THE TREATMENT OF 
PNEUMONIA IN ST. FRANCIS 
HOSPITAL 
WITH RESULTS IN TWO HUNDRED AND TWENTY- 
EIGHT CASES 
By 
ARNOT SPENCE, M.D. 
NEW YORK 
Reprinted from the Medical Record, July 1, 1893 
NEW YORK 
TROW DIRECTORY, PRINTING AND BOOKBINDING CO. 
201-213 East Twelfth Street 
' THE TREATMENT OF 
PNEUMONIA IN ST. FRANCIS 
HOSPITAL 
WITH RESULTS IN TWO HUNDRED AND TWENTY- 
EIGHT CASES 
By 
ARNOT SPENCE, M.D. 
NEW YORK 
Reprinted from the Medical Record, July i 
NEW YORK 
TROW DIRECTORY, PRINTING AND BOOKBINDING CO. 
201-213 East Twelfth Street 
1893 THE TREATMENT OF PNEUMONIA IN ST. 
FRANCIS HOSPITAL. 
With Results in Two Hundred and Twenty-eight 
Cases. 
In view of the great mortality of pneumonia, its treat- 
ment is a question of pre-eminent importance. It is still, 
we must admit, in an unsettled state, and for that reason 
every effort should be made to advance it. In this article 
the subject of treatment alone will claim attention. 
Professor William Osier, in a very interesting paper on 
“ Mortality in Pneumonia,” quotes the rate obtained in 
the Pennsylvania General Hospital, during 1885, 1886, 
and 1887, as 36.1 per cent. ; and of all the cases since 
1845, was 29.1 per cent. Also, at the Boston City 
Hospital he says they report a death-rate of 29.1 per cent., 
when all the cases for the past thirteen years are consid- 
ered. In the New Orleans Charity Hospital, in a series 
of nearly four thousand cases, he quotes them as report- 
ing a rate of mortality of 28.01 per cent. 
In a report made by Dr. Latta, of 257 cases of pneu- 
monia treated for the Pennsylvania Railroad Relief De- 
partment, he gives the death-rate as 20.23 Per cent. In 
explanation of this rather low rate, he describes his pa- 
tients as strong and healthy men, of temperate habits, 
and engaged in healthy out-door work. Thus he shows 
his appreciation of the fact that he had the best possible 
material for good results. 
Professor A. L. Loomis reports the mortality as ob- 
tained by him, in 255 cases treatedjn- hre-wards at Belle- 4 
vue Hospital during a period of four years, as 34.1 per 
cent. In physical condition his patients were the oppo- 
site of those of the Pennsylvania Railroad Relief Depart- 
ment, for nearly one-half of them were complicated 
cases. These figures suffice to show the great severity 
of pneumonia, in this country at least; and they are a 
sufficient argument in themselves for the presentation 
of facts in support of a treatment which has given better 
results. 
The cases forming the subject-matter of this report, 
were treated on the service of Dr. J. H. Ripley, at St. 
Francis Hospital, during the period from October 1, 1884, 
to October 1, 1892. As the previous condition and sur- 
roundings of the patients are of such importance when 
comparing the results obtained by different methods of 
treatment, a few words bearing on these cases cannot fail 
to be of interest. 
They were, with but few exceptions, residents of the 
East Side tenements, and of most every nationality. The 
majority, however, were Germans. Owing to the unsani- 
tary state of these dwellings, the hardships of breadwin- 
ning, and the dissipations these people indulge in, their 
physical condition is seldom even fair ; and they are thus 
heavily handicapped in the struggle with any grave dis- 
ease. In addition, they allow ignorance and superstition 
to stand in the way of their well-being, and very often 
delay applying for treatment until treatment can be of 
little avail. They are firm believers in the self-limitation 
of disease, and suffer patiently in the hope that the next 
day will find them better. 
The treatment, as pursued in all of the cases, was in ac- 
cordance with a plan suggested by Dr. Ripley, and 
through his directions carried out. To begin with, the 
bowels were freely moved. For that purpose five grains 
of calomel, well rubbed up with sugar and milk, was given 
if the patient’s condition allowed ; or if too weak, a more 
gentle laxative was employed. After the bowels had 5 
acted, the following mixture was given, a half-ounce 
every two hours: 
5. Tr. aconiti TTf xxiv. 
Tr. opii camphoratse 3 ij. 
Liq. ammonii acetatis 3 iv. 
Syr. zingiberis 3 ii. 
Aquae q. s. ad § vj. 
M. Sig. : § ss. every two hours. 
The aconite was given primarily for its effect on the 
heart and blood vessels, and thus on the inflamed lung, 
and secondarily to reduce the temperature. It produces 
a quieting and slowing of the irritable and rapid heart, 
and a reduction of the arterial pressure, thereby lessening 
the amount of blood in the congested lung. It controls 
the temperature within a safe range, and prevents the 
marked exacerbations so common in typical cases of this 
disease. In strong and full-blooded patients, veratrum 
viride was substituted for the aconite in this mixture, and 
used in about the same dose. The paregoric is added to 
ease the short and harassing cough, which is often such a 
disturber of rest. The spirit of mindererus acts as a dia- 
phoretic, keeping the skin moist, and in its way relieving 
the kidneys to some extent. Besides assisting thus to 
keep the temperature down, it is also a stimulant. 
Throughout the administration of this mixture the 
heart was most carefully watched to note the effects of 
the drugs, and, all things being favorable, it was contin- 
ued until the fall in temperature denoted the crisis of the 
disease. When further stimulation seemed necessary, 
whiskey was freely given, but never unless it was indi- 
cated. The administration of alcoholic stimulants all 
through this disease, as is frequently done, is a practice 
capable of doing great harm. 
In obstinate sleeplessness from any cause, as well as 
that caused by troublesome cough or pleuritic pain, a 
drachm of the U. S. solution of morphine was occasionally 
given at night. The free or constant use of morphine 6 
was never resorted to, for its injurious effects in most in- 
stances far over balance any relief it might afford the pa- 
tient. It masks the signs, which to the observant attend- 
ant are the danger signals of the disease, and adds, when 
given too freely, another and greater danger, by its action 
in diminishing the number of the respirations, thereby 
interfering with the proper oxygenation of the blood. 
If, notwithstanding the use of this, our pneumonia mixt- 
ure, the temperature should rise and remain above 104° 
F., the cold half pack was resorted to in most cases. 
The antipyretic drugs were given only on rare occasions, 
and then never by order of the visiting physician, who 
has always strenuously opposed their use; but rather in 
response to the uncontrollable impulse, that seems to be 
epidemic not alone among the younger members of the 
profession, that every rise in temperature, whether extreme 
or otherwise, must be combated by the administration of 
one of these dangerous drugs. It is unreasonable to ex- 
pect that a few hours’ remission of fever, the result of any 
of these depressing antipyretics, can better the condition 
of the patient, or even compensate for the bad effect the 
drug leaves on the heart. The indiscriminate employ- 
ment of these antipyretic drugs in every case of fever or 
rise of temperature, cannot be too severely condemned. 
The only attempt at local measures or applications was 
the wearing of an oil-silk jacket over the chest, immedi- 
ately next the skin. This was worn throughout the treat- 
ment. While flax-seed poultices, when correctly applied, 
seem to favorably influence the course of pneumonia in 
children, they cannot be used with comfort in the adult. 
For without being of immense bulk and weight, we can- 
not make them sufficiently large to completely encircle 
an adult chest; and certainly they are of no value when 
otherwise applied. The small poultice, equal in size to 
one’s hand, as usually applied by the amateur nurse, is 
but a useless substitute. 
The diet in all of our cases was limited, until convales- 7 
cence set in, to milk, meat broths, soups, and farinaceous 
gruels. The reclining posture was preferred, and the 
patient was not allowed to leave the bed for any purpose. 
Much praise is due to the nurses, the Sisters in charge of 
the hospital, for their intelligent and untiring attention 
to these patients. During the period mentioned, from 
October 1, 1884, to October 1, 1892, Dr. Ripley’s wards 
cared for 276 cases of pneumonia; while 228 of those re- 
ceived this particular treatment. These 228 cases can 
be classified as follows: 
Cases. 
Deaths. M°rtali,y- 
Per cent. 
Croupous pneumonia, uncomplicated.... 
.... 125 
18 14.4 
Croupous pneumonia, complicated 
.... 76 
25 32-8 
Catarrhal pneumonia, uncomplicated.... 
.... 25 
5 20.0 
Catarrhal pneumonia, complicated 
0 0.0 
Total number 
48 21.05 
Thus, of the 228 cases treated according to the plan 
already described, 48 died, showing a mortality-rate of 
21.05 Per cent. 
A glance at the different groups and at the results given, 
shows very conclusively that the complications which at- 
tend this disease, and the affections it is so commonly 
associated with, have much to do with its great fatality. 
Notice the low rate, only fourteen per cent., obtained in 
the uncomplicated cases of croupous pneumonia, or those 
cases in which only one lung was involved and no other 
disease coexisted; while in the complicated cases of the 
same variety the mortality was 32.8 per cent.—two and 
one-third times as great. That more than one-third of 
the croupous pneumonia cases were complicated is another 
important fact. The death-rate of the uncomplicated cases 
of the catarrhal form was twenty per cent. This was 
higher than that of the same class of the croupous variety 
by nearly one-half. Owing to the small number (only 
two cases) in the complicated group, we cannot make 
any comparison between the two classes of the catarrhal 8 
form of this disease. Since we have observed in a gen- 
eral way the serious effect these complications have on 
the main result, it must prove of greater importance to 
note which of them are most dangerous. In the follow- 
ing table, the cases have been so arranged as to show the 
number complicated by the different affections, and the 
number of each that have ended in death : 
Variety and Complications. 
Double croupous pneumonia 
with pleurisy 
with empyema (pyothorax) 
with pleurisy and pericarditis 
with pericarditis and nephritis 
with nephritis and valvular disease of heart ... 
with miscarriage at months 
Croupous pneumonia with pleurisy 
with empyema (pyothorax) 
with pleurisy and pericarditis 
with hemorrhagic pleurisy, nephritis, and phthi 
Cases. 
13 
2 
1 
2 
I 
I 
I 
20 
3 
I 
I 
Deaths. 
7 
1 
1 
1 
1 
1 
with pericarditis and valvular disease of heart... 
2 
with pericarditis and phthisis 
I 
1 
with valvular disease of the heart 
3 
with valvular disease of heart and acute rheu- 
1 
with nephritis 
4 
2 
with nephritis and fatty heart 
1 
1 
with phthisis 
4 
with emphysema 
2 
2 
with acute alcoholism 
3 
3 
with chronic alcoholism 
1 
1 
with malarial cachexia 
I 
with acute tonsillitis 
1 
with perihepatitis 
1 
.. 
with hepatic abscess and morphine habit 
1 
with purulent infiltration 
1 
1 
with pulmonary abscess 
1 
1 
with cellulitis of the hand 
1 
1 
with melancholia 
1 
Catarrhal pneumonia with pleurisy 
1 
with phthisis 
1 
Total 
78 
25 9 
Double pneumonia, alone and with other complications, 
was present in twenty-one cases, and of these ten died. 
Pleurisy, including serous, hemorrhagic, and purulent 
effusions, occurred in thirty-one cases, four being fatal; 
two of these were double pneumonias, one having in ad- 
dition acute pericarditis. In only one case with empyema 
did death occur. Acute pericarditis was present in seven 
cases, and caused death in four of them. 
Of the co-existing diseases nephritis was present, alone 
and with other complications, in 8 cases, and 5 of them 
died. Valvular disease of the heart was present in 7 
cases, of which number, one, also complicated by ne- 
phritis, died. Phthisis affected 7 of the cases, and only one 
of these ended fatally. Of our patients, 3 had very seri- 
ous complications, which fortunately did not cause death. 
A nineteen-year-old wife miscarried a six and one-half 
months’ foetus during the height of the pneumonia. The 
second one was complicated by hemorrhagic pleurisy, 
phthisis, and chronic nephritis; and the third, a male 
nurse with the morphine habit, had, in addition to his 
pneumonia, a hepatic abscess. Thus we had, all told, 78 
cases with complications, 25 of which proved fatal. This 
makes the death-rate, in complicated cases alone, thirty- 
two per cent. 
In the following list the causes of death have been 
enumerated, and the sex of these cases given : 
Causes of Death. 
Male. 
Female. 
Total. 
Croupous pneumonia, uncomplicated 
H 
4 
18 
Catarrhal pneumonia, uncomplicated 
5 
5 
Double croupous pneumonia 
7 
7 
with pleurisy 
I 
i 
with pleurisy and pericarditis 
I 
I 
with nephritis and valvular disease of heart 
i 
i 
Croupous pneumonia with empyema (pyothorax). 
i 
I 
with pleurisy and pericarditis 
I 
I 
with pericarditis and phthisis . 
i 
i 
with nephritis 
I 
I 
2 
with nephritis and fatty heart , 
I 
I 10 
Causes of Death. 
Male. 
Female. Total. 
Croupous pneumonia with emphysema .... 
2 
with acute alcoholism 
3 
3 
with chronic alcoholism 
i 
with purulent infiltration 
i 
.. i 
with pulmonary abscess 
.. .. i 
.. i 
with cellulitis of hand 
.. i 
Totals 
8 48 
We have classed the cases as uncomplicated so long as 
the process was confined to one lung, and no other com- 
plication existed. 
In only 23, or ten per cent, of all the cases, was death 
due to uncomplicated pneumonia. Again, but 37 of the 
fatal cases, or 16.2 per cent., had in addition to the pneu- 
monia such complications as commonly spring from it; 
as extension of the process to the other lung, pleurisy, 
serous or purulent, and pericarditis. Of the remaining 
deaths, three per cent, were due to chronic and incurable 
diseases of the heart, lungs, and kidneys, and 1.7 per cent, 
to alcoholism. In 1.3 per cent, was death due to septic 
infection, there being one case each of purulent infiltra- 
tion of the lung, pulmonary abscess, and cellulitis of the 
hand. 
The mortality caused by uncomplicated deaths, 10.08 
per cent., agrees as to the result, with that obtained in 
1,000 cases in the Massachusetts General Hospital, which 
were reported by C. N. Townsend and A. Coolidge, Jr. 
They concluded that their death-rate was but a little over 
ten per cent., after they had omitted of the fatal cases, 
those that were necessarily fatal, also the deaths occurring 
in persons who were delicate, or intemperate, or the sub- 
ject of some complication. Our rate (10.08 per cent.) 
represents the results after the omission of only compli- 
cated cases. A dissipated subject was not put down as 
an alcoholic case, unless he showed the immediate effects 
of alcohol while under observation. Should we eliminate 
all the delicate or intemperate from among our fatal 11 
cases this rate would be very decidedly diminished. 
Only one-sixth of the fatal cases were females, but as it 
will be shown later on, that is about the proportion of 
the sexes when all the cases are considered. 
When we note separately each year’s work, the results 
obtained were as follows : 
Oct. 
Oct. 
Oct. 
Oct. 
Oct. 
Oct. 
Oct. 
Oct. 
VO'O 00 00 00 OC 00 CO 
O VO C\U\ 4- 
ooooooco 
< 
a 
coccococ 
or, ocoooo 
r r r r r r r 
V£5 vO vO Oo Oo OO Oc OC 
tv) H o VO Cvoyi 
VO OJ to to to to to OJ 
OJ 4-* CC to to M vjut 
Number of 
cases. 
« On VO to to 00 
Number of 
deaths. 
to « 10 w M 
C/C “ 00 O NO to 
to Ov-P- M vo on 4v oo 
Rate of mor- 
tality. 
Per cent. 
Number of 
« U) to 
uncom- 
plicated 
deaths. 
to to Ln 4^ 
M o r t a 1 ity 
from uncom- 
p1ica t ed 
deaths, 
per cent. 
1 he most noticeable feature when comparing the re- 
sults from year to year is the wide variations shown; 
and this very fact proves the uselessness of drawing con- 
clusions from the treatment of a small collection of cases. 
In 1885-86 the rate of mortality was only 7.4 per cent., 
and when the results of 1885-86 and 1886-87 are com- 
bined, we have the very low death-rate of 8.3 per cent, 
in 48 cases. On the other hand, in 1887-88 our mor- 
tality was very high, it being 40.9 per cent. During that 
year we were unfortunate in the class of cases, for 6 of 
the 9 deaths were due to complications. As to the re- 
sults of the other years, the table speaks for itself. 
The mortality in every year was not in an equal de- 
gree affected by the omission of the complicated fatal 
cases; but in every instance the rate is greatly reduced 
when these cases are not included. The 40.9 per cent, 
mortality can in this way be brought down to 13.6 per 
cent., and even the 8.3 per cent, rate (1885-86 and 12 
1886-87) can be reduced to 4.08 per cent. It is impor- 
tant to note that only one uncomplicated death occurred 
in each of the two years 1885-86 and 1888-89. 
In order to satisfactorily explain the want of agreement 
in the results obtained during different years, we should 
have to take into consideration the general physical con- 
dition of the patients, their ages, and the variations which 
are observed in all acute diseases. As an instance of 
the influence age had on these results, let us look at the 
ages of the fatal cases occurring in the year when the 
mortality was so high. Of the 9 deaths none were un- 
der thirty years of age ; 3 were between thirty and forty 
years, 2 between forty and fifty, 2 between fifty and sixty ; 
and 1 each at the sixtieth and seventieth year of age. 
These ages, as will be demonstrated later on, accounted 
to some extent for that forty per cent. rate. 
In order to show that these results vary much less when 
the cases are arranged in larger groups, we have in the 
following table divided the cases in larger series : 
First ioo cases 
Second ioo cases 
1884-88, 105 cases. ... 
1888-92, 123 cases 
Total, 228 cases 
OCVO OC OC^J 
0 Ov-£* VO 
Number of recov- 
eries. 
4* W *-< to 
~ ON -• 
Number of 
deaths. 
U tO M h (0 
n h p ON « 
O NO O O O 
Ln 
Rate of mortal- 
ity, per cent. 
JO M M M 1-4 
OJ 0 O O 
Number of un- 
co m p 1 i cated 
deaths. 
O P '0 O O 
Olnln O 6 
Mortality from 
uncomplicated 
deaths, per 
cent. 
Here the lowest mortality was in the second series ot 
ioo cases only sixteen per cent. Taking a glance at 
the other groups, the rates are quite constant, there being 
a variation of less than two per cent, between the lowest 
and the highest. In the mortality of uncomplicated 13 
deaths this difference in the rates is only one per cent. 
If the first two groups are combined, we have a series ot 
200 consecutive cases, with a death-rate of only 18.5 per 
cent. The result obtained after a consideration of all 
the cases, 21.05 Per cent., compares very favorably with 
the rates of the other hospitals, as quoted at the beginning 
of this article. 
Age.—The patients ranged in age from five to seventy- 
eight years, there being one case at each of these limits and 
both recovered. The seventy-eight-year-old patient was 
a man with a severe pleuro-pneumonia. 
Age. 
Cases. 
Deaths. 
Mortality, 
per cent. 
Under io years 
3 
O 
0.0 
From io to 20 years 
O 
0.0 
From 20 to 30 years 
15 
17.0 
From 30 to 40 years 
11 
18.3 
From 40 to 50 years 
IO 
31.2 
From 50 to 60 years 
15 
6 
40.0 
From 60 to 70 years 
9 
4 
44.4 
At 70 years and over 
2 
66.6 
The small number of cases under ten years of age is ex- 
plained, when it is understood that St. Francis Hospital 
does not, as a rule, admit children for treatment. Under 
twenty years of age there were no deaths, while 21 cases 
below that age were treated. Nearly one-half our pa- 
tients were under thirty years old, and over two-thirds were 
less than forty years of age. While the mortality of those 
between twenty and thirty years old was seventeen per 
cent., when we consider all the cases under thirty years, 109 
in number, the rate is only 13.7 per cent. This very low 
death-rate is undoubtedly due to the vigorous and sound 
constitutions of these young subjects. There were 169 
cases under forty years of age, of which 26, or 15.3 per 
cent., died ; and 201 cases under fifty years, with 36 
deaths, a mortality of T7.8 per cent. These figures can 
be compared with the mortality reported by Dr. Latta, of 
the Pennsylvania Railroad Relief Department, which has 14 
been previously mentioned. In all probability those rail- 
road men were under forty years of age ; but in order to 
allow for some being older, we can place them for com- 
parison in the class of cases under fifty years of age. It 
will be remembered Dr. Latta’s results gave a mortality 
of 20.23 Per cent. 
It is interesting to note how steadily the rate runs up 
with the age, thus proving the great influence that factor 
has on the main result. To be sure, the small number of 
cases at the advanced ages, makes the mortality-rates for 
those periods less valuable ; still, for comparison with each 
other they are sufficiently reliable. This marked influ- 
ence that age exerts on the mortality can be easily under- 
stood. A constitution generally weakened by age cannot 
hope to battle against an exhausting disease with the 
same success as a younger one; and again, the patient 
with advancing years is more likely to be the subject of 
some chronic disease, which with the advent of pneumo- 
nia will help toward a fatal termination. When we in- 
quire into the two deaths that occurred in patients at the 
seventieth year, we find both died after seven days of 
treatment; one had a catarrhal pneumonia uncompli- 
cated except by age, and the other a croupous pneumo- 
nia complicated by an old emphysema. In like manner, 
of the four fatal cases between sixty and seventy years of 
age, two were uncomplicated, except by years. Of the 
other two, one had double pneumonia, pleurisy, and peri- 
carditis, and the other chronic nephritis and fatty heart 
in addition to the pneumonia. 
While it is generally conceded that this is one of the 
most fatal of the acute diseases in old age, according to 
some observers patients over sixty years of age, recover 
much more frequently than would be supposed. In these 
patients the grade of fever is not so high, and the process 
semes to be much less active. 
Sex.—The female sex claimed 37 of our cases, and 191 
were males. Death terminated the disease in 8 of the 15 
female cases, a mortality of 21.6 per cent.; and 40 of the 
males died, or 20.9 per cent. These figures tend to cor- 
roborate the general conclusions, that pneumonia is more 
fatal among females, while the disease seems to show a 
preference for the male sex. 
Season.—Most of these cases occurred during the 
changeable and wet months of the spring of the year, the 
number being nearly as large as those of the fall and 
winter combined. 
Cases. 
Deaths. 
Mortality. 
Per cent. 
Summer 
8 
26.6 
Autumn 
8 
I9.5 
Winter 
11 
18.6 
Spring 
98 
21 
2I.4 
While this disease is usually looked upon as most prev- 
alent and fatal during the spring of the year, in our cases 
the summer months gave the highest mortality. The 
heat and humidity, so distressing and exhausting to a 
person sick and confined to bed, are particularly unbear- 
able when the lungs and heart are disabled. This prob- 
ably explains the increased mortality during the warm 
season. While the winter gave the lowest rate, during 
the spring months we had the largest number of cases, 
with a mortality of only 21.4 per cent. 
Thus it is evident that age, sex, and season, all exercise 
an influence to a greater or less degree on the result, and 
these we certainly cannot counteract. The complications 
which caused death in over eleven per cent, of our cases we 
cannot expect to prevent by any method of treatment, al- 
though it must be acknowledged we can modify their course. 
There is sufficient room for reduction, when we reflect 
that ten per cent, of our mortality was in uncomplicated 
cases. While we were able to show a death-rate of only 
7.4 per cent, in 27 cases, and 8.3 per cent, in a series of 
48, it is hardly to be expected that such results could be 
realized in a collection of 200 consecutive cases, espe- 
cially in hospital practice. At the present time, how- 16 
ever, the rate ot mortality, 21.05 Per cent* which has 
been obtained in these cases, must be considered good. 
The claim that can be made for this plan of treatment 
is that it is rational, and meets the indications as well as 
they can be met with our present knowledge, and the 
means at our command. It certainly does not retard 
nature, but aims to save the strength and aid the resisting 
power of the patient, until the disease has run its course. 
That it is of some assistance, is shown by the results we 
have obtained ; a mortality-rate which certainly com- 
pares very favorably with that of other hospital reports. 
In conclusion, the writer wishes to express his apprecia- 
tion of the kindness of Dr. J. H. Ripley, in permitting 
him to report these cases, and his gratitude for valuable 
suggestions and advice. 
70 West Seventy-first Street.