, and go at once to bed. I would send for a physician who I felt sure was strong in general practice more particularly than in this one disease.

him to look most carefully for those three or four symytoms that may almost always be found, and by exclusion to eliminate every other possible condition and, unless my case was likely to be an unusually mild one, would suggest his prescribing small doses of calomel for two or three or four or six days, according to the severity of the onslaught, and that not another dose of medicine be given me till I was well again. I would beg his promise that nothing but desperation would tempt

him to give me a single dose of any antipyretic or opiate. I would secure his promise to see me every day in his careful lookout for complications, and to resort to stimulants with a free hand when he knew the time had come. I would ask my nurse for from twentyfour to thirty ounces a day of milk and enough of clear cold water, and would warn her that my temperature must never remain at 103°; I would remind her how often a tepid sponging will make a restless patient sleep. And then I would lie down with a strong confidence that there were a good deal more than ninety chances in a hundred, that on the morning of the twenty-sixth or twenty-seventh or twenty-eighth day my temperature would again be normal and all be well.

Windsor, Ontario.

TREATMENT OF ACUTE PNEUMONIA.*

BY THOMAS J. MAYS, A.M., M.D.

Acute pneumonia is a disease the symptoms and physical signs and course and duration of which are constant and characteristic; yet, strange to say, its treatment is as variable and vacillating as its death-roll is long and appalling. In the city of Philadelphia alone fifteen hundred lives are annually sacrificed to this disease. Is this frightful mortality inevitable, or is there a way to escape it? I believe that it can be materially lessened, but before this can be done we must realize the shortcomings and the mis. chievous tendencies of professional thought on this subject at the present day. believe that the want of uniformity in the therapeutics of this disease is partly traceable to the prevailing but mistaken theory that pneumonia, like measles and smallpox, is a self limited disease, and therefore beyond the touch of successful active medication. Then again, the general skepticism of this age has invaded the field of therapeutics and cast a gloom of doubt on the remedial effects of the long-honored articles of our materia medica. Both of these tendencies, in connection with the fact which has been shown over and over again that the

* Read before the Philadelphia County Medical Society.

practical results of the let-alone treatment of pneumonia are superior to those obtained when the disease receives the active routine treatment of days gone by, have brought the therapeutic art into undeserved discredit, and sown broadcast a belief that the less active the treatment the better it is for the patient. In accordance with this view it is held the disease must pursue a natural course, and all that can be done is to stand by and watch and treat any incidental danger which may develop.

What ground is there, then, for believing that the pneumonic process is self-limited, and that the therapeutic art is powerless in making a local impression on it? So far as I can see, there is no more reason for regarding the disease as self-limited than for considering any other ordinary acute disease in the same light. All maladies of this kind are limited in duration, but there is no inherent limitation in the same sense as there is in smallpox or measles. Let us say pneumonia suddenly attacks a single lobe of a lung, and in the course of three or four days it suddenly ends in crisis, and every vestige of the disease disappears.

Its sud

den onset and termination in many instances lead us to infer that it is due to the absorption and explosion of a specific poison which exhausts its energy in a few days, and to see an analogy between its behavior and that of smallpox. On the other hand let us suppose another case of pneumonia involving the same lobe of the lung: In about three days the temperature suddenly drops to within a degree of the normal line, and a favorable termination is anxiously looked for, but instead the temperature rises higher, and on physical examination it is now found that the whole of the adjoining lobe is impli cated in the process. A similar succession of events may take place in case another lobe or part of a lobe becomes involved. These

phenomena are familiar to every practitioner, and yet can anyone say that this is definite proof of the self-limitation of pneumonia? Has anyone ever heard of smallpox or measles attacking the body by piecemeal, first invading one area, then another, and so on? Is it not more probable that the duration of the pneumonic process is chiefly governed by the length of time which it natur

ally takes for the fibrinous exudation to undergo fatty degeneration, and that when the fibrinous deposit occurs successively in different lung areas the disease will be more protracted on this account than if it confines itself to the area which became primarily involved?

Moreover, it is my firm conviction that the prevailing impression that the pneumonic process cannot be controlled or restrained by means of active medication, rests on an equally insecure foundation. I am not rash enough, however, to assume that any form of treatment can be devised which will always insure against death from pneumonia, but from recent experience I believe that a mortality of twenty per cent., which is the usual death rate, is too high, and that this may be materially reduced.

I also firmly

believe that this reduction in the mortality cannot be brought about exclusively through internal medication, feeding, or stimulation, valuable as these measures are. The profession fully realizes the vital importance of sustaining the strength of the patient throughout this disease, and practically this part of the treatment is carried out with very desirable results. Far above the efficacy of all these measures, however, stands ice, or ice-cold water, the local application of which has the undoubted power of subduing and circumventing the inflammatory process in the lung.

I base this favorable opinion on the results which were brought out in my collective report on "Ice in the Treatment of Acute Pneumonia," which was published in the Medical News of June 24th, 1893. This paper embodies the condensed histories of fifty cases which were treated locally with ice or cold applications, and reported to me by professional friends, collected from the literature of the subject, or from personal observation. Out of the entire number, two died, making a death-rate of four per cent. Additionally I refer to one hundred and six other cases of pneumonia treated in the same way by Dr. Fieandt, a physician of Finland, who had a mortality only of 2.82 per cent.— giving us a death-rate among all of these cases of 3.2 per cent. Moreover, since the appearance of my paper I have succeeded in securing a number of other reports of cases

thus treated, which continue to maintain the favorable impression made by the ice treatment in the first report, and which I hope to include in a future contribution on this interesting problem.

Aside from the fact that both of the cases which died among those reported in my list were suffering from probable incurable diseases when they were smitten with pneumonia, and were, perhaps, on this account not the most impartial test for any new remedy, it is quite evident that the total showing is still better than appears on the surface. Great weight must, I think, be laid on the fact that these cases emanate from fourteen independent observers, half of which number report only one case each. This excludes largely the existence of a personal factor-an attribute and a power which grows out of accumulated knowledge and experience and gives its possessor a certain advantage over those less equipped in this direction, and goes far to demonstrate that the curative effects of ice applications do not depend on any very special artistic skill of the medical attendant.

I am often asked whether ice is as efficacious in catarrhal as it is in croupous pneumonia. On theoretic grounds one would be led to believe that it is of greater service in the latter than in the former, because the whole inflammatory process is more ephemeral and entails less organic change on the lungs in that form. While my first cases in which the ice was used were exclusively those of the croupous variety, my later experience has taught me that this measure has a similar beneficial effect in catarrhal pneumonia, provided it is pursuing an acute

course.

This is fully demonstrated by a number of the cases contained in my report, notably by some treated by Dr. Lees, and also by one reported by Dr. Franklin. Indeed, I believe it is impossible sometimes to discriminate between croupous and catarrhal pneumonia during life when the latter pursues an acute course, and especially when it takes place in infants or small children.

In what special manner should the ice be employed? For want of a better method, the front, side, and back of the affected area are surrounded with rubber bags filled with ice and wrapped in towels. The number of bags

which are needed depends on the size of the area which is involved. If this is small, only one or two bags are necessary, but in cases where an extensive area is affected I have applied as many as six and seven, which suffice to cover the whole chest. They are allowed to remain until the temperature becomes nearly normal. Very often it is found that the application of the ice to an affected spot is immediately followed by a marked lowering of the temperature, and improvement in the physical signs in the part. In a very short time, and perhaps in the midst of this amelioration, the temperature rises again, and the patient feels less comfortable than before. Further examination shows that the disease has invaded a new and probably an adjoining territory. Removal of the icebags to the fresh spot, or the application of new ones, will again be followed by improvement. This creeping feature of pneumonia must always be borne in mind, and followed up until it ceases.

One difficulty in the use of the ice-bags is to keep them constantly applied to the chest in restless patients, and this has led me to look into the feasibility of making a hollow tin jacket, which adapts itself to the chest, and through which a constant current of icecold water may be passed. Such an apparatus I have in contemplation, and when it is perfected I think it will add much to the effectiveness of the application, and will also be a greater convenience to the patient.

The subject of diet demands the most serious consideration of the practitioner, whose aim should be to administer food of the most nourishing character and in the most concentrated and digestible form. In other words, he should strive to give the stomach as little work to do as possible, and at the same time maintain the nutrition of the patient at the highest point. For this reason two ounces of fresh beef-juice, pressed out of round steak, should be given alternately every hour and a half or two hours, with eight tablespoonsful of milk, one of whiskey, and one of limewater. Beef-powder, and nutrient wine of beef-peptone, may also be given.

So far as internal medication is concerned, I would say that strychnine stands first in this respect and should be given unstintedly. Adults should receive or grain,

grain

twice a day, hypodermatically, and by the mouth every four hours, until there is a manifestation of toxic symptoms, such as an increase of the reflexes, especially of the lower extremities. A quarter of a grain of morphine is to be given subcutaneously in the evening to produce sleep. An ice-bag to the head will also help to allay cerebral excitability and restore quiet. Evacuation of the bowels should be secured by the administration of small doses of calomel and sodium bicarbonate.

When cyanosis and difficult respiration become very marked, inhalations of oxygen must be employed. The patient may inhale the gas out of an ordinary-sized rubber gasbag through a suitable mouth-piece which is attached to it. The amount of oxygen which must be given in a case is entirely dependent on the severity of the symptoms, but it is a good rule to push it until the lips and fingernails assume a more healthy appearance and the breathing becomes less oppressed, and to give it as often as it is necessary to suppress these symptoms.

Now when we compare the results of the ice treatment of pneumonia with those which are obtained from the prevailing treatment, it will show very much in favor of the former mode of treatment. Thus the mortality of 1,012 cases in the Montreal General Hospital was 20 per cent.; while in the Charity Hospital, of New Orleans, it was 20.01 per cent. From 1822 to 1889 the mortality from pneumonia in the Massachusetts General Hospital was 25 per cent. Dr. Hartshorne estimates that the death-rate from this disease in the Pennsylvania Hospital, this city, was about 31 per cent. during the years of 1884, 1885, and 1886. A comparison of this mortalityrate with that which has been derived from the treatment advocated in the present paper, shows that the latter produces results which are at least 75 per cent. better than those which are obtained when the cold applications are not employed. I know that the number of my cases is rather small to draw such promising deductions, but from my experience since they were published I am encouraged to believe that this form of treatment will not only maintain its excellent reputation, but will grow in increased favor on closer acquaintance.

Philadelphia, Pa.