ACUTE BROCHO PNEUMONIA IN CHILDREN.*

By CHARLES PINCKNEY HOUGH, M.D.,

President of Rocky Mountain Inter-State Medical Association; Member American Medical
Association; Member Association of Military Surgeons of the United States;
Member Medical Association of Montana; Member State
Medical Society of Utah,

Mr. President and Gentlemen: I will not trespass upon your valuable time with tedious and laborious references to pathological anatomy, physical signs and symptomatology in this most serious and frequent disease, it being a fair presumption that ail are informed on those essential points upon which our text books are quite agreed.

Broncho-pneumonia, usually designated catarrhal pneumonia, is essentially the pneumonia of infancy. It is a bilateral disease, and when fully developed gives scattered areas of dullness on percussion. In this disease we should bear in mind the double circulation of the lungs; that is, the functional and the nutritive, and also remember the pulse-respiration ratio common to infants in health, and, as found in pneumonia.‡this is often the principal diagnostic feature early in the attack, that attracts the attention of the observing and wide-awake physician, which, with a high temperature always expected, and circumscribed rales, is good ground for apprehending this often insidious disease.

Nearly all cases of primary pneumonia in children under two years of age are of this kind, as are nearly all secondary pneumonias during childhood. In the primary affection, the mortality is high on account of the age, and in the secondary form on account of the complications to which it is sequel. It is very infrequent after four years of age as a primary disease. Male children seem to be more subject to it, and about 70 per cent. of the cases occur in the winter and spring, children with poor hygienic surroundings being most frequently attacked. posure to cold and sudden atmospheric changes are still recog nized as potent factors in its causation. To this fact I would especially ask your attention, you may protect some precious little one if you still believe that people catch cold or catch hot, as you may choose to term it. Broncho-pneumonia as sequela to diphtheria is usually due to the streptococcus infection. In twenty-five cases reported by Netter, in which only one form of bacteria was present, in ten only the pneumococcus was found, in * Read before the Wyoming State Medical Society. TA H. Smith.

W. P. Northrop.

eight only the streptococcus, in five only the staphylococcus, and in two only the Friedlander bacillus; this observation of the dif ferent kinds of cocci by the microscope would suggest some factor of irritation preceding their activity. In primary cases the pneumococcus is nearly always present, and in a large per cent. of such cases it appears alone. The mixed infection is common in secondary cases, while those cases that show the streptococcus infection are usually the most severe. The cases resembling lobar pneumonia are usually due to the pneumococcus infection.

I think it would be wise if authors and teachers would discard all synonyms in writing and lecturing upon this disease. It would do away with much confusion in the minds of medical men. The more clear our understanding in pathology, the wiser and safer our therapeutics.

The rule is for the catarrhal inflammation to extend from the bronchial tubes to the bronchioles and air vesicles, yet in some cases the disease would appear to begin in the bronchioles and air vescicles at the same time. A very large per cent. of autopsies show very general disease in both lungs; while the pathological process may be arrested at any stage, death may also occur at any stage. Resolution sometimes takes place quickly, but when it is very slow or only partial, there is likely to be recurring attacks, after which you may have chronic interstitial pneumonia Pleurisy is almost invavriably found over every large area of dullness after the fourth day, while autopsy in cases fatal on or before the third day show that up to that time the pleura is normal or only congested. Large serous effusions are rare in the pleural cavity; the disease is without typical course; while prostration is extreme from the beginning, cyanosis is usually present in some degree and is rarely absent before the fatal issue. Cough may be slight or absent; cerebral symptoms are often quite prominent. Physical signs are often few and slightly marked. Death has been reported within twelve hours after the attack, diagnosis being verified by autopsy. This type of disease passes for malignant scarlet fever or measles, with suppressed eruption, or possibly cerebro-spinal meningitis. We should not overlook this serious feature and should always examine the lungs in infants who are suddenly taken ill with embarrassed respiration, cyanosis or cerebral symptoms. The severity of the symptoms in these cases is explained by compression of the air vesicles from the intense engorgement of the tissues, almost as much as from the exudates.

The treatment is largely a matter of individual personal experience, influenced for or against the patient in accordance with the good judgment and attention of the mother or nurse,

as well as the therapeutic ability of the physician. A close clinical observer once said that in broncho pneumonia we can do but little for the disease, but much for the patient. This being recognized to be most frequently secondary pneumonia, we should not overlook prophylactic measures in those diseases that are chiefly productive of broncho pneumonia. The nose, mouth and pharynx should command our attention and be kept as clean as possible. The position of the patient should be often changed, and expectoration should be aided and encouraged. Tepid bathing and cold douching is recommended as an efficient agent in preventing broncho pneumonia, or, if it be in the incipient stage, checking its further development. By some the cold pack is preferred. The child should have a large, airy room, with an even temperature of not less than seventy (70). The atmosphere should be kept somewhat moist with vapor. The diet should be nutritious and easily assimilable; the bowels should be freely moved, by preference with calomel. Alcohol or a combination of alcohol and strychnia should be given in sufficient amount to maintain a good heart action. The preparations of ammonia with expectorants, while condemned by some, are generally accepted as being beneficial. It is my custom to irritate the chest with mustard, afterwards freely with camphorated oil, or simply use camphorated oil and turpentine, covering the chest with flannel or cotton wadding, not changing it until it becomes soiled from the excretions. I never use the oiled silk jacket, as I wish to give the full benefit of evaporation. I have much faith in diaphorsis in broncho-pneumonia. The kidneys receive my especial care. Since this is not self-limited disease and we can

not calculate as to its duration, I would urge especial attention to the diet and drink. A new fad in the diseases of infancy is to rely largely on the latter, to which I give my partial endorsement, believing it to act as an eliminant. As a rule, children get too little water, especially when indisposed. I have confidence in quinia as a tonic, in combination with ammonia and digitalis. Aconite is an efficient remedy in the acute stage. I am wholly wtihout experience with the cold bath and pack, but frequently resort to the hot mustard bath in threatened collapse or sinking, and have had from it prompt and happy effect. In reducing the temperature, cold to the head and sponging the face and upper extremities give good results. I have found it quite impossible to adopt in my family practice many highly praised hospital methods, and have believed it good judgment not to try to force methods of external treatment wherein I could not have the full co-operation of the family and the nurse. It is possibly mortifying to confess unfamiliarity with the highly commended

antipyretics, the cold bath and the cold pack, but a due regard for truthfulness justifies the statement. When mucus accumulates and the patient cannot expectorate, an emetic of ipecac or alum is beneficial. Strychnia through central stimulation is an aid to expectoration. The alternating of the hot and cold douche is said to be efficient. Frequent cough frees the bronchial tubes, but if it be annoying I use small doses of antipyrin or tinet. opii. camph. Oxygen gas is by some used with satisfaction, and the inhalation of creosote is said to be good. For extreme nervousness the bromides, antipyrin and phenaticin are used, while for failing circulation I would ommend the hot mustard bath, strychnia, nitro-glycerine, nitrite of amyl, or perhaps atropia or caf feine, hypodermically. Good and intelligent nursing and feeding is, in my opinion, the great essential, and in this particular trouble I place as much confidence in wise and tender motherly care as I do in medication.

ANCIENT VERSUS MODERN THERAPEUTICS.

By JOHN R. BAER, M.D.,

Chief Surgeon, Philadelphia Eye, Ear, Nose and Throat Dispensary,
Philadelphia, Pennsylvania.

The old saying, "Do not throw over an old and tried friend for one yet untried," does not seem to apply to medicine as much as to some associations of life, for in this progressive age of ours science has made and is constantly making such wonderful strides forward, that only those of us who take advantage of these opportunities of advancement can be classed amongst the modern therapeutists, and I fear too many of us belong to the class that is unwilling to take up any new preparations brought to our notice, because they are new and have not yet been used for decades, even though they come to us very highly recom-· mended by scores of our brethren. They are still new to us because we have not given them a trial, and instead of trying them and advancing in our therapeutics, we are willing to plod along at the same old gait and to be overtaken and passed by our more ambitious brethren with the remark, "Dr. A.; yes, he is all right, but the truth is he does not keep posted; his treatments are obsolete; I am sorry for the old gentleman, but he is losing ground daily," which is only too true. Do not misunderstand me. It is not by aimlessly jumping from one new preparation to another that we succeed, but if we find one treatment exploited, one drug explained, giving better results than what we are get

ting, we are surely serving the interest of our patients better by cautiously adopting those treatments and drugs and slowly dropping our old friend as our experiment in the new warrants our faith; in other words, drop the ancient and adopt the modern therapeutics. I have in mind one particular case where adopting the above brought about the best of results and paid very well both financially and in the gaining of new patients, while the consultants, by adhering to old methods, lost all. I will give the complete history and let you judge which of the two pays best in results.

N. D., aged 6, female. On the 25th of October, 1898, while she and her sister were playing with matches, they ignited and set fire to the dress of N. D. The result was a most severe burn, extending from the ninth rib on the left side to axilla, and from axilla to forearm. The pain (goes without saying) was dreadful and the shock severe. I was called in immediately after the accident and found the patient almost hysterical from pain. I at once gave her morphia. After the quieting effect of the opiate began to show itself, without any further ado I covered the wound with dressing of Unguentine. In a very short time the cries ceased and the child went into a quiet sleep. The family physician, with my permission, was called in, and he advised carron oil. I put that on and the next morning when I called the dressing stuck to the wound and was removed with considerable difficulty. I again put on the same dressing with the same result. Then I refused to use carron oil again and went back to Unguentine. The next time I took off the bandage the dressing proper fell off of its own accord. The result was a pleased child and a grateful mother. The consultant came and was very much provoked at my presuming to change the dressing and ordered me back to the old dressing. This I refused to do. He then sent the, family vaseline to use. I tried it once and went back to unguentine. Consultant again condemned unguentine, and this time he sent me one pound of cold cream. I applied once as before and then went back to unguentine again. This time the consultant refused to call again unless I was dismissed from the case. Unguentine won the day and I remained. The other physicians consulted all agreed that this child would be dreadfully scarred, no matter what the dressing would be. I kept on with my dressing and the result was a very complete recovery, without a scar to show for it, no eschar tissue having formed, and having had no trouble transplanting skin, not even having had to wash or cleanse the wound, as the dressing seemed to take care of itself. I was very highly gratified at the results. Would not you be so, Doctor?

I hope this will be read and accepted in the same kindly spirit in which it was written.