The Treatment of Pneumonia, with Special Reference to the Value of Heat. BY CHARLES WILSON INGRAHAM, M. D., BINGHAMTON, N. Y. REPRINTED FROM THE Neto York IHeGfcal journal for May 18,1895. Reprinted from, the New York Medical Journal for May 18, 1895. THE TREATMENT OF PNEUMONIA, WITH SPECIAL REFERENCE TO THE VALUE OF HEAT By CHARLES WILSON INGRAHAM, M.D., BINGHAMTON, N. Y. Called to treat an adult case of acute lobar pneumonia in its first stage, or stage of congestion, what means can we employ which shall have the effect to minimize danger and magnify the chances of recovery ? What remedies ad- ministered internally; what substances or apparatus ap- plied externally ; what inhalations-gas, vapor, sprays, or other means whatsoever-are to day at the command of the general practitioner which will have the effect to modify symptoms, to reduce, avoid, or control the dangerous fea- tures of the disease, and to facilitate convalescence ? Uncomplicated pneumonia is in a large percentage of cases a self-limited disease, and any treatment or method administered with a view to shorten its duration is fruitless and may even be harmful. After consolidation has oc- curred it is as impossible to abort pneumonia as to abort typhoid fever after the formation of Peyer's patches ; and instead of loading down the system of the patient with de- pressing drugs, and depleting his vitality by drastic purga- , -aw* Copyright, 1895, by D. Appleton and Company. 2 THE TREATMENT OF PNEUMONIA. tives in vain efforts to accomplish this impossible feat, we should concentrate our efforts upon a definite line of treat- ment that has for its motive the achievement of three fundamental principles-namely, to support nutrition, and by so doing sustain strength, vitality, and resistance; to modify painful or distressing symptoms, and by so doing encourage mental and muscular rest; to relieve, uphold, and fortify the cardiac functions. These three essential points kept constantly in mind and given careful, intelligent, and systematic attentica, combat a multitude of more or less serious conditions and complications, which stand ever in readiness to break in upon the field and disorganize and confuse the whole out- look. In order to more clearly present my subject and render a more intelligent conception of my theory, it will be neces- sary to draw a descriptive picture of a typical case of acute lobar pneumonia occurring in an adult, and color the same with the physiological and pathological demonstrations ordinarily associated with the disease. Many practitioners are enabled to recognize a case of pneumonia at a first glance, because of certain visible changes or conditions. The dark, flushed hue of the face and temples; the general expression of anxiety ; the pant- ing, rapid breathing, which calls into play the extraordinary muscles of respiration, the sterno-mastoid muscles standing out prominently ; the harsh cough-all contribute to the diagnosis of acute pneumonia, and the physician knows what he is going to hear before he puts his ear to the chest. These symptoms are external indications of the in- ternal condition. Put an animal under a bell glass and as the air becomes exhausted we see the typical symptoms present in pneu- monia-the blueness of the skin, the rapid breathing bring- THE TREATMENT OF PNEUMONIA. 3 ing into play all the muscles of respiration, the anxious expression; in fact, everything but the cough. The symptoms in either case depend upon a lack of oxygen and an excess of carbonic acid, and our most skill- ful efforts in the treatment of pneumonia should be directed to increase the amount of oxygen in the system, to elimi- nate the excess of carbonic acid, and to bring them as near as possible to their proportions in health. With the onset of pneumonia, one or more lobes of the affected lung become consolidated and-like a depositor's money in an insolvent bank-the blood circulating through the affected portion of the lung at the inception of the dis- ease becomes stagnated and coagulated, thus depriving the system of the quantity of blood that the pulmonarv vessels of the involved area ordinarily contain. We know that more than double the same amount of blood could be drawn from the system -following the onset of the disease -with little or no constitutional effects; without causing any depressing results or inducing any functional disturb- ance of any one of the various organs of the body. In- deed, the results might be favorable following such an operation. Therefore it is not the loss of blood that causes the intense depression of the vital forces following the on- set of acute lobar pneumonia. The lungs are composed of five lobes. Will the con- solidation of one lobe and consequent total suspension of its functions so disorganize the equilibrium of the respira- tory mechanism or so diminish the breathing surface of the pulmonary organ as to endanger the system from lack of oxygen, from inability to eliminate the poisonous prod- ucts ordinarily thrown off by the lungs, or from any other pathological condition consequent upon impairment of the respiratory functions ? It is a very common occurrence to see a person afflicted 4 THE TREATMENT OF PNEUMONIA. with pulmonary phthisis - the extent of destruction of whose lungs more than aggregates one or even two com- plete lobes-in whom there are not present at any period of his disease any of the respiratory or cardiac symptoms present in acute pneumonia. Furthermore, such an indi- vidual might undergo a severe pulmonary haemorrhage from the effects of which he would lose a large quantity of blood, much more than could be imprisoned in the vessels of a consolidated lobe, and yet experience none of the phe- nomena associated with pneumonia. It is thus easy to prove by analogy, by the comparison of two pathological conditions which sufficiently resemble one another to allow of the comparison, that it is not the restriction of pulmonary surface or loss of blood that occa- sions the typical symptoms of pneumonia, and that they con- tribute to the condition as a whole only to a limited extent. Neither is the condition resultant of the initial chill, the pleurisy, the temperature, the systemic shock, nor any other symptoms typically associated with the inception of the disease. We thus find, upon dissection of the visible symptoms and conditions, examined singly and collectively, no cause that would give rise to the effect. Without knowing the actual working capacity of the veins, arteries, and capillaries of a healthy pulmonary lobe, let us assume, for example, that such a lobe has constantly under motion in its vessels one fortieth of the whole quan- tity of blood in the body. In order to maintain the correct proportion of oxygen and carbonic acid in the tissues and fluids of the body, this lobe must oxidize and purify one fifth of the whole amount of blood in the system. What effect upon the system, local and constitutional, will be the result of the consolidation of one lobe ? TI1E TREATMENT OF PNEUMONIA. 5 The superior and inferior vena cava steadily pour their flow into the right auricle, and the right ventricle is obliged to pump the full amount brought to it, through the dimin- ished area of the pulmonary circulation. In order to compensate for the loss of one fifth of the oxidizing surface and blood capacity, the veins, arteries, and capillaries of the uninvolved area are worked to their utmost capacity, and the blood tension in these vessels must be increased twenty per cent, above the normal, while the tension in the blood-vessels of the systemic circulation is nearly or quite normal. Take, as an example, a system of rubber pipes supply- ing water to a large factory. Suppose that, by the main- tenance of a pressure of fifty pounds to the square inch, a condition of perfect equilibrium is maintained-that is, the entire supply is exactly disposed of-the supply is pre- cisely equal to the demand. An accident occurs to one portion of the piping representing one fifth of the capa- city of the entire system, and the water is shut off from this damaged part, but it is impossible to diminish the amount of water supply or pressure. Therefore the re- maining four fifths of the tubing must have its capacity in- creased in proportion to the extent of the damaged area. As water can not be compressed, the tubing must of neces- sity expand, and the pressure thrown back upon the boiler is in exact proportion to the amount of force required to sustain this expansion. More fuel is required to generate the required amount of force, and if the amount of force required is above the ordinary capacity of the boiler (as a diseased heart from organic or systemic cause), serious re- sults may be expected to occur. It is principally a ques- tion of fuel; but the best of boilers can not support a ten- sion twenty per cent above their capacity for any lengthy period. 6 THE TREATMENT OF PNEUMONIA. The situation would be rendered more dangerous if the piping from neglect or abuse has become hardened and can not yield or expand to accommodate the additional water pressure. Such a condition would be analogous to that found in the blood-vessels in the chronic inebriate, in the gouty, in the rheumatic; and in such cases the condition is more critical because the heart is usually below the normal standard. This example, which gives a perfect picture of the con- dition of the heart and the circulation in monolobular pneu- monia, shows us exactly what we must accomplish if we ex- pect our treatment to increase the chances of recovery. We must dilate, relax, or enlarge the blood vessels of the healthy portion of the pulmonary organ, so that it will accommodate the extra twenty per cent, of blood which is required to circulate regularly through the lungs in order to maintain the equilibrium of the circulation, so as to sup- ply the system with a sufficient amount of oxygen, and to relieve the system of the poisonous products of respiration. But how are we to accomplish this and reduce the ten- sion in the pulmonary vessels to a sufficient degree to ap- preciably relieve the heart ? The old-time practice of bleeding the patient accom- plished this to a certain extent. By drawing blood from one of the extremities, the amount drawn was immediately replaced from the portion of the body where there was the greatest tension. It served to equalize the circulation and quiet the arterial excitement, and in plethoric patients it was attended with success to a certain extent; but, as only a small percentage of pneumonia patients were plethoric, the universal practice of bleeding did, on the average, more harm than good. The number of deaths caused by bleed- ing, without doubt, exceeded the number of lives saved. The result of bleeding has the undesirable effect of greatly THE TREATMENT OF PNEUMONIA. 7 diminishing the number of red blood-corpuscles, which should be increased rather than diminished. This blood represented a certain amount of vitality and force, and was needed by the patient to carry him through the systemic exhaustion of the disease, and by depriving him of it, even though it for a short time effected a very desirable physiological result, his chances of recovery were diminished in proportion to the amount of blood with- drawn. Veratrum viride lowers the blood pressure by its action upon the heart muscle and by its depression of the vaso- motor center, and in the early stage of pneumonia will bring about the same physiological results that follow the operation of bleeding. " It bleeds the patient into his own blood vessels." But, while it accomplishes temporarily cer- tain desirable effects, its use is not to be thought of for a moment. It is worse than valueless. There is but one remaining agent that will produce the desired effect, and that is heat, the king of all remedies as regards results, immediate and permanent. It is a power- ful stimulant and antispasmodic, and the whole effect of heat properly applied reaches a higher degree of perfection in the treatment of acute pneumonia than is possible in any other pathological condition. It relieves pleuritic pain. It induces copious but not exhaustive perspiration. It is a reliable antipyretic if used in a way to obtain its full physiological effects at an early stage of the disease. It controls the disease and prevents its further spread. It is a powerful and reliable cardiac stimulant, a fact long recognized by the laity as well as the profession. Its powerful antispasmodic effects have long been rec- ognized in the treatment of dysmenorrhoea, spasmodic 8 THE TREATMENT OF PNEUMONIA. croup, gastralgia, neuralgia, rheumatism; and its power of vascular relaxation is demonstrated in sprains, bruises, in- flammatory rheumatism, etc. In my experience heat, moist or dry, has proved most reliable and valuable, and, if I were obliged to choose be- tween heat and all other remedies, internal or external, I should choose the former. The great and only shadow which has enveloped this truly grand remedy has been the lack of an apparatus by the aid of which it can be applied to bring forth its full therapeutic effects. To properly apply heat in the treat- ment of pneumonia, a high temperature should be contin- uously and uninterruptedly maintained. The old-time poul- tice is possessed of so many disadvantages as to more than neutralize its good effects. Poultices are, as a rule, ap- plied over the involved area with what expected ultimate effect I know not, but presumably to hasten resolution of the hepatized tissue and relieve pain. While it is possible that they may possess this power to a limited degree, 1 can not believe that the benefit actually obtained warrants the inconvenience and possible dangers, even when the process of poulticing is in the hands of careful and experienced nurses, as it is almost an impossibility to keep the body from being chilled more or less when the changes are made. The more experience I had with poultices in the treatment of pneumonia, the more convinced I became that the patient would recover fully as soon and with as much certainty when poultices were not used. The more I saw of the effect of heat as a therapeutical agent, the more I became impressed with the idea that if this agent could be utilized in a manner to obtain a maximum amount of its advantages, with a minimum amount of dangers and in- conveniences attending its use, it would be one of the most valuable and reliable remedies at our command in the TIIE TREATMENT OF PNEUMONIA. 9 treatment of pneumonia as well as a multitude of other affections. I obtained the services of a skilled engineer and mechanic, and, pointing out to him the inadequate means at the command of physicians and nurses to utilize heat, requested him to invent an apparatus which would overcome the obstacles with which we had to contend, lie conceived the idea of utilizing known scientific princi- ples and, with occasional advice from me, finally completed the construction of an apparatus. In two years' experience, during which time it has seen much service, the faults in its general workings have been corrected and improvements added so that it now approaches a degree of perfection not dreamed of when its structure was begun. The apparatus on the whole is exceedingly simple and consists of an adjustable flannel jacket which covers the thorax anteriorly and posteriorly. To this jacket is at- tached rubber tubing, coiled and arranged about an inch apart, and attached to such an extent of the jacket as to completely envelop the sides and front of the thorax. The rubber tubing is skillfully mounted in such a manner as to prevent kinking at the curves, and the patient may lie upon it with perfect ease and comfort, and not interfere in the least with the working of the apparatus. After the complete jacket is adjusted to the patient, a feed tube is attached to a small reservoir of hot water, the heat of which is maintained by a kerosene, alcohol, or gas burner. The reservoir is placed several feet higher than the patient, and the hot water circulates through the tubing and is finally conducted by a discharge tube to a vessel at the foot of the bed. A thermometer is placed in the sup- ply tank and the heat kept at an exact temperature. As the water flows through the tubing it diffuses a gentle penetrating heat, and in its passage through the entire jacket only a slight cooling of the water takes place, for 10 THE TREATMENT OF PNEUMONIA. the thermometer will indicate only a few degrees lower at the discharge tube. When the jacket is first applied the water should be allowed to How under a full head for a few moments, fol- lowing which it may be so checked as only to drop into the discharge tank. The flow of the water is controlled by stopcocks at the reservoir and at the end of the discharge tube. The rubber tubing is so arranged that it can be re- moved from the jacket in order to facilitate the cleansing and disinfecting of the apparatus. After treating a considerable number of cases of pneu- monia as well as a variety of less dangerous acute diseases of the lungs, I have yet to see the patient who did not ex- perience the most marked benefit from the effect of the apparatus. Respiration became deeper, less laborious, and markedly reduced in rapidity. This effect is explained by the fact that a high degree of heat so generally applied as to act upon the entire surface of the respiratory organ, enlarges the caliber of the blood-vessels of the uninvolved portion, thus allowing of the reception at a normal tension of the blood which would in the healthy state go to the area now consolidated. This has the effect of relieving arterial ten- sion, of exposing a greater surface or area of blood to the air-cells (by the increase in the capacity or caliber of the veins, arteries, and capillaries), thereby relieving the heart action and encouraging a normal interchange of oxygen and carbonic acid. In a period of six hours, in cases of true lobar pneumo- nia, I have known respirations to diminish one third in number, accompanied with a corresponding diminution of temperature and pulse beat. Recent experiments have proved that a high degree of THE TREATMENT OF PNEUMONIA. 11 heat continuously applied to the abdomen will have the effect of greatly increasing the capacity of the abdominal blood-vessels, and by virtue of this physiological effect it has been proposed to apply heat to this region of the body in the treatment of pneumonia, with the belief that it would relieve the arterial tension in the pulmonary circulation. But this method appears to me to have one serious draw- back-namely, that the blood accumulated in the abdom- inal blood-vessels would not be sufficiently oxidized, and we would be working to our harm in thus favoring an accumu- lation of carbonic acid in the system. By dilating the pulmonary blood-vessels to the extent of allowing them to easily compensate for the consolidated area, thereby receiving at the normal tension or pressure the venous blood as fast as it flows into the right heart from the systemic circulation, we are approaching the height of perfection in the treatment and management of pneumonia. In cases where an abnormal amount of adipose tissue retards the action of the heat, an abdominal appliance has been arranged for attachment to the jacket. The ab- dominal appliance would also be indicated if the patient was a chronic inebriate or affected with any disease which would have been liable to have hardened the walls of the blood-vessels, allowing of only a limited relaxation. The "pneumonia jacket" has the following principal advantages over the ordinary methods of applying heat to the chest: 1. The heat can be accurately regulated to suit the re- quirements of any case. 2. The heat can be continuously applied without dis- turbing or exposing the patient. 3. There is no dampness or chilliness, as is apt to be the case with other methods of applying heat. The mois- 12 THE TREATMENT OE PNEUMONIA. tore from the skin when the apparatus is being operated allows all the action of moist heat. 4. A continuous even temperature can be maintained indefinitely. 5. The different appliances are light and adjustable, are never out of repair, and are perfectly comfortable for the patient. 6. The working of the apparatus is entirely automatic and the labor in operating it is very slight. The work and anxiety of the nurses and attendants are reduced to a mini- mum, as the thermometer in the reservoir furnishes an ac- curate and reliable guide, while by other methods every- thing is uncertain and the temperature constantly varying. 7. The uninvolved as well as the involved area has the advantage of the heat with the splendid effects above de- tailed. 8. The patient need not be disturbed or the chest ex- posed during the entire course of the disease. Having considered the effects of heat, the general man- agement of the disease can now be considered. In the treatment of pneumonia remedies may be ad- ministered by the following methods : 1. By the alimentary canal. 2. By hypodermic injection. 3. By inhalation. 4. By external application. As early as possible a five grain dose of calomel should be administered for the purpose of unloading the bowels, increasing the How of gastric and intestinal fluids, stimu- lating the hepatic circulation, and thereby increasing the patient's powers of digestion and assimilation. If pleuritic pains are intense an eighth of a grain of morphine sulphate should be administered hypodermically at once and the pain subsequently controlled by opium in THE TREATMENT OF PNEUMONIA. 13 one-grain doses, which not only controls pain but exerts a general stimulant effect upon the circulation. The pain and irritant cough controlled by opium, no other remedy need be given internally unless called for to support the heart, with the only exception of perhaps con- trolling some simple functional disorder. To sustain nutrition the nurse should be instructed to give the patient a glass of milk every hour, night and day. The form of milk should be occasionally changed, which will usually prevent the patient from rebelling against the method. Ilorlick's malted milk or Fairchild's peptonized milk powder may be alternated with ordinary milk. The former preparation is particularly nutritious and sustaining, and to the majority of sick people it presents a very pleasing and palatable beverage. There should be no laxity in the regulation of a " glassful every hour," and the rule should be carried out with as strict regularity as though we were giving the most important medicine, which it in reality is. Beef foods in the form of " Wyeth's beef juice," " liquid beef peptonoids," or " beef juice extracted by means of a hand press " should be administered at regular intervals, so that the liquid equivalent of three pounds of beef is taken daily. With this milk and beef diet systematically carried out we have the patient supplied with nourishment which will sustain a high degree of nerve and muscular strength suffi- cient to uphold a vigorous, comfortable, and unendangered heart action that should carry the patient through any ordinary attack, other conditions receiving equal atten- tion. It is not in the scope of this paper to discuss the many remedies designed to support the action of the heart. Medical literature on this subject is excessive and is accu- mulating daily. I will, however, state that I believe no 14 THE TREATMENT OE PNEUMONIA. cardiac stimulant should be administered until the same is plainly indicated. The stimulant treatment should be ex- clusively withheld until an embarrassed heart action de- mands the administration of the same, and it should then be given to the physiological limit. The successful general holds in reserve his heaviest guns, and at the proper mo- ment concentrates their fire upon the enemy with unresist- ing vigor, and so with the judicious physician: he ever holds in reserve, ready for instant use, the cardiac stimu- lant, and finally, at the critical period (should such a period occur), by administering the same to the full physiological limit or until the desired effect is produced, he remains master of the situation. The question of inhalations is an important one, but may be disposed of in a very few words, for there is but one respirable agent that has stood the test of experience and proved to be of undoubted merit. This agent is oxygen gas, given absolutely pure or diluted with air. In my ex- perience, pure oxygen gas given in quantities of from twenty to fifty gallons daily, beginning with the first incep- tion of the disease, has demonstrated a physiological and chemical control over certain conditions of the system in- variably associated with pneumonia. As the crisis ap- proaches it should be administered more or less continu- ously, particularly if there is blueness of the lips and finger-nails, which indicate systemic poisoning from accu- mulations of carbonic acid. Oxygen gas is, however, a very much abused agent, as many physicians do not begin its use in a case of pneumonia until alarmed at the develop- ment of unfavorable symptoms. They then commence its administration; but in many instances the condition is so far advanced, the system is so saturated by the accumula- tion of the poisonous products of impaired respiration which have paralyzed and disorganized the nerve centers THE TREATMENT OF PNEUMONIA. 15 and thereby depressed the vital forces, that reaction would be impossible even though the entire aggregation of delete rious substances could be instantly withdrawn. The physi- cian exposes his patient to unjustifiable danger in postpon- ing to the extreme limit the administration of oxygen, and at the same time reflects unfavorable criticism upon a valuable and reliable therapeutical agent. To reduce the temperature by the use of antipyreticsis analogous to pouring water on the fuel of an overworked engine, and is to be condemned in unqualified terms. By the use of antipyretics in pneumonia we are working to our own defeat and to the destruction of the patient. We are antagonizing the efforts of Nature. To shorten the duration of the disease and promote resolution should not be our object in view. If we properly treat the condition and maintain nutrition, avoid complica- tions, support the vital organs, and sustain the natural resisting powers, the disease will retain the verdict of the majority of physicians and prove itself to be self-limited. The following cases will serve to illustrate the prompt- ness with •which the rubber jacket transmits the effects of heat: Miss B., aged twenty-four years. Symptoms: Contracted acute bronchitis in a severe form, which quickly developed into lobar pneumonia. Profuse expectoration of typical rusty sputum. Temperature when first seen, 103° F. Respiration, 35. Breathing much distressed. Patient's condition rendered more critical by the presence also of pulmonary tuberculosis in the first stage. Oxygen gas was administered, but without appreciable effect. Six hours later (9 p. m ) a rubber jacket was applied and a high degree of heat maintained. Within an hour respi- rations diminished markedly in frequency. Breathing much relieved. The following day the temperature did not exceed 102° F. Expectoration free. Respiration nearly normal. The 16 THE TREATMENT OF PNEUMONIA. patient made a perfect recovery, and at no time was the heart embarrassed. Miss C., aged eighteen years. Symptoms: Following ex- posure, suddenly developed acute pneumonia. When I first saw her the temperature was 104° F.; pulse, 120; respiration rapid ; face flushed ; breathing labored ; expectoration typical. Severe pleuritic pain over the middle lobe of right lung. All efforts to relieve her condition proved unavailing, and two days later I applied the rubber jacket. Almost immediate relief followed. Respirations diminished in frequency. The heart became less embarrassed. A high degree of heat was maintained for sev- eral days, when resolution occurred and the patient made a good recovery. Mr. A., aged thirty-five years. While suffering from an at- tack of la grippe was suddenly seized by a chill, followed with severe pain over the middle lobe of the right lung. Respira- tion at once became labored, and when I saw him several hours later temperature was 103-5° F.; respiration, 32; pulse, 110; face flushed. Physical examination disclosed rough respiratory sounds localized to the middle lobe. No consolidation had yet oc- curred. Cough dry and exceedingly irritating. Applied rubber jacket at once. A high degree of heat was maintained. The patient became much relieved from the first. The following day at noon the temperature was 99-5° F.; pulse, 100; respiration normal; cough loose; pain wholly relieved. Second day, pulse 90; temperature normal. The patient made an uninterrupted recovery. The New York Medical Journal. A WEEKLY REVIEW OF MEDICINE. EDITED BY FRANK P. 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