Lobar Pneumonia.


Synonyms.—Croupous or Fibrous Pneumonia; Pneumonitis; Lung Fever; Inflammation of the Lungs, and Winter Fever.

Definition.—From time immemorial, the term pneumonia has been used to designate an inflammation of the parenchyma of the lungs as distinguished from inflammation of other parts of the respiratory apparatus.

The more modern definition would be: an acute infectious disease, characterized by an inflammation of the lung tissue, in which there is, first, congestion or engorgement; second, exudation or consolidation; and, third, resolution or suppuration.

General Remarks.—One has but to consult the census reports in order to be convinced that pneumonia is the most widespread and fatal of all acute diseases. There are few countries, indeed, where the death rate per one thousand does not run from 1.10 to 2.30 per cent, and the mortality ranges from ten to forty per cent. In the United States, strange to say, the death rate is higher in the Southern States than in the Northern.

Another unpleasant fact, according to the census reports of 1870, 1880, and 1890, is that the death rate has slightly increased, and that in the State of Massachusetts, from the year 1852 to 1894, there has been a progressive increase in the death rate. Osler, in his late addition, gives the mortality of pneumonia at from twenty to forty per cent.

To one who has practiced Eclecticism, especially specific medication, this mortality seems almost incredible, and one is ready to believe that, just in proportion as the medication is heroic, the death rate increases. The disease is usually confined to one lung, when it is called single pneumonia; when both are involved, double pneumonia.

Etiology.—Predisposing causes are age, sex, season, habits, environment, race, and previous attack.

Age.—While no age is exempt, the extremes of life are more liable to the disease. The greatest number occur before the fifth year, and perhaps the least number between the ages of ten and fifteen years, and from this age increasing with each decade.

Sex.—That sex predisposes to pneumonia is readily shown by consulting the census reports, and while this is explained in adults by greater exposure to inclement weather by males, and also to greater intemperance in the latter, it does not explain the greater frequency in male infants.

Race.—The colored race are not only more prone to pneumonitis, but the mortality is also greater.

Season.—Pneumonia prevails more largely during the months of December, January, February, and March, beginning in December and reaching its climax in February and March; but few cases occur between the months of April and November.

Climate.—Climate, perhaps, acts less as a predisposing cause than season, though reports show a slight increase in the number of cases in the Southern States over those above the thirty-ninth parallel.

Habits.—The drink habit has made giant strides during the last fifty years in all the countries of the world, and the drink bill of the United States, according to official reports of the past year, amounted to one billion dollars. This amount of alcohol was consumed in fermented and distilled liquors, to say nothing of that vast amount consumed in patent medicines, with which this country is flooded, and which the American people so blindly consume. Add to this a billion-dollar tobacco-bill and a growing cocaine and morphine habit, and some light is thrown on the increased mortality.

Alcohol, nicotine, and the narcotic drugs enter the blood and are carried to every tissue of the body, impairing the vitality of the whole. Alcohol diminishes the sensibility and activity of alt nerve cells, and, by combining with the free oxygen of the blood, impairs that vital stimulant and renders it less efficacious in the tissue changes of which it is so large a factor. Taken day after day, even by the so-called moderate drinker, the blood loses its vivifying qualities, the natural metabolic changes are impaired, toxic agents are retained, and the power of vital resistance to pathogenic germs or toxins materially lessened. Not only this, but the offspring of the moderate drinker comes into the world handicapped by a more feeble resisting power than that of the abstainer. If this follows the moderate use of alcoholic drinking, what are we to expect from the habitual immoderate drinker? Drunkenness tends to poverty with all its attendant ills; poorly clothed, poorly housed, and poorly fed children make up a very large class in all our large cities, and when the germs of pneumonia invade the body, they find not only a soil suitable for propagation, but with a vitality of so little resisting power that the battle between the phagocytes and parasites is but a short one.

Environment.—The increasing migration of the youth of both sexes to the cities is another important factor in the problem. In 1850 the population of the United States numbered twenty-three million people, of which twelve per cent lived in the cities. In 1900 the population numbered seventy-eight million people, of which twenty-six per cent resided in the cities. One-fourth of the people, then, are quartered in cities.

Exchanging the pure fresh air of the country for the smoke-begrimed and less pure air of the city workshops, stores, offices, and tenement-houses, in many of which a ray of sun never enters and where pure air is an unknown quantity, they are compelled to take less oxygen into their lungs, are deprived of outdoor exercise, observe less regular hours, suffer the mental strain of trying to solve the problem of how to keep the wolf away from the home, to say nothing of the dissipations that are engendered by a life in the city, and we have all the conditions that impair digestion and assimilation of food, increase excitability of the nervous system, impair the action of secretion, and weaken the vital resistance of the individual. A trip through the tenement district of any of our large cities, where the sanitary conditions are vile, will convince the most skeptical.

Previous Attacks.—Pneumonia leaves the person peculiarly susceptible to future attacks, and it is not infrequent to find patients having their third, fourth, or fifth attack.

Infectious Diseases.—Certain infectious diseases are very prone to have pneumonia as a complication, notably typhus,. typhoid fever, measles, and dysentery.

Exciting Cause.—The old idea that cold, exposure, and the sudden arrest of the secretions was the direct cause of an attack of pneumonia still has a very large following, notwithstanding the general acceptance by the profession that it is due to the micrococcus lanceolatus of Fraenkel. That cold figures very largely as a causal factor can not be gainsaid, and the frequent attacks of pneumonia, following immediately after a sudden chilling of the body and temporary arrest of the cutaneous secretions, causes a retention of excrementitious material in the blood, and which, seeking to be eliminated through the lungs, sets up an irritation sufficient to produce an inflammatory condition. Whether these same excrementitious materials produce a toxin which creates the inflammation; or whether these conditions simply prepare the soil for microbic invasion and afterwards infection,—the experimenter of the future will have to determine.

Bacteriology.—The micrococcus lanceolatus, pneumococcus or diplococcus pneumoniae of Fraenkel and Weichselbaum was first discovered by Sternberg in September, 1880. In December of the same year, Pasteur discovered the same organism, not being aware of a prior discovery; neither one, however, recognized any relation existing between the germ and pneumonia.

Sternberg's discovery resulted from isolating the micrococcus as a result of inoculating rabbits with his own sputum, while Pasteur found the same coccus in the saliva of a child dead of hydrophobia. It was not until April, 1884, that A. Fraenkel came to the conclusion that the organism discovered by Sternberg and Pasteur, and which had come to be known as the coccus of sputum septicemia, was the causal factor of pneumonia, since it was the organism most frequently found in that disease.

In 1886, Fraenkel and Weichselbaum were able to demonstrate the micrococcus as the causal agent in most cases of pneumonia. These and other experiments seem to justify the etiologist in naming this germ as the specific cause of lobar pneumonia. We are not to forget, however, that this same organism is found in the saliva of twenty per cent of healthy individuals, and in many other diseases, such as pleurisy, pericarditis, peritonitis, cerebro-spinal meningitis, and others.

This organism is a lance-shaped coccus, united in pairs; hence the term diplococcus; and is found in health in the nose, Eustachian tubes, and larynx, and in various diseases besides pneumonia.

Pathology.—The right lung- is more frequently involved than the left, and one lobe, or one entire lung, rather than both lungs at the same time. A reference to the following table compiled by Juergensen will show the relative frequency of the parts affected:

Right Lung 53.70
Right Upper Lobe 12.15
Right Middle Lobe 1.77
Right Lower Lobe 22.14
Right Whole Lung 9.35
Left Lung 38.23
Left Upper Lobe 6.96
Left Lower Lobe 22.73
Left Whole Lung 8.54
Both Lungs 8.07
Both Lungs, Upper Lobes 1.09
Both Lungs, Lower Lobes 3.34

The anatomical changes that take place in pneumonia have for years been considered under three heads or stages.

  1. The stage of congestion or engorgement.
  2. Stage of consolidation or red hepatization.
  3. Stage of gray hepatization.

Stage of Engorgement.—In this stage there is hyperemia of the part or parts involved, which increases till there is marked engorgement. At this time the tissues are of a deep-red color, firmer in consistency and heavier than normal lung tissue, and, on making an incision, the cut surfaces will be bathed in a bloody serum; there is still some crepitation on pressure, and the lung will still float. The capillaries are greatly distended, the white corpuscles appear in great numbers, and the alveolar epithelium becomes detached and undergoes granular degeneration. The hyperemia, with its accompanying redness, extends into the bronchi, which at first are dry, but this condition is soon replaced by mucus. In the smaller tubes similar changes to that of the air vesicles take place.

This stage may occupy but a few hours or extend over a couple of days. As a result of this engorgement, there is exuded into the air vesicles and smaller bronchioles a fibrous exudate, in which are found epithelial cells, fibrin and granular matter, thus giving rise to the second stage, or consolidation.

Red Hepatization.—This stage takes its name from the resemblance of the affected parts to the liver. The volume of the organ is increased, the color is purplish or mottled, and frequently there is indentation from the ribs. The tissue is now solid, no air in the cells, no crepitation, and the lung will sink if placed in water. The tissue is friable, and may be easily broken down.

The cut surfaces show a granular material, consisting of fibrinous plugs, alveolar epithelial cells, red corpuscles, and leucocytes which have filled the air vesicles. If a large portion of the lung be involved, the irritation extends to the pulmonary pleura, and this surface is soon covered with a film of fibrous exudate, and the sac may contain a serous effusion. The interlobular tissue contains the same characteristic exudate.

Gray Hepatization.—This is the stage of resolution or diffuse suppuration. The color of the lung tissue, as the name indicates, loses its dark-red color and becomes pale or grayish white. The tissue is more friable and the granular elements less distinct, and, as fatty and granular degeneration takes place, the exudate breaks down, becomes moist, and, on making a section, a turbid, purulent fluid appears. The air vesicles are filled with leukocytes, the fibrin and red corpuscles having disappeared; with this disintegration of the cellular elements, resolution is fully established and the absorbents carry it off.

Where the recuperative powers are feeble, this stage of gray hepatization may remain for several weeks, and if the exudation has been quite extensive, abscesses may form, which may open into a bronchus, or it may become encapsuled, undergoing caseous degeneration.

Changes in Other Organs.—The heart is frequently pale and flabby and contains large, firm clots, especially the right chamber, which can be removed in the shape of a cast. In no other disease is the coagula so firm and tenacious.

Pericarditis occurs in about five per cent of the cases, usually when the left lung is involved or in double pneumonia. Osler found five cases in one hundred autopsies. Endocarditis is more frequent, sixteen being reported in one hundred cases examined, five of which were of a simple character, while eleven were of the ulcerative type.

Chronic interstitial inflammation and parenchymatous degeneration of the kidneys may result.

The liver and spleen may show parenchymatous degeneration and are slightly enlarged.

Croupous or diphtheritic inflammations are among the very rare complications, and when seen are usually in the form of a thin, flaky exudate.

General Symptoms.—The period of incubation is usually of short duration, not over twenty-four or forty-eight hours, save in old people or delicate subjects, when it may last for three or four days. During this stage there may be catarrhal symptoms, with a short bronchial cough, oppression of the chest, and hurried respiration; headache and general malaise, make up the list. Usually, however, the onset is quite sudden, being ushered in with a chill of pronounced character, lasting from thirty to sixty minutes. This may occur while the patient is at his work, or may awaken him in the night. So pronounced is the chill that it is characteristic of this affection, no other acute disease comparing with it; for this reason it is one of the earliest diagnostic symptoms.

In children, a convulsion may replace the chill, while in old people a sense of chilliness may replace the rigor. Febrile reaction follows, the temperature rapidly rising to 104° or 105° within the first twenty-four or forty-eight hours. The skin is hot, dry, and constricted, the face flushed, especially the cheek of the affected side. The eyes are bright, pupils contracted, there is headache, and the patient is quite restless. The urine is scanty and highly colored, and the bowels are constipated, though occasionally diarrhea is seen from the beginning. The tongue is dry and covered with a white, pasty coating; there is loss of appetite, and the patient experiences great thirst.

His position in bed is another characteristic feature, the patient lying upon the affected side; by this means the lung and pleura are held more quiet, and thus the acute pain is lessened.

After three or four days, the patient assumes the dorsal position. A short, dry, hacking cough is one of the early symptoms, which is attended with but little expectoration. The breathing is short and rapid, expiration often being audible and accompanied by a "grunt;" there is unusual expansion of the chest, and the alae nasi dilate forcibly on inspiration. The pulse is full and bounding, save in the aged and those of feeble vitality. Herpes of the lips occurs more frequently in this than in any other disease.

Special Symptoms.—Temperature.—The temperature rises rapidly, reaching 105° or 106° within fifteen or twenty hours. Having reached the maximum height, it runs a uniform course for from five to seven or eight days, there, being but from one-half to one degree difference between the evening and the morning temperature. This uniformity of temperature continues to the crisis, which takes place from the fifth to the. tenth day, when it rapidly declines, frequently reaching the normal in eight or ten hours, and not infrequently becoming subnormal. In old people, drunkards, and delicate people, the temperature does not run so high, rarely exceeding 103°.

Pain.—Pain is a prominent symptom of most cases, the exception being where but a small portion of the interior portion of the lung is affected, or where the apex is the seat of the disease. The pain is sharp, lancinating, or throbbing in character, and usually in the region of the nipple. A full inspiration increases the pain; hence we find the patient grasping the side as if to prevent the motion of the lung, and the breathing is shallow. With the consolidation of the lung, the pain becomes much less severe, often disappearing entirely.

Respiration.—While the respiration is rapid in all fevers, in pneumonia it is characteristic, dyspnea being a marked feature.

Following the chill, the respiration is short and rapid, ranging from thirty to sixty in the adult, and from fifty to a hundred in the child. As the stage of engorgement passes to that of hepatization the breathing becomes quite labored. When the cough is paroxysmal and when the expectoration is unusually viscid, the breathing is very distressing, the patient being propped up in bed, while he grasps some object to give greater freedom to the expiratory muscles. The face takes on an anxious expression, and the gravity of the case is evident to the merest tyro in medicine.

Cough.—Beginning with the invasion of the disease, a short, dry, hacking cough, attended by more or less pain, suggests a wrong of the respiratory apparatus, and by the third or fourth day it is characteristic, the patient using every effort to suppress the paroxysmal, frequent cough. In hard drinkers, or in feeble, aged patients, it may be much lighter and in some cases entirely absent.

Expectoration.—The expectoration is often delayed for two or three days, though a white, frothy mucus may be raised the first day. The mucus is foamy or filled with little bubbles, and is readily recognized as coming from the lung. Occasionally a hemorrhage is the first material to appear.

By the second or third day the sputum is characteristic; thick, viscid, and so tenacious that it runs together in the vessel, which may be inverted without discharging it. Occasionally this tenacious, gluey mucus is streaked with blood, though this more often occurs in bronchitis. By the fourth or fifth day the mucus has become opaque, and is intimately mixed with blood, giving it a rusty or orange color, and so characteristic is this sputum as to be pathognomonic.

In low grades of the disease, and sometimes in old people, the mucus may be of a watery character, and of a prune-juice color. The quantity varies—in some it is very scanty, while in others it is very profuse. As resolution takes place, the rusty color gives way to a yellow mucosity.

Physical Signs.—Inspection.—As before remarked, the patient will be found lying upon the affected side if one lung be affected, or on the back if both lungs are involved. The first few hours may not reveal to the eye the changes that are taking place; but, after twenty-four hours, inspection of the chest shows a restricted motion on the side involved, and increased expansion on the well side; and later, when complete consolidation has taken place, the expansive power entirely disappears. The frequency and difficulty of respiration and the dilation of the alae nasi are not to be overlooked.

Mensuration will show an increase in volume on the affected side.

Palpation.—The tactile fremitus is increased over the congested area, while the absence of expansive power is very suggestive.

Percussion.—During the stage of engorgement, but little information will be gained on percussion, and if the inflammation be in the more central part of the lung, and but little of its circumference be involved, the percussion note will be normal. As the exudate takes place, however, the dullness increases, and in the second stage is complete.

Figure 19. Lobar Pneumonia. With the beginning of resolution the peculiar dead or flat note begins to disappear, resonance becoming more marked each day, till the exudate entirely disappears and the lung is restored to health.

In some cases, restoration is not complete for weeks or months; and in some, never. Percussion gives us valuable information in these cases.

Auscultation.—In the early stage, the rhythmical respiratory murmur is replaced by a dry or sibilant rhonchus, which soon is replaced by the coarse crepitant rhonchus, this latter sound resembling the crackling noise of salt when thrown on the fire, this crackling becoming finer each day as the air cells and finer bronchi become filled with the exudate. The sounds now are fine, resembling the sound of hair rubbed between the fingers. When consolidation is complete, crepitation ceases, to be resumed as resolution takes place, the crepitant sounds being reversed; viz., the very fine crepitant sounds being followed by the coarser or loud crackling sound, and in time by the musical rhythmical murmur of health.

Figure 20. Acute Pneumonic Phthisis. During the stage of red hepatization, when the crepitant rales disappear, we have tubular breathing, as heard in health over the larger bronchi. The sound of the voice is transmitted through the consolidated lung with peculiar intensity, and is termed bronchophony; and when a peculiar nasal sound is imparted, the term egophony is used.

Complications.—Pleurisy.—The pleura is involved to some extent, in all cases of pneumonia where the surface of the lung is involved, and can hardly be called a complication; but where the pleura is early involved or takes precedence in the inflammatory process, it is termed pleuro-pneumonia. Occasionally we find pneumonia of one lung, and pleurisy on the opposite side. With this complication there is increased difficulty in breathing, the respiration being shallower and the pain more severe.

Bronchitis.—The inflammation often extends to the bronchi, and bronchitis is a frequent complication. Here the breathing becomes more difficult and the cough more harassing; the sibilant rales, followed by the mucous rhonchus, determine the condition.

Pericarditis.—This is not a very frequent complication, though in children it is found more frequently than in the adult. It occurs more often when the left lung and pleura are involved. The history of rheumatism is of importance in these cases. The symptoms are, increased dyspnea, diminished heart sounds, and a feeble pulse.

Endocarditis.—This occurs more frequently than pericarditis, and like the latter is more apt to occur when the left lung and pleura are involved. If valvular troubles have previously existed, there is a greater tendency to this complication. The symptoms are obscure, even in severe cases, the conditions generally being discovered post-mortem.

Meningitis is a serious complication, though not very frequent. It occurs more frequently in children of an active nervous temperament. It will be recognized in the child by restlessness, rolling of the head, and starting in the sleep.

Gastric Complications.—These are recognized in two conditions,—one of irritation, and the other, atony. In the one, there is nausea and retching and tenderness over the epigastrium; the tongue is narrow and elongated, reddened at tip and edges. With this condition the inflammation is more active and the temperature higher.

Where there is atony, the tongue is full, broad, and heavily coated. The skin is not so dry and harsh, and the temperature does not run so high. Resolution is delayed, and there is a greater tendency to congestion of other organs.

Jaundice is rot uncommon; when it occurs, all the symptoms are more intense.

Typhoid Pneumonia.—While pneumonia is a frequent complication of typhoid fever, enteritis seldom occurs as a complication of pneumonia. In the rare case where it occurs the symptoms are as follows:

"A protracted chill; febrile reaction coming up slowly; the pulse frequent, soft, and fluent; heat of the surface not greater than natural; coldness of extremities; bowels easily acted upon or tendency to diarrhea; limpid, frothy urine; dirty coating of the tongue; and especially that dullness and indifference so characteristic of typhoid or typhus diseases. The inflammation in this case is ataxic; there is difficult breathing and cough, with watery expectoration.

"Physical examination gives us rapidly increasing dullness on percussion to a certain degree, at which point it remains, sometimes, during the entire progress of the disease; there is no crepitant rhonchus, and the mucous rhonchus sounds hollow and distinct. This condition is of variable duration, sometimes the disease is slow and protracted for weeks; at other times it is rapidly fatal." (Scudder.)

Recurrence.—There are few acute diseases in which there is a recurrence as often as in pneumonia. Each attack may be more severe, though this is not necessarily so.

Diagnosis.—The diagnosis is usually not difficult. The sudden and marked chill or rigor lasting from thirty to sixty minutes; the high febrile reaction; the anxious expression on the face and the dusky red spot upon the cheek; the quick, shallow respiration; the short, dry, hacking cough; the sharp pain over the affected part; the sharp, crackling, crepitant rhonchus, followed by the fine crepitant rales; the dullness on percussion; the frothy sputum the first twenty-four or forty-eight hours, followed by rusty expectoration,—are symptoms that are so characteristic as to leave but little doubt, not only as to the disease, but also as to the degree and stage of the inflammation.

The doubtful case is found in old people, where the initial chill is either slight or entirely absent, and where the cough is slight or absent, and when the inflammation is deep-seated and but few physical signs are present.

Prognosis.—Although pneumonia is regarded as one of the most fatal of acute diseases, and, according to recent allopathic authorities, is progressively increasing, I am sure that a very large per cent should recover; that the mortality should not be over from three to five per cent. This may seem to be an extravagant statement to one who has practiced the treatment as advocated by the dominant school, but the record of Eclectic treatment in pneumonia will bear me out in the assertion. If seen early, the inflammatory process can be so modified that the severer types will be seldom seen, and an early convalescence assured.

Treatment.—If there is any one disease more than another that shows the superiority of Specific Medication over the old methods of treatment—and I might also add the present methods that are attended by a mortality of from twenty to forty per cent—it is pneumonia. The experience of the profession, for the last century or more, is that the more active or heroic the medication, the greater the mortality.

The expectant treatment, which is no medication, has yielded far better results than the old method of drugging, and while we would prefer that to the old, we believe that there is still a much better way.

Pneumonia is a typical inflammatory disease, and if we have remedies that will overcome these conditions, we certainly have remedies that are curative.

General Management.—Where possible the patient should be placed in a large, sunny, and well-ventilated room. Plenty of fresh air must be admitted, though all draughts of air should be avoided. The temperature should be uniform, and not over 68° or 70°. The patient should have a loose woolen night-dress, and only sufficient covering to keep him comfortable. The care of the bed and secretions must be as scrupulous as in typhoid. Only one attendant should be with the patient.

Diet.—The diet should be liquid and consist of milk in some form or broths, and given at regular intervals. A good table water may be used freely.

Medication.—Wrongs of the circulation occupy the first place in many cases, but not in all. In some, wrongs of the blood itself precede all others; while in another class, wrongs of the nervous system take precedence. Such being the case, conditions have to be met and overcome before we can effect a cure, and it is this prescribing for definite conditions that brings about success.

If we keep well in mind the pathology of the different stages of this disease, we are not apt to become confused or go far wrong in the treatment. Thus, in the first stage, there is usually an active condition of the circulation; the heart beats rapidly, the pulse being full, strong, and bounding; the capillaries become full and distended, giving us the stage of engorgement. If we are to relieve tills engorged condition, we must slow the heart and circulation, and I know of no remedy that will accomplish this end with such happy results as veratrum, if used skillfully. It does not depress and weaken the heart like the coal-tar products, but acts kindly, slows the pulse, reduces the temperature, and relieves the obstructed venous capillaries. Its action is uniform and easily controlled, even in the large dose.

Aconite is the remedy where the heart's action is rapid, but the pulse is small but hard and wiry. It is generally prescribed in the sthenia of children, while veratrum acts better in the adult. Should the heart be weak, as shown by a small, feeble pulse, aconite must not be given, save in the very small dose.

Pilocarpus or jaborandi acts kindly, where there is high temperature, great excitement of the nervous system, and a dry, hot skin.

With these remedies as our sedatives, we have the foundation for a successful treatment, for they not only relieve engorgement in the early stage, but materially assist in the removal of the exu-dates that follow, and, where carefully used, the second and third stages are so modified as to furnish but little need for alarm.

The indication for the remedies that have been so successfully used in pneumonia is as follows:

Veratrum.—One of the characteristic symptoms of the majority of pneumonia patients is a full, free, bounding pulse; in other words, there is an excess of heart power. Now, if we have a remedy that can reduce the force and frequency of the pulse, without reducing at the same time the vitality or resisting power, we have a remedy for this condition. Experience proves that we have such a remedy in veratrum. Our prescription, then, for this active, sthenic condition, as marked by the full, bounding pulse, will be this agent, and we will administer it as follows:

Veratrum 1 drachm.
Sulphate of Morphia 1 grain.
Aqua 4 ounces. M.
Sig. Teaspoonful every one, two, or three hours as the symptoms indicate.

The morphia used is to counteract the nauseating effects that sometimes follow the use of veratrum.

Jaborandi.—This is the remedy so highly extolled by some Eclectics, where the temperature is high, there is great excitement of the nervous system, and where the skin is hot and dry:

Specific Jaborandi 1 drachm.
Aqua 4 ounces. M.
Sig. Teaspoonful every hour.

Aconite.—While the average pneumonia patient has a full, strong, bounding pulse, there are cases where just the opposite condition exists; the pulse is small and frequent and shows a defect in the heart's action, debility; the heart beats rapidly to make up for want of power. We find this pulse in children and patients of delicate constitution, and frequently in old people. The heart needs a stimulant or tonic; in such cases the small dose of aconite slows the pulse and increases the tone of the heart by overcoming irritation and quieting the nervous system. Aconite in the small dose is not a depressant. The prescription here will be:

Aconite 5 drops
Water 4 ounces
Sig. Teaspoonful every hour.

Given in this way the heart is not depressed, nor the vitality of the patient impaired. In the place of adding to the load the patient has to carry, we have relieved him of a part of his burden.

These three remedies form the foundation upon which we will build a successful treatment.

Bryonia.—This agent has been found of great value in diseases of the chest of an acute nature. When the pulse is hard and vibratile, and when the pain is sharp and lancinating, with flushing of the cheek, and there is a hard, harassing cough, bryonia will be the remedy to give relief. It also favors absorption of the exudate. If the pleura be involved, it is an additional reason for its use. It combines nicely either with aconite or veratrum, and can be dispensed with the sedative, or it may be used separately, alternating each hour with the sedative. It should be given in the small dose, not over five or ten drops in half a glass of water.

Asclepias.—This is another excellent remedy in diseases of the respiratory apparatus, and occupies an important place in the treatment of pneumonia. It acts upon the sudoriferous glands, overcomes the dryness of the skin, relieves the tight, hard cough, modifies the sharp pain, and hastens absorption. It also takes the edge off the sharp pulse, adds tone to the heart, and quiets the nervous system. To get the best effects, give from five to ten drops in hot water every one, two, or three hours. It is especially useful in infantile pneumonia with high fever and dry skin.

Ipecac.—Ipecac, if given in small doses, is one of our best remedies in overcoming irritation of the mucous surfaces; and in children, where there is an irritating cough and the child is unable to obtain rest, the small dose, say five to ten drops in half a glass of water, will be found of great value.

Lobelia.—I would hardly know how to treat infantile pneumonia without the small dose of this old but valuable remedy. In those cases where the finer bronchioles become choked with the exudate, and the child's breathing is labored, and there is a mucous rattle, I know of no other agent that can take its place. In the adult, there is labored respiration, a sense of fullness and weight and oppression about the heart, while the pulse is oppressed or small and feeble. There is increased secretion of mucus in the respiratory passages, but the patient seems unable to remove it. In these cases lobelia, five to ten drops, in water four ounces, will give the best results.

If the patient is seen early, few cases will need any other than the above-named remedies, and the mortality will be very low.

Occasional Remedies.—Macrotys.—When the patient complains of muscular soreness, or where there is a tendency to rheumatism, macrotys will prove an excellent agent, ten to twenty drops, in water four ounces, a teaspoonful every hour.

Sanguinaria.—This is a good remedy where there is a tickling sensation in the throat, resulting in an almost constant paroxysm of coughing. I like the action of nitrate of sanguinaria here better than that of the tincture and give,

Sanguinaria 1/4 grain.
Aqua and Simple Syrup 2 ounces each. M.
Sig. Teaspoonful every hour.

Phosphorus.—Where the pulse is small, the skin cool, and temperature subnormal, this is a good remedy to start up the fires and give the patient a chance for his life. Very rusty sputum is also an indication for this agent.

Sticta Pulmonaria.—Where the patient has a hard, racking cough, with pain in the occiput and between the shoulders, we should not forget this remedy; ten to thirty drops, to water four ounces, a teaspoonful every hour.

Complications.—Gastro-Intestinal.—In some cases there is great irritation of the stomach and bowels; so much so that neither food nor medicine is retained. The tongue is red at the tip and edges, and it is narrow and elongated; there is nausea and vomiting and retching, tenderness on pressure over the epigastrium, and frequently diarrhea. Respiration is shallow and painful; skin dry, and constricted. Fortunately the remedies to give relief to this irritable condition are also useful for the primary lesion—aconite and ipecac, with a sinapism over the epigastrium. If the nausea persists, bismuth in mint-water will be useful. Small bits of ice may be held in the mouth, thus allaying the thirst and quieting the nausea.

In place of this condition there may be atony; in either case, absorption of food and remedies is prevented. Here the tongue is broad and pallid, with paleness of the mucous membranes, or there may be a heavy, pasty coating upon the tongue. The temperature is not so high as in the former case, nor the cough so continuous or harassing.

Nux Vomica.—If the tongue be broad and pale, with pallidity of the mucous surfaces, five to ten drops of nux, in water four ounces, a teaspoonful every hour, will be good medication.

Podophyllin.—If the tongue be broad and full, with a dirty, yellow coating, and a sense of fullness of the abdomen, and if there is a dirty, yellow, doughy skin, the bowels sluggish, the respiration oppressed, the superficial veins full and prominent, Podophyllin will do good service. It may be given in one-half-grain doses every two, three, or four hours, till the bowels open and the tongue cleans, or we may use the second trituration, three to five grains, in the same way.

Antiseptics.—During some epidemics, there seems to be a tendency to sepsis, and the symptoms are of the typhoid type. The principal remedies in these cases are the antiseptics.

Sulphite of Sodium.—Where the tongue is moist, with a nasty, dirty coating, a saturated solution of sulphite of sodium in table-spoonful doses every three hours, is a most excellent remedy.

Chlorate of Potassium.—Where the tongue has a moist, yellow, pasty coating, with a fetid breath, a saturated solution of potassium chlorate and phosphate of hydrastin, will be the best remedy.

Acids.—If the tongue be dry and grown, with redness of the mucous membranes, then hydrochloric acid, C. P. 10 to 20 drops, to water and syrup, two ounces each, will replace the alkalies.

Echinacea.—When the tongue is full and of a dusky hue, and the tissues of the same dusky color, echinacea from one to two drams, to water four ounces, a teaspoonful every hour, gives good results.

Baptisia.—The tissues appear as though frozen, are full and dusky; the tongue is full and purplish in character, while the expectoration is dark, thin, and of a prune-juice order; there is diarrhea of an offensive character,—with these conditions, baptisia becomes a prominent agent: ten to thirty drops of the tincture, to water four ounces, a teaspoonful every hour.

Wrongs of the Nervous System.—Irritation of the nervous system, with a tendency to meningitis, will give us the flushed face, bright eyes, and contracted pupils; the patient is restless, uneasy, and wakeful; the temperature is high. To the appropriate sedative we add ten to thirty drops of gelsemium, and give a teaspoonful every hour.

Rhus Tox.—Where there is irritation of the cerebro-spinal centers—as will be shown by the sharp stroke of the pulse, the restless, irritable condition, the sudden starting in the sleep, the contracted and pinched features—rhus tox. will be our most valuable remedy; five to ten drops, in water four ounces, to which has been added aconite five drops; a teaspoonful every hour.

Belladonna.—There is not infrequently marked capillary congestion. The pulse is obstructed and feeble, the face is flushed and dusky, the extremities are cool, the eyes dull, and the pupils dilated, where the patient is inclined to doze or sleep most of the time. With these evidences of general congestion, we give belladonna 10 drops, to water four ounces, a teaspoonful every hour.

Quinia.—If periodicity is a marked feature and the tongue is moist, quinia and hydrastin will prove beneficial.

Strychnia.—Where there is a feeble pulse, with tendency to heart-failure, strychnia, one-thirtieth grain every four or five hours, is demanded.

Local Applications.—It will be difficult to convince some of the older practitioners that a pneumonia patient will do as well, if not better, with a light flannel bandage over the chest, than the mush-jacket or the old hop-poultice. I am sure that many patients have been harmed by the improper application of the poultice. Where they are allowed to grow cold, there is great danger of chilling the patient. If they must be used, always have two poultices made, and while one is on the patient, the other may be in a steamer on the stove, and as soon as one begins to get cold, have the hot one at the bedside so that it may immediately be placed upon the chest as the other is removed.

A better plan, however, is to spread a flannel or cotton cloth with lard, and dust emetic powder over the surface, and, after heating this, envelop the chest; or if but one lung be involved, cover the affected side. Where the skin is very tender, this powder sets up too great an irritation, and we resort to other measures.

Libradol spread upon a cloth, and applied hot, will give good results. It should be renewed night and morning. These latter applications are light, do not oppress the patient, are easily applied, and there is no danger of taking cold while changing them.

The Eclectic Practice of Medicine, 1907, was written by Rolla L. Thomas, M. S., M. D.