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Chapter IV.

Pneumonia.

One of the diseases in which cough is an invariable symptom is pneumonia or true inflammation of the lungs. Pneumonia differs from bronchitis in this respect—in the latter only the air passages (bronchi) are inflamed; in pneumonia the parenchyma or substance of the lung is inflamed; in bronchitis the product of the inflammation is mucus, which is poured out into the bronchi; in pneumonia, in addition to mucus, there is an actual filling up of the minute air cells by solid deposit—the result of plastic exudation from the blood vessels. In bronchitis the lung will float in water, in pneumonia, at least after the very earliest stage has passed, it will not float in water, but becomes a solid carnified mass.

The causes of pneumonia may be various: cold is perhaps the most frequent, especially if the person is already the subject of tubercle. But pneumonia occurs in the course of many diseases, such as fevers. The chief symptoms are, shivering followed by fever, sometimes headache, pain in the side affected, difficulty of breathing, greatly quickened respiration, cough not very severe, accompanied by the expectoration of tough mucus, which after the first day or two is tinged with blood, and is hence described as rusty coloured. Often, indeed most frequently, there is more or less inflammation of that part of the pleura situated over the inflamed portion of lung. Pneumonia generally attacks first, the lower parts of the lung, and spreads upwards. It may however attack the upper parts first, or it may be confined to isolated portions of the lung.

There have been great disputes in the profession as to the treatment of pneumonia. One party is for bleeding, or at least cupping, followed by tartarized antimony, mercury, purgatives and salines, low diet, blisters and the whole apparatus of the antiphlogistic treatment. Another party, at the head of which was the late Dr. Todd, Physician to King's College Hospital, is for giving brandy in every case. A third party exists in Germany which gives nothing at all, but trusts to the vis medicatrix naturæ.

The real fact is that none of these extreme parties are right. Pneumonia must be treated entirely according to the symptoms manifested in the particular case, and the constitution of the patient. I have never lost a case of pneumonia, and my only principles have been to he guided entirely by the state of the patient, and never to give mercury. I have had a case of double pneumonia occurring in a robust countryman in which I bled to two pints, and am sorry I did not bleed more, page 20 and gave tartarized antimony in enormous doses, without causing sickness, or producing more than a very slight effect on the pulse. On the other hand I have had many cases in which with exactly the same physical signs as in the above-named, I have given wine or brandy freely, with beef tea and tonics.

If I were in practice in a rural district among well-fed fanners, I should probably have to bleed frequently; in towns the stimulating plan is more usually required. In many cases great relief to the pain, cough, and breathing, may be given by the application of a few leeches, say half-a-dozen, to the affected side, followed by fomentations. The loss of blood is so slight as to do no permanent injury, and the ease given is well worth the loss, and is not so quickly obtainable in any other way. Whether leeches are used or not, fomentations, made more stimulating by^* mustard or turpentine, should be assiduously applied. Then if the pulse is rapid and the fever high I give tincture of aconite. I generally use Fleming's tincture in doses of three to five minims. It reduces the pulse and fever as quickly and well as tartar emetic, without producing nausea or vomiting. Nevertheless tartarized antimony may be given with great advantage in robust persons, as it promotes expectoration, while aconite merely lowers the pulse, and subdues fever. At the same time a saline, as nitrate or citrate of potash, or the solution of acetate of ammonia, should be given. After a certain number of days, differing according to the constitution of the patient, the inflammation subsides, and a gradual return to the healthy state of the lungs takes place. This "turn" in the disease is immediately known by the examination of the chest with the ear or stethoscope, and also by a remarkable change in the urine. While the pneumonia is advancing, the salts called chlorides, of which common table salt is the most familiar example, are absent from the urine; as soon as the pneumonia ceases they return to it, and may be distinguished by a very simple chemical test.

Now, if the treatment of the pneumonia has been simple, and if the strength of the patient has not been reduced by violent lowering remedies, the favourable turn in the disease will take place very speedily—more speedily than the practitioners of the old school would readily believe. The following case is an instance,—certainly it is the quickest I ever saw. I was called on Saturday, April 10th, to a stout, healthy-looking young man who was complaining of pain in the right side, with cough, spitting of rusty coloured mucus, feverishness, &c. On examining the lung the signs of pneumonia were particularly well marked. He had been ill a day or two. I ordered six leeches to the side, followed by fomentations, and gave him a saline mixture with a small dose of antimony. The next day the pain in the right side was relieved, but the fever was very high, and during the night the left side had been attacked with sharp pain. On examining the left side I found evidences of pleurisy with some effusion of fluid. Two-thirds of the right lung were solid. Ordered leeches to the left side. The next day he was page 21 much better, very little pain in either side. Cough and spitting of rusty coloured mucus much as before. The chlorides had returned to the urine. Gave him nitrate of potash, and a small dose of compound tincture of iodine, with the view of promoting the absorption of the fluid on the left side, and the inflammatory exudation on the right side. On Tuesday, the 14th, found the lung nearly restored to its healthy state on both sides; he was entirely free from pain, and there was very little cough. The next day when I called he had gone out for a walk! very much to my disgust, as he was thereby risking a relapse. I saw nothing more of him till the Friday, when he was quite well as to the lungs, out a little weak. With the exception of one bottle of tonic mixture which I then gave him, all the medicine this young man had, during a violent attack of pneumonia and pleurisy was confined to three small bottles.

In another case a young man who was attacked on the 4th of August, and seen first by me on the 5th, was convalescent on the 12th, having during that time gone through a violent and severe attack of pneumonia. On one day the breathing reached as high as 55 per minute—the healthy number being about 20. In this case, as the youth was delicate, no leeches were used.

Of course, cases occur frequently, especially in large towns, and among a low half-starved class of the population, in which it is necessary to administer wine and beef tea freely, almost from the first. This is also needful when the patient is consumptive, or affected with disease of the kidneys.

When the patient is recovering the diet should be generous and nourishing. Stout, or good ale may be given with advantage, and quinine or some of the vegetable bitters, perhaps in combination with iron, if the patient be pale and anæmic.

I believe that the lengthened and dangerous cases of pneumonia we frequently hear of, are more owing to the pernicious practice of giving mercury, and large doses of antimony, than to anything in the disease itself. Mercury lowers the vital powers, injures the constitution, and retards the recovery more than any other medicine which has been used in this complaint, while at the same time it exercises no influence whatever for good on the inflammation.