Ernest Watson Cushing.

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the body, when oxidized within the system, produces the re-
quisite amount of heat, keeps in motion and stimulates the
nervous mechanism and chemical mutations necessarv to main-
tain animal life, without overtaxing the energies, is the ideal food.
Heat produced by the oxidization of foods, acts upon the cerebro-
spinal centres, and is conveyed by impulse to the central nervous



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FEEDINO OF THE SICE. 59

system, and makes impression upon the secreting glands and
tissues, which keeps up the uniform action throughout the entire
body.

These chemico-physiological compounds understood as they
should be, give excellent working advantages, whereby the phy-
sician and patient may perfectly understand each other, and work
out a harmonious whole in the management of the case. These
scientific principles can be demonstrated and proved unquestion-
ably true.

Knowing the composition possibilities and nutritive values of
food, as well as the laws of digestion, assimilation and cell struct-
ure development, the changes taking place in the laboratories of
the system, the molecular value of each substance entering it, is
it not possible for the physician to combat disease with diets alone
and upon purely scientific principles?

Certain diseases we know are dealt with exclusively on dietetic
principles, such as, rickets, diabetes and muscular atrophy.

If we take the table of comparison given by Professors
Moleschott, Porter, HofFmeister, Cheadle and others, as a work-
ing basis, we may take our patients from an almost exhausted
condition through each change, by diet alone, to a complete re-
storation of health.

In acute febrile disease where liquid secretions are rapidly
exhausted, the body should be compensated as rapidly as waste
takes place. Liquid diets, peptonized soups and broths, with
milks, beef and fruit juices should form the compensative diet.
Where destructive metamorphosis has gone on long and a vast
amount of destruction of cell element has taken place, we may
add eggs, meat and pre-digested food, containing reparative prin-
ciples, with sufficient stimulants to conserve the waning forces.

Xucleine and proto-nucleine possess wonderful recuperative
powers and are readily utilized by the system. I have found
bread-crust, crumbed and roasted, added to peptonized boiled milk
with a pinch of salt, highly efficacious and palatable. Whipped
egg with cream, with a little brandy is often tolerated by the
system, and taken up and utilized rapidly. The white meat from
turkey or chicken, free from fat, boiled, dried and powdered,
mixed liberally with peptonized cream, makes a palatable and
nutritious diet. Often it is absolutely necessary to add wines or
some alcoholic compound to the regular diet; the very best of



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60 O. P. KERNODLE.

wines or spirits should always be used, and the results will be
simply magical.

We change the character of secretions by diet, give to the
nursing mother a sustaining principle, and the food given to
her offspring through the lacteal glands, conforms in a large
measure to the nourishment the mother receives. Where there
is a nitrogenous or non-nitrogenous food given, where the se-
cretions are devoid of the nutritive principles of perfect develop-
ment to the child, it may be modified in such a way, by foods
alone, that a perfect physical development may be obtained. We
often see the ill-nourished child through faulty feeding from the
breast, and we can and do remedy the fault through the mother
by prescribing for the mother a diet with a full compensative
amount of nutritive constituents.

Nature places a limit to a redundancy and has so carefully ar-
ranged the organs of assimilation that an over-accumulation is
cast off as waste, yet we may and do increase the capacity of an
organ or the system to a competency to fulfill a required want
So far we have not been able to limit the true action of lactation,
yet we know that diet changes have worked almost miracles in
infants at the breasts. It is through the energies of our more
recent physiologists and chemists that we have learned to adjust
with any show of approximating accuracy the definite proportions
of increase or decrease in perfect cell nutrition and development.
We need only to observe closely to become familiar with the
needs of the case, and call to our aid the wise counsel and practi-
cal suggestions made by the chemist and physiologists of today to
succeed.

If by transfusion of saline solution we may sustain life, how
much more may be done by giving to the living cells food of
such nutritive value that a perfect conservation of force and
complete restoration of functional activity may be brought about.

Foods from the primordial, or protoplasmic, the albuminoid
cell structure substances for the sick, to a complete and complex
food may be given, and with a judicious hand the bark of life may
he steered past the reefs and shoals of disease, with food as a
guide, into the broad deep ocean of health.

Surrounding us, upon the broad plains of therapeutics, lies an
unknown wealth of hidden health, and beneath the magical touch
of the skilled chemist and learned physician, from the dross and



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BRONCHO-PNEUMONIA- 6 1

sands of nature, the golden stream pours upon the pathway to
success, and we see written across the broad expanse of futurity,
this inscription, in lines of increasing brilliancy — Learn dietetics.
304 Ohio Street, Sedalia, Missouri.



BROXCHO-PNEUMOOTA.*



I SHALL endeavor to impart to you some of the practical points
in my observation of acute broncho-pneumonia in infancy and
childhood. It is peculiarly a disease of early life, and, while we
find it at all ages, what I have to say will have special reference
to the disease in children from infancy to three years of age. It
has little respect for sex, perhaps the larger number of primary
cases appearing in the male. It affects all classes, but as other
diseases, it is more frequent where we have poor hygienic sur-
roundings or the system is debilitated from other causes, either
local or constitutional diseases, particularly rachitic or syphilitic.
It is a frequent complication or sequel of the infectious diseases
and oftentimes so of ilio-colitis or intestinal ptomaine infection.
Its appearing most frequently in the winter or early spring months
and when the weather is most changeable is conclusive evidence
that cold or atmospheric changes is one of its etiological factors.
The microscope demonstrates that the different bacilli are causa-
tive factors, the pneumococcus, the streptococcus and the
staphylococcus, any one, two or all three of them appearing in
the same case. The pneumococcus is the more frequent, the
streptococcus next so, and where there are only two found they
are most apt to be the ones. The pneumococcus is nearly always
present in the primary form of broncho-pneumonia and appears
alone in the majority of cases, the secondary cases are usually
due to a mixed infection and are most frequently associated with
streptococcus, and while we have the pneumococcus in a large
number of these cases, they do not seem to play as important a
part as the streptococcus. The staphylococcus are second in point

*Read before the Medical Association of Missouri at Excelsior
brings, May, 1898.



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62 J. D. BRUMMALL.

of frequency in the mixed cases. The cases in which tho
streptococcus appears are more apt to be of the severe type.

The pathology in broncho-pneumonia is very varied, there
being no regular order of changes as in lobar pneumonia, al-
though a certain number of cases appear to follow tolerably well
defined stages of congestion, red hepatization, gray hepatization,
and resolution. But the disease may be arrested at any of the
stages and the case recover, or death may occur at any stage and
the autopsy reveal portions of the lung representing all the stages
mentioned. The process may begin in the larger tubes and grad-
ually extend to those of smaller calibre finally invading the
pulmonary lobules, in which these tubes terminate, or to the air
vesicles which surround the tubes in its course through the lung,
producing zones of pneumonia surrounding the small bronchi.
The bronchi and air vesicles may be the seat of trouble at the
beginning as they have been found affected in cases which proved
fatal in a few hours after the first symptoms. A few cases bear no
relation to the bronchi, these being smaller or larger areas of
pneumonia scattered through the lung, usually near the surface.
It is most often found in the posterior portions of the lower lobes
of both lungs and when in the upper lobes the posterior portions,
the left is apt to be the most severely affected. During the first
three or four days there is an acute congestion of the affected
areas, catarrhal inflammation of the bronchi, the air vesicles be-
ing filled with red blood corpuscles, epithelial cells, and a few
leucocytes; from the fourth to the fourteenth day large areas of
consolidation are formed oftentimes complicated with pleurisy as
the affected parts of the lungs are most apt to be superficial. The
small bronchi are much thickened and filled with leucocytes, the
air vesicles being packed with the same, a small amount of
fibrin and a few red blood corpuscles and epithelial cells. The
longer the disease continues the greater the consolidation, until
it would seem the whole lungs were consolidated and enlarged,
there being thickening of the wall of the bronchi with dilatation
of their calibre. That part of the lung not consolidated may be
almost white owing to vesicular emphysema, and there may be
interstital emphysema ; the air vesicles are completely distended
with leucocytes and there may be found small cavities containing
pus. Death may occur at any stage, or the disease may be ar-
rested at any stage and the case recover. If resolution takes place



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BRONCHO-PNEUMONIA. 68

dnring the congested state before there is any consolidation, re-
covery is apt to be very rapid; after consolidation re-
covery will be slower and relapses are quite frequent, thus pro-
longing the case and producing a chronic condition.

The clinical picture presented by broncho-pneumonia
is an exceedingly varied one. The severe symptoms may
come suddenly as a congestion of the air cells of an
infant's lungs interferes with their function almost as
much as consolidation. However, the onset is more apt
to be gradual with the premonitory symptoms of an influenza or
bronchitis. We have rapid and labored breathing, a rapid, weak,
and compressible pulse. The temperature is high, but not ex-
tremely so except in very severe cases. There may be prostration,
cyanosis and cerebral symptoms. Pain is slight, but there is often
restlessness. The respiratory murmur is everywhere feeble.
There are first sibilant and afterwards subcrepitant rales over the
entire chest mingled with coarser moist rales. Percussion is
usually unsatisfactory, as we may get increased resonance over
consolidated lungs owing to the accompanying emphysema.

Broncho-pneumonia is always a serious disease and the younger
Broncho-pneumonia is always a serious disease and the younger
the patient the more grave the prognosis. The previous condition
and surroundings of the patient very materially influence the
disease. The primary cases are more tractable than the second-
ary. Xer\'ous symptoms early in the disease need not give alarm,
but occurring later in the trouble are to be apprehended with
fear; continuous high temperature is to be dreaded.

The prophylactic and hygienic treatment of broncho-pneumonia
is all-important. If proper attention were paid to the mild cases, we
would have fewer cases of pneumonia to treat. Well ventilated
rooms and moderately heated air are to be sought that plenty of
oxygen may be secured, while the entire surface of the child, ex-
cept its head and face, should be protected from direct contact
with the air, when, in a vast majority of cases, nothing more need
be done unless it be to attend to the condition of the bowels, kid-
neys and other secretions. Local applications are quite useful;
turpentine and camphor stupes, iodine salve, mustard paste, hot
cloths, etc., all have their places. The oil silk jacket has its ad-
vocates, and while I have observed its usefulness, I believe that
it is oftentimes used detrimentally. If the oil-silk is of any ser-



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64 J. D. BRUMMALL.

vice, it is within the first few days and should not be used longer
than about three days, as by its imperviousness it will produce a
moist, clammy condition of the surface covered and lose its bene-
ficial effect and I believe will do harm. I had rather at that,
time substitute a flannel cloth or cotton jacket during the con-
gestive stage when the child is cross and restless, and where
narcotics have failed to bring the desired quiet I have, by the
application of an onion poultice sufficiently large to envelope the
chest and applied warm, secured that needed rest almost as if by
magic and arrested the disease. Rewarm the poultice as often
as required to sustain the proper amount of heat about every two
hours. The only objection I find to them is that if you begin
them you must continue their use two or three days and some-
times longer, or on their removal you will in twelve or twenty-
four hours have a return of symptoms and will then have to re-
new their use. However, if on removal of the poultice you will
apply a mustard paste or hot flannel cloths, you will likely have
no cause for complaint. An occasional emetic may be of service,
but should be used very cautiously; a slight and continuous effect
of ipecac is usually better. The iodides are useful and in cases
tending to chronicity creosote is beneficial. In cases requiring
stimulants, which are not a few, whiskey may be used freely, a tea-
spoonful every two or three hours to a child one year old. It may
be combined with strychnia if necessary. The nerves must be
quieted or stimulated as required; strychnia for the latter and
chloral or phenacetine for the former. Phenacetine has a pleas-
ant influence on the temperature, which, however, need not be
reduced unless it is responsible for some nerve symptoms. The
temperature under 103*^ rarely gives trouble and may not as high
as 105°. I have usually found the antipyretics to act very nicely
in reducing the temperature, and have not resorted to the pack
or cold bath, although they are recommended very highly.
Salisbury, Missouri.



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MEMBRANOUS CROUP AND INTUBATION. 65

MEMBRANOUS CROUP AND INTUBATION.*

G. G. THORNTON, M.D.

Gentlemen of the Kentucky State Medical Society:

A remark which was made by one of my classmates while at-
tending lectures in 1886 made a deep impression on me and
aroused a train of thought which led me to think how near and
yet how far from a true conception of the doctor's duties and
abilities he had.

After hearing lectures on pneumonia, typhoid fever and
pulmonary tuberculosis, and learning to his surprise that the pro-
fession had no specific, "guaranteed to cure," remedy for these
as well as many other diseases, he seemed much disappointed and
said: ^'What's the use of our studying medicine? We can't cure
anything, hardly. There are consumption, typhoid, fever, pneu-
monia, scarlet fever, diphtheria, mumps, measles and many other
diseases which will sometimes get well without medicine and
often die in spite of medical skill, none of which the faculty
claim they can cure. They say the disease must run its course
and that we must meet indications (treat symptoms) and safely
guide the bark (the patient) through the tempestuous storms of
a high fever and feeble heart and delirious brain to Old Point
Comfort of convalescence." ^*What I want to learn," said he, "is
how to cure something."

And this same want has been felt by every disciple of Escula-
pius and has served to inspire the profession with a hope that
by the combined efforts and experience of the whole profession
the number of curable diseases will be multiplied by diminishing
the number of incurable ones. Diphtheria and typhoid fever, two
diseases which only a few years ago ^liad to run their course" are
now as amenable to treatment as any which we are called to
treat when seen early. Others find us still groping, now by em-
piricism, and again by dim scintillations of some scientific re-
searchy hoping soon to base our treatment on more promising and
assuring grounds.

♦Read before the Kentucky State Medical Society at Maysville,
May 12, 1898.



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66 G. G. THORNTON.

To this latter class belongs "membranous croup" or pseudo-
diphtheritic laryngitis, the subject of this paper. I say this advis-
edly because every man who is at all up on the subject knows that
some bacteriologists, as well as practitioners, regard diphtheria and
membranous croup, as being the same disease, the only difference
being in the location of the membrane — ^believing the Klebs-
Loeffler bacillus to be the germ cause of the membrane in either
the larynx or pharynx. Others believe that membranous croup
is a separate and distinct disease caused by an entirely different
germ if caused by a germ at all. To this class I belong. Situ-
ated in the country where there have not been a half dozen cases
of diphtheria in 10 years, but where I have seen from one to three
cases of croup every year during that time, I feel perfectly satis-
fied that they are different diseases. I can understand how a
physician who is located in a city where there is always more or
less diphtheria and where the source of infection cannot be traced
as it can in the country, where 20 cases of diphtheria are seen to
one of membranous croup, how he might easily be led to believe
that all cases were diphtheria. I have seen many cases of croup
and have never isolated any of them and have never seen a case
where there could, on the most diligent inquiry, be traced any
source of infection, neither have I ever seen any cases that were
infected from these cases, though there were exposures to all. I
would say, then, that one is infectious, the other is not; one may
kill by systemic poisoning- or by local obstruction, the other
always kills, if at all, by local obstruction ; one does not seem to
be influenced by heredity, while so far as my experience goes
the other is. I know a brother and sister where it seems to be
very pronounced. The brother has lost three children and the
sister has had five cases in her family, losing four of the five from
this disease. Of these eight cases there were only two that oc-
curred within one year of each other. I note this fact to show
that it was not diphtheria which passed by infection from one to
another.

Treatment. — ^Believing antitoxin to be a specific for diphtheria
and that croup is not diphtheria, I leave it out of the treatment
where a positive diagnosis can be made and believe that if we
ever have a specific for this disease it is yet to be discovered.

This much-to-be-desired discovery has long been sought and
ever and anon some enthusiast has shouted, "eureka!"; yet today



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MEMBIL\NOUS CROUP AND INTUBATION. 67

we are almost hopeless medicinally when confronted by a case of
croup. Who of you have not tried with eager hope and anxious
expectation the new remedies as they have unfurled their ban-
ners, only to go down in disappointment at the bed side of the
little fellow who was dying "for the want of breath." I have tried
pilocarpine, ipecac, fumes from slacking lime, fumes from turpen-
tine on boiling water, "coal oil" and many of the other remedies
recommended, both singly and combined and have seen no effect
from them which would inspire me with any confidence in their
curative properties in this disease.

Recently I see lac sulphur recommended as being a specific,
but have had no opportunity of trying it. However, I expect
when I do try it to go down in defeat with it as I have done with
other specifics. By the way, isn't it strange how members of our
profession, sensible men, will go off on a certain drug, or line of
treatment for some disease, or some surgical operation which they
believe to be a panacea for all the ills to which flesh is heir, which
when weighed by the profession is found wanting?

What then are we to do? Either perform tracheotomy or in-
tubation. The latter has many advantages over the former and
some disadvantages. The advantages are, you don't have to use
the knife which is such a terror to most people, hence the family
will more often give their consent early; you don't make any
wound, you can do the operation much more quickly, you don't
have to give an anaesthetic, you excite the little fellow less and
give him no real pain.

Although my experience with intubation has been very
limited, only having had three cases, I will here report them.

Case I. — Oscar W., male, age 6^ years, white. Had been
subject to hoarse spells for which they had always used domestic
remedies, was brought to me on September 6, 1897, very hoarse.
His breathing labored, slight cough, appetite good, temperature
normal. He had been hoarse for five or six days and gradually
getting worse. No membrane visible on tonsils or fauces. Treat-
ment from the list of remedies above mentioned till on the night
of the 7th at 11 p. M. I was summoned and found him
struggling for breath. With such assistance as the family could
give I intubated him with an O'Dyer tube, with but little diffi-
culty. Within five minutes he was breathing easier and in
fifteen minutes he was asleep and slept very well the remainder



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68 G. G. THORNTON.

of the night. The tube gave him very little inconvenience ex-
cept in swallowing and as he was a little spoiled and nothing
hurting him he was allowed to be up and about the house. Medi-
cine was discontinued and his nourishment was liquid and mostly
milk, part of it being given per rectum on account of the diffi-
culty in swallowing. The tube was removed after 81 hours, his
breathing remaining easy and the hoarseness gradually disappear-
ing after several days.

Case II. — ^Male, age 2 years, white. Had been hoarse four
or five days, though, as is usual with these cases, the insidious
nature of the disease had led the parents to believe there was
nothing serious the matter. The day I saw him first (December
2, 1897), he had been taken by his parents in an open top buggy
a distance of 7 or 8 miles, through a cold, drizzling rain. When
I first examined him I thought it was a case of spasmodic croup,
but I soon found that it was worse than that. He grew worse
rapidly and when I arrived on the 3d, he was in such a condition
as to indicate that he might die before I could get ready to in-
tubate, as my hands were cold and it took some time to get them
warm enough for the tactics eruditus to be normal. Intubation
was performed at 8 a. m. His breathing became much more
quiet though it was about 30 respirations per minute. In 2 hours
it was 35. I left with instructions to remove the tube if the dysp-
noea became very marked. This was done at- 4 p. m., and I
arrived soon after and as I then regarded his case as hopeless I
made no farther effort and he-died at 6 p. m.

Case III. — Marguerite G., female, white, age 6^ years. Saw
her first on January 7, 1898. Her pulse was 110, temperature
101°, breathing labored and respirations 30 per minute. She had
not been well for a week, the hoarseness gradually growing more
marked. There was a patch of white membrane on each tonsil
as large as a dime. This is the second time I have ever seen the
membrane in a case of croup and at first I thought this might be
diphtheria, although there were no other cases in the neighborhood
and the child had been at home all winter. Treatment was tenta-
tive till on the 8th at 1.30 p. m., her condition was such that
intubation was performed. Relief was immediate and she con-
tinued to do well on the 9th and 10th, her pulse being about 100
and breathing about 30 per minute, but on the 11th her breath-
ing became more labored and respirations from 35 to 45 per



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MEMBRANOUS CROUP AND INTUBATION. 69

minute. After remaining in position 64 hours the tube wa:* re-
moved and its caliber found to be considerably obstructed. Her
breathing was much better for a while now, but in a few hours
became worse and after remaining out for 9 hours the tube was



Online LibraryErnest Watson CushingAnnals of medical practice → online text (page 7 of 77)