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appetite good; physical signs of bronchitis, with exception of very slight dullness on percussion over seat of pneumonia.
CASE XII.- March 10th. James Brown, æt. 25, steward of steamer, was admitted with severe typhus fever, of which he had been ill one week. There was great prostration on entrance, with no signs or symptoms of any other disease, except the secondary bronchitis so frequent in connection with typhus.
The usual treatment, by proper nourishment and stimulus, was resorted to. There was no material change in his condition until the 13th, when it was observed that there was a great aggravation of his pectoral trouble. The pulse was 120; respiration 36. Over the ward could be heard the loud tracheal rattle indicative of effusion into the air tubes.With the cough, which was very troublesome, rusty colored, viscid expectoration, with copious bronchitic aerated mucus, was seen. The chest was resonant on percussion, except at the lower posterior half, on each side, where the dullness was well marked. Over the whole thorax were heard coarse subcrepitant râles, except where dull percussion had been observed. Here, there was finer crepitation, with well-marked bronchial respiration, and broncophony. To relieve the threatened suffocation, which seemed imminent, emetics of sulphate of zinc were used, as in Case II. Their action was most satisfactory, the lungs being promptly disgorged of their accuniulated secretions, and the dyspncea relieved, without subsequent nausea or prostration of strength. For forty-eight hours, it was found necessary to resort to them, generally twice in the day. During all this time, beef tea with milk punch and carbonate of ammonia, were regularly administered. His posture in bed was from time to time changed. March 15th. Improved in every respect. Coughs and ex pectorates freely, dyspnoa less, strength better. Dullness over hepatized lung diminished ; coarse subcrepitant rhonchus audible at this portion of chest. March 26. Discharged cured.
Of the two fatal cases, one was fairly moribund when first seen. It occurred in the person of a confirmed inebriate, and attacked the upper part of the lung, as is not unfrequently seen in the pneumonia of sufferers from delirium tremens. Treatment seemed to produce no good effect; nor do I think venesection or calomel would have proved useful in the case (VI).
The other fatal result (Case II.) was in the person of a man with completely developed spanaemia, the result of a malarious fever of the Isthmus, in whom the pulmonary inflammation was complicated with universal bronchitis, and whose extremely prostrated state allowed nothing more heroic than calomel to be used. This seemed productive of no good, and he ultimately died of the secondary bronchitis.
In the other cases, the treatment, with the exception of that which had reference to particular symptoms, was negative, so far as it was specially addressed to the cure of the disease. Diet, repose, change of posture, and relief by vomiting free accumulated bronchial mucus, constituted the whole.
It often occurs that patients enter the New York and Bellevue Hospitals, whose histories are such as have been related in the foregoing cases. They have been taken ill with a chill, pain in the side, cough and fever, which have disabled them from work. Looking upon their illness as a “bad cold,” from which a few days' rest, with a dose of oil or salts, will relieve them, they take to bed, and remain, in expectation of recovery, from four or five days to a week, when, finding no improvement in their condition, they have recourse to the Hospital. The account given of themselves, taken with the results of physical exploration, leaves no doubt that inflammation of the lungs is the disease in question.
On referring to those who have written systematically on the pathology and therapeutics of this malady, and whe, with students and young practitioners, constitute authority, I have been struck with the almost uniform tendency to consider pneumonia as a disease which threatens life in a most serious manner, and which requires, for its successful management, the energetic employment of antiphlogistic remedies. True, there are, by some, exceptions made in the cases of very old people—of those who have been attacked whilst greatly debilitated, and in epidemics of typhoid pneumonia ; but there is still, no doubt, a very general recognition of the necessity for opposing what is looked upon as a formidable disease by heroic remedies. By some authors, implicit reliance is placed upon early resort to the lancet, to scarified cups, and to the production of the constitutional effect of mercury on the system, by inducing ptyalism. By others, the Rasorian administration of tartar emetic is regarded as the means most likely to insure a certain and speedy cure of the disease. It would not, perhaps, be erroneous to state that one or other of these, or a combination of the two, constitute the basis of En. glish and American therapeutics.
Observation, by comparing the progress of cases in which bleeding and mercurialization had been trusted to, with those in which rest, proper regulation of ventilation, and appropriate diet, together with such juvantia as might be indicated in any particular case, has seemed to convince me that in pneumonia, as we see it in New York, entirely too much stress has been laid on the necessity of having recourse to the former therapeutical course. Nor can I resist the conviction that, in other localities, a careful study of the natural history of the disease would tend to lower the general estimate in which blood-letting and calomel are held, as potent agents in curing pneumonia.
Skoda, drawing not a drop of blood, employing solely extractum graminis, or a few grains of niter, and in a few instances corrosive sublimate, lost three, only, of forty-four patients, whose average age was between twenty-five and twenty-six years.
Varrentrapp, following the example of Wacherer and Baumgärtner, teaches us how the disease may be successfully brought to convalescence by giving no medicine internally except chloroform vapor, applied by inhalation to the mucous membrane of the lungs. His results show a mortality of one in twenty of those treated in this way, or 5 per cent., agreeing very closely with those of Wacherer, Baumgärtner, Helbing, and Schmidt, who, in one hundred and ninety-three cases lost nine, or 4.25 per cent., on the chloroform treatment.
In 1848, Dr. Dietl, of Cracow, published the result of one hundred and eighty-nine cases of pneumonia, treated by diet and rest alone. Of these he lost only 7.4 per cent. In 1853, he published a second pamphlet, detailing the success he met with in seven hundred and fifty or sixty cases, treated entirely by hygienic and dietetic means. I regret that this monograph has been mislaid. I can only state that the general result accords with that above mentioned, and served to confirm in his mind the superiority of the expectant, over the methods by venesection, calomel, or tartar emetic.
Skoda, Varrentrapp, and Dietl, had all previously commenced their practice by treating inflammation of the lungs according to the traditional means last mentioned. None of them, although good diagnosticians and men of great intelligence, have been otherwise than satisfied with the result of their change of practice. Skoda is not more active in reality than Dietl, in his treatment; nor can it be truly said that the inhalation of chloroform does any thing in the way of curing the disease. They all trust to the well-known potency of nature, when allowed to act without restraint or interference ; and if they had never made any other contribution to medical science, these physicians would deserve the gratitude of the
profession for the information, so little possessed before their researches and so inadequately diffused at present, that pneumonia has a natural tendency to get well when let alone, in a great majority of cases in which it attacks healthy subjects; and that more harm than good results, as a general rule, from the employment of what are called heroic remedies in its therapeutics.
Had Dietl, Skoda, or Varrentrapp, experimented with the infinitesimal puerilities of Hahneman, instead of adopting the course actually pursued, we might easily imagine the result on their minds, if they had been as susceptibly constituted as those of many men who, having compared the results of Sangradaism with those of Hahnemanism have joyfully embraced the latter creed, without ever entertaining a suspicion that truth was to be found neither in one extreme nor the other, but where it usually exists, in the happy medium.
The above is the substance of some clinical remarks delivered at the New York Hospital, when reviewing the treatment of pneumonia, during the months of January, February, and March, of the present year. I have not touched on the questions as to whether there may not be means employed which will relieve particular symptoms, such as pain, cough, and dyspnea, from excessive secretion and from intestinal accumulations. I am very sure that we do possess such juvantia, and that the result of common experience has left no doubt of their value. What I have endeavored to inculcate is the fact that, in the disease under consideration, there is no absolute necessity for resorting to extreme measures.
In examining candidates for posts in the House Staff of Bellevue Hospital, since the year 1847, I have had graduates from nearly all sections of the United States among the applicants, and have been impressed with the fact, that nearly all of them have been imbued with the firm conviction that inflammation of the lungs was a most dangerous affection, one which, if not promptly attacked with the lancet and cal. omel, or by antimonial medicines, would be very apt to prove fatal to the patient. To such, it has given me satisfaction to show the progress of the disease in cases which have entered the service with all the signs and symptoms of pneumonia, which have had no medicine previously to admission, and for the management of which, attention to diet, ventilation, posture, and a few teaspoonfuls of mucilage of gum arabic in the day, have constituted the sole treatment. Nearly all have been persons of the laboring class, whose return to health was a matter of importance. How different their condition, after the subsidence of the disease, from
that of others who had been copiously bled, or who had undergone "a course of mercury !"
I do not speak of the power of venesection, as an ectrotic, in the first stage of the disease. My experience has reference to it as seen in hospitals, and as it is almost always met with in private practice. It would be instructive to have a number of such cases detailed, with the evidence that the disease really was the one in question.
34 East 14th street, April 16, 1855.
Case of Perforating Ulcer of the Stomach, with obscure symptoms ; death
in fifteen hours. By SAMUEL A. PURDY, M. D.
The following case, occurring in my practice, may be of some interest to the profession, not, perhaps, so much from the infrequency of its occurrence, or its bearings upon practice, as from the disguised character of the symptoms, its rapid progress, and the suddenness of its termination.
I was sent for in great haste at 2 o'clock in the morning of March 19th, to see Joanna B., about 20 years of age. She was a servant in one of the families that I attend, and had been with them about three weeks. Upon making some inquiries, the following is all that I could ascertain in reference to her case : Prior to my attendance on her, she was
noticed to be pale and sickly-looking, and though anxious to fill the . duties of her station, moved about as if in pain, with an appearance of languor and debility. She was occasionally sick at her stomach, and complained of a constant pain at the epigastrium. The vomiting, however, was not a prominent symptom, occurring only at long intervals, but the pain she described as peculiar in its nature, being, as she frequently expressed it, dragging in its sensation. There was loss of appetite, and other symptoms such as are observable in any ordinary case of dyspepsia.
She retired to bed on Sunday evening, March 18th, at 10 o'clock. After being in bed about half an hour she was seized with a violent pain at the epigastrium, so severe, in fact, that she started up suddenly in bed, and screamed out as if in great agony. A number of domestic remedies were used in the hope of procuring relief; but the pain continued unabated until 2 o'clock the next morning, when I was called in. On arriving at the house I saw at a glance that she had been suffering intensely. Her face was pale, almost collapsed in its appearance, the