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OUR EXPERIENCE IN BRONCHO-PNEUMONIA.*
By C. S. McVICAR, M.B.,
Hospital for Sick Children, Toronto.
In the past seven years 75 cases of Broncho-Pneumonia have been admitted to the medical wards of the Hospital for Sick Children. Number of cases of Primary Broncho-Pneumonia.... 64 Number of cases of Secondary Broncho-Pneumonia.. 11
38% 25% 24% 13%
Deaths from Primary Broncho-Pneumonia
25-39% Deaths from Secondary Broncho-Pneumonia
8-73% Number of cases under 2 years
32-43% Number of cases under 2 years
20—66% Number of males in whole series
45—60% Number of females in whole series
30-40% Number of deaths in males
19-44% Number of deaths in females
14-46% Month of greatest incidence, February Comparison of seasons as to incidence:
Remittent in 56 or 75%
Continued in 19 or 25%
Decline was by Lysis 29, or 69%
Cyanosis was noted in 61, or 80% It is perhaps impossible from Hospital records to get a correct idea of the relative severity of cases, but if we take the averages of the maximum temperatures, pulse rates, and respiration rates, in each series, we have, at least, an approximate conception of the disturbance caused.
* Read at meeting of Canadian Medical Association, Ottawa, June, 1908.
The following table may be used for purposes of comparison :
Max. Temp. Max, Pulse. Respiration. In 39 primary cases with recovery.
104 153 58 In 25 primary cases with death ... 104 161 68 In 8 secondary cases with death 103"
153 63 In 3 secondary cases with recovery 103 152 53
From this table it seems reasonable to infer that increased respiration rate is the most serious feature in determining the prognosis—although the pulse rate is also higher in the fatal cases -while the temperature is not significant.
In the whole series of 75, the temperature rose above 106 degrees in four cases—three with death, and one with recovery.
A few facts in connection with treatment may be of interest. Eight cases with recovery were treated without stimulation or local application of any sort. Eighteen cases with recovery were treated without stimulation. Some idea of the severity of these cases may be gained from the following table:
Respiration. Eight cases with recovery without
stimulation or local application.: 103 142 53 Eighteen car's with recovery without stimulation
103' 143 53 The therapeutic measures used may be conveniently classified as follows:
1. MEANS USED FOR RELIEF OF TOXIC SYMPTOMS.
(a) Antipyretic drugs were used in five cases, of which two died and three recovered. In two cases no effect was noted. In one case the temperature fell with each dose and rose again in a few hours, indicating that while the manifestation of toxaemia was modified, the toxaemia itself persisted. In one case depres sion of the medullary centres as shown by increased cyanosis is noted.
(b) Hydrotherapy has proven of greatest value. The administration of as much fluid by the mouth as the child will take has always seemed valuable. The hot pack is the best external means of controlling nervous symptoms. It seldom fails to keep the temperature within bounds. Cold packs and cold sponging have proven, in so many instances, distressing to the child, that they are to be avoided as routine measures. When the hot pack fails to control either temperature or nervous symptoms, tepid sponging should be tried before resorting to cold.
2. LOCAL APPLICATIONS.
The quilted pneumonia jacket was used in six cases with recovery, and in six cases with death. No reason is recorded in any instance for its use, and no benefit is noted as a result of its use in any case. In three cases it was removed because it hampered the movements of respiration. The jacket seems to have no advantage over a light woollen shirt, which opens along the side of the chest to permit ready examination.
Poultices have been used in a few instances. In many cases they are uncomfortable, and in nearly all instances they are a mechanical hindrance to respiration, as shown by an increased rate of respiration following their use.
Counter-irritation by means of the ice-bag or thin mustard paste is of value in the few cases in which pleuritic pain requires attention. Beyond the relief of pain they furnish a mechanical embarrassment to respiration.
3. MEASURES FOR THE RELIEF OF CARDIO-VASCULAR DISTRESS.
Bleeding was used in two cases of extreme cyanosis with dilated right heart. It was repeated in each case and was of value in relieving the immediate distress in each instance. Both cases, however, terminated fatally, because the mechanical cause of the cardiac distress persisted.
Strychnine and whiskey were used separately or together in 57 cases; five cases are recorded in which the use of strychnine was discontinued because of muscular twitchings, with cessation of twitching in each case.
Whiskey, on the other hand, is perhaps of greatest value, because of its action as a cerebral sedative, soothing the restlessness of the little sufferer after the manner of the “night cap” in the insomnia of old age, and so providing the mental quiet necessary to physical rest. 4. MEASURES DIRECTED TO THE RELIEF OF RESPIRATORY
DISTRESS. Some interference with the function of respiration, shown by cyanosis, increased respiratory rate, or shallow respiratory excursion, is, according to our records, much the most important indication for treatment.
Expectorants were used in nine cases with recovery and in thirteen cases with death. Four instances are recorded of their being discontinued because of gastric disturbance. No record is found of any benefit to be ascribed to their use.
Steam inhalations have proven of value only in those cases where laryngitis or tracheitis were a feature. So far, no apparatus for the administration of steam has been used here, which has not the disadvantage of interfering with the circulation of sufficient fresh air.
Belladonna or atropine was used in nine cases, as follows:
In two cases as a respiratory stimulant; two cases report improvement, one case is negative.
In three cases as an antispasmodic in cough with a good result in each case.
Oxygen was used in nineteen cases, ten of which were fatal, while nine cases recovered. The results of its use are recorded as follows:
In two cases without effect.
In thirteen cases improvement is noted in the lessening of cyanosis and diminution of respiration rate.
In nine cases with recovery the severity of the cases is shown by the average maximum temperature, pulse, and respiration, viz: Average maximum temperature, 104”; pulse, 163; respiration, 64.
These rates are above the average severity as shown by a comparison with the table above.
It appears therefore that of all the means used for the treatment of broncho-pneumonia in this hospital, none have been more uniformly useful than inhalation of oxygen. I believe that in broncho-pneumonia the greatest need of the little patient is a plentiful supply of oxygen, whether we consider his need from the standpoint of limiting the bacterial growth, mitigating the effect of the toxins, stimulating the individual immunity, guarding against cardiac disability, or preventing respiratory failure. Most other therapeutic measures may be safely neglected in order to provide a plentiful supply of fresh air, and when fresh air is inadequate inhalation of oxygen will save more lives than drugs or local applications.
Toronto, June S. 1908.
INFLUENZA AND ITS TREATMENT.
By G. C. H. MEIER, M.D., NEW YORK CITY, N.Y.
Since the first severe epidemic of la grippe in the United States in 1889, which resulted in a large number of deaths, mostly due to pneumonia, there have been frequent repetitions, but it seems that the virulence of the disease has decreased or that a degree of tolerance has developed. The last occurrence during November and December, 1907, was especially mild; only in exceptional cases were acute nervous symptoms noted, and severe bronchitis, pneumonia and pleurisy were of comparatively rare occurrence.
As I have observed it, la grippe usually begins with slight chilly sensations, pain in the limbs or entire body and marked pain between the eyes. In most cases there is also present some coryza, with much sneezing and teasing, dry cough. The appetite is lost, the bowels are constipated, and there is a marked feeling of malaise and debility. The fever is usually characterized by slight fluctuation and rarely reaches a higher point than 103 F. when no complications are present.
A diagnostic feature is the marked prostration of the vital powers, even when the attack is of mild character. It generally takes the patient two to three weeks to recuperate, and often its exhausting effect persists for months. The complications and sequelae of la grippe, of which pneumonia is the most common and most serious, are numerous, and include inflammations of all the serous and mucous membranes of the body, constituting the chief risk in the debilitated, the aged, and those suffering from previous diseases.
In the chronic form a general neurasthenia, with mental depression, a peculiar irritability of temper, and sometimes hallucinations, is present.
In the treatment of this malady we know of no specific that will positively cut short the disease, but must rely on the indicated remedies, according to the existing symptoms. A solution of carbolic acid, 1 to 5 per cent., a teaspoonful every two hours, according to age, has been found to greatly modify the symptoms. Dr. Dessau treated 3,000 cases in this manner with satisfactory results. Oil of cassia (Ceylon) has been employed for 16 years by Dr. Ross in doses of 10 to 12 drops every two hours until the temperature becomes normal, and then three times a day for 3 days in 1-2 glass