COMPLIMENTS OF 
LOVIS F. BISHOP, M. !>., 
30 West 36th Street, 
New York. 
I. 
THE SCIENTIFIC SPIRIT IN PRACTICAL 
MEDICINE. 
II. 
THE IMPORTANCE OF THE HABIT OF 
PROGNOSIS IN THE DEVELOP- 
MENT OF THE INDIVIDUAL 
PHYSICIAN. 
III. 
SOME POINTS, IMPORTANT FOR CON- 
SIDERATION, IN THE TREAT- 
MENT OF ACUTE LOBAR 
PNEUMONIA. 
BY 
LOUIS FAUGERES BISHOP, A. M., M. D„ 
NEW YORK. 
Papers on various occasions reprinted from several sources. 
i897- I. 
THE SCIENTIFIC SPIRIT IN PRACTICAL 
MEDICINE. 
An Address before the Section on General Medicine, 
New York Academy of Medicine. 
II. 
THE IMPORTANCE OF THE HABIT OF 
PROGNOSIS IN THE DEVELOPMENT 
OF THE INDIVIDUAL 
PHYSICIAN. 
An Essay Read in the Section on Practice of Medicine 
of the American Medical Association. 
III. 
SOME POINTS, IMPORTANT FOR CONSID- 
ERATION, IN THE TREATMENT OF 
ACUTE LOBAR PNEUMONIA. 
A Paper Read before the New Jersey State Medical 
Society. 
by 
LOUIS FAUGERES'BISHOP, A. M., M. D. 
NEW YORK. 
1897. THE SCIENTIFIC SPIRIT IN PRACTICAL 
MEDICINE.* 
In assuming the chair of the medical section of 
the New York Academy of Medicine, I can but 
feel the grave responsibilities which inhere to this 
position. In this section all the currents and un- 
dercurrents of our science should meet, to form 
a strong tide toward truth and unity in medicine. 
It is the duty of this section to uphold the dignity of 
general medicine in its relation to the other sciences 
and to the needs of humanity. The specialist has to 
do more frequently with local diseases, which, impor- 
tant though they maybe to the individual at the time, 
still as a rule are mere incidents in his life. In condi- 
tions which permanently affect health and happiness, 
which lengthen or shorten life, and which threaten 
death, it is the general practitioner whose advice, 
counsel, and support are sought. 
We must, in the first place, invoke the true scien- 
tific spirit to control our deliberations and direct our 
work. The scientific spirit places the love of truth 
above prejudice, expediency, or even immediate con- 
crete application. It approaches all subjects with an 
open mind, willing to receive light from any source 
and whatsoever be the medium through which it 
comes. It denies nothing, however improbable, until 
it has been disproved ; it accepts nothing, however 
plausible, until it has been verified by the experimen- 
tal method. The scientific spirit, while it seeks 
enthusiastically new truth and rejoices in fresh fields, 
finds its truest expression in that love of exact knowl- 
edge which labors patiently and intelligently for the 
*Reprinted from the report in the "Medical Record" of the Meeting of 
the Section on General Medicine of Feb. 16, 1897. 4 
perfecting of established truth and the correction of 
error. Thus, while from time to time we may have 
presented to us new products of discovery, yet if we 
meet here to perfect, chasten, and simplify our 
knowledge of the fundamental art and practice of 
medicine, we shall accomplish what, to my mind, is 
the chief value of the work of this section, both to 
ourselves and to the profession at large. 
Truth, however old, is always attractive. I re- 
member, when the beauties of chemistry were first re- 
vealed to me, spending hour after hour repeating over 
and over again simple chemical reactions. There was 
nothing new to learn and nothing new to see in the 
immediate precipitations or the play of colors. The 
enjoyment consisted in the fact that after earlier years 
of harassing study in the school-room, there had 
dawned at last the image of something fixed and defi- 
nite in human knowledge, the recognition of a sphere 
in which the appeal was to truth alone, and not to 
human authority or tradition. 
We must not be discouraged with the constant 
repetition of medical and scientific truth. If we have 
the true scientific spirit, the repetition will give us 
pleasure, will give us a sense of stability, will 
strengthen our love of truth, and relieve us from the 
pathological craving for novelty. We should seek 
always that which is true, rather than that which is 
novel. But we should equally be ready to give a fair, 
impartial, and unbiased hearing to any one who has 
something which he believes contains the germ or 
truth. Many a man is saved from the propagation or 
a false theory, or the carrying on of a false system or 
practice, or even the founding of a new sect in medi- 
cine, by kindly criticism and correction ; such kindly 
reception and criticism should certainly be granted to 
those who bring the results of honest thought and 
faithful investigation before a body of men actuated 
by the scientific spirit. Every living error has in it 
a germ of truth, that gives it vitality and allows it to 5 
live. If by dogmatic assertion or violent criticism we 
attempt to destroy this error, the germ of truth may 
become forever inseparably adherent to falsehood; 
but take the new theory into the scientific assembly, 
allow it full expression and opportunity to vindicate 
itself, and by and by the gentle handling of mature 
and judicious minds will separate the little germ of 
truth, to add it to the sum of human knowledge, and 
the mass of error will fade so quietly away that its 
previous presence is almost instantly forgotten. 
We, therefore, appeal to you to bring to this sec- 
tion the results of your work, however incomplete or 
unfruitful they may seem, and we pledge you a fair 
hearing, kindly criticism, and, we trust, helpful sug- 
gestion. THE IMPORTANCE OF THE HABIT OF 
PROGNOSIS IN THE DEVELOPMENT 
OF THE INDIVIDUAL 
PHYSICIAN.* 
It is the duty of a physician to himself and to his 
patients, not only to be well informed, but also to 
seek such methods as tend to the best possible train- 
ing for his work. Habits, good and bad, are the 
relentless masters of our lives and actions. Powerful 
as they are for evil, they are equally potent for good, 
if seized upon, developed, and directed. Habits of 
mind and thought are just as much habits as those 
pertaining to the physical nature. 
Now there is a particular attitude in approaching a 
medical case that would seem, more than almost any 
other, to lead to sound judgments and judicious man- 
agement, the attitude that takes account not only of 
present conditions, but discounts them by the prob- 
able future. It not alone considers what the course of 
disease will be, if treated, but its course if untreated 
or treated in a different way. This we may call the 
habit of prognosis, and upon it must be based all 
thoroughly judicious and honest therapeutics. 
Medicine is a science and at the same time an art. 
Indeed, it is a combination of many sciences and many 
arts. Thus there is the science of pathology, the sci- 
ence of chemistry, the art of treatment, the art of feed- 
ing, the science of diagnosis, and the art of prognosis. 
The power of prognosis is at the same time an ac- 
* Read in the Section on Practice of Medicine, at the forty-eighth 
annual meeting of the American Medical Association, held at Philadelphia, 
Pa., June 1-4, 1897. Reprinted from the Journal of the Association, 
July 10, 1897. 7 
quirement and a gift. Like all other faculties, it is 
improved by exercise and increased by cultivation. 
Its basis, though largely personal experience, is 
equally found in a knowledge of medical literature. 
Thus the experience of a long lifetime may not afford 
as good a basis for prognosis in a particular case as 
an hour intelligently spent in a medical library. The 
faculty is best cultivated by the exercise of the habit 
of forming, with care and study, the most definite 
possible prognosis in every case that comes under 
observation, and then faithfully promulgating it to 
those who have a right to such an opinion. The first 
step in prognosis is accurate diagnosis, not the mere 
naming of disease, so that it may fall within the list 
of diseases such as is found in the index of a text- 
book of medicine, but the placing of a case in a par- 
ticular group of a particular variety of the disease. 
Then, by recalling from personal experience and 
searching literature, as many parallel cases as possi- 
ble are summoned as witnesses ; then the mathemati- 
cal theory of chances and probabilities is brought to 
bear, and the conclusion is reached. It seems strange, 
at first sight, that in an art so varied as medicine, math- 
ematics should have any possible bearing, and yet in 
the almost parallel science of life insurance, mathe- 
matics has found one of its most useful applications. 
The life insurance company cannot say with certainty 
that a certain man of forty years of age will live so 
many years, but it can say with very close certainty 
of a particular group of ten thousand men, that so 
many will be alive and so many will be dead in ten 
years. It is the same way with the prognosis of par- 
ticular classes of disease. If we can assemble, from 
personal experience and experience as recorded in 
literature, a group of one hundred of whom ninety 
have survived a year, we can give a prognosis in the 
particular case, all attending circumstances being care- 
fully considered, that the chances of survival for a 
year are nine out of the ten ; in the same way is the 8 
prognosis of the time of recovery in particular cases. 
If we have summoned to our aid, truthfully, a group 
of parallel cases, and have intelligently discounted 
particular surrounding circumstances, we can give a 
prognosis as to the time of recovery which will be 
correct six times out of seven ; seven times out of 
eight; eight times out of nine, or nine times out of 
ten, according to the breadth of our knowledge and 
the accuracy of our observation. 
The value of the constant habit of prognosis can- 
not but be very great to the individual physician. It 
will give him encouragement and hope in many a 
desperate case, and save him from undue disappoint- 
ment when the inevitable laws of nature have run 
their relentless course. He who has mastered the art 
of prognosis stands, as it were, on the summit of a 
mountain, where he can see beyond his fellows who 
have not climbed up the steep and laborious path. 
Observe the calm philosophy of this man, who, with 
his eye ever on the future, neither urges rash meas- 
ures nor advocates undue delay, and who is not car- 
ried away by the promises of false prophets. He is 
not deceived by the bright coloring given to the land- 
scape, by the passing meteor, into the belief that the 
face of all nature has been permanently changed. 
The idea) opportunity for the study of therapeutics 
would be by the treatment of exactly parallel cases by 
several methods, and their comparison at the same 
time with cases untreated and pursuing the natural 
course of the disease. These conditions are only 
found in rare instances and in large hospitals. Usu- 
ally, if cases are treated by various methods, it is at 
different times, and the mind pictures of older cases 
are dim and indistinct. The untreated case is hardly 
to be found. It is in supplying the place of untreated 
cases that the development of the habit of prognosis 
finds its most important place. By careful analysis 
of the case in hand, by summoning to one's use the 
records of previous cases accurately observed, by dis- 9 
counting the treatment of one by the treatment of 
another, and observing the course and outcome under 
various conditions, one may construct an ideal case 
similar to the one in hand, but with its history con- 
tinued into the future. This ideal case supplies a 
prognosis by which to be guided in the selection of 
therapeutic measures, the judgment of their efficacy, 
and the expectation as to cure. 
Prognosis is often enough modified by the wealth 
or poverty of the patient, by bis character, by his 
hopefulness or depression, and by a thousand other 
things that arise in the individual case, but the dis- 
cussion of more exact methods of prognosis must find 
a place elsewhere. What would be emphasized is 
this, that every physician should form the habit of 
constructing a well-founded judgment as to the future 
course of any case of which he seriously undertakes 
the care. With this judgment he should constantly 
compare the course of this case while under treatment, 
and honestly acknowledge the futility of useless thera- 
peutics, as well as the modifying influence of really 
valuable measures. 
The remark is often made that prognosis is not 
worth while, that it does not influence the outcome 
of the case, that a wrong prognosis is apt to bring 
disrepute, and that it is better to treat the case from 
day to day, and leave the result with Providence. 
This is the reasoning of those who take a superficial, 
and as it were, a symptomatic view of disease ; is the 
reasoning begotten of intellectual laziness, timidity, 
and self-conceit. How much more moral courage 
does the physician exhibit, who, throwing his whole 
intellectual acumen into a case, carefully studies 
all the circumstances, carefully summons to his aid 
his own experience, and that of others, and then 
having given the results of his very best work, is 
willing to stake his reputation on the result. Even 
from a lower standpoint, that of professional reputa- 
tion and success, this in the long run pays best. The 10 
greatest physicians in all times have macle errors, but 
the consultants, the men whose counsel is sought in 
time of great clanger, have been men of strong char- 
acteristics, who were able and willing to form an 
opinion and to stand faithfully by that opinion when 
formed. The mistakes of such men are apt to be 
condoned, while their successes become a glory to 
their profession, which obscure practitioners are 
proud to promulgate. SOME POINTS, IMPORTANT FOR CONSID- 
ERATION, IN THE TREATMENT OF 
ACUTE LOBAR PNEUMONIA.* 
The proceedings of our medical societies are some- 
times criticised by superficial observers, and by those 
who do not take an earnest part in the work, for the 
frequent recurrence of old topics and the absence of 
novelty and originality. Such persons mistake the 
office of the scientific medical society and the motives 
of those workers who can always be counted upon to 
express freely, honestly, and with humility what they 
know or to acknowledge their ignorance of any sub- 
ject that may be brought forward. The object of the 
work is more to crystallize truth than to disseminate 
what is new. Such novel information has a spread- 
ing power in itself that easily carries it to the whole 
profession. In the medical society men gather to 
compare, correct, and fill out their experience. Here 
the immature views of young men germinate and 
develop, while even the oldest has his established 
beliefs pruned into better form by free discussion. 
The introduction of the subject of pneumonia with- 
out special original observations, without new statis- 
tics, or even a settled plan of management, requires 
only the excuse that we are actively seeking the best 
plan of treatment. Every physician has some mode 
of procedure that he has acquired from his pre- 
ceptor or has carried from his hospital. That any 
one shall approach the treatment of a case of acute 
lobar pneumonia with confidence of a successful out- 
come is impossible, so long as the present death-rate 
*Read before the New Jersey State Medical Society at Atlantic City, 
June 22, 1897. Reprint from " Medical Record," August 14, 1897. 12 
remains. A mortality approaching twenty-five per 
cent., which has not been materially diminished in 
modern times, is certainly sufficient reason for free 
and frequent discussion. 
There are two ways in which the treatment of dis- 
ease may be improved : By a gradual advance in the 
details of treatment, with a better appreciation of the 
disease and an improved technique ; or some specific 
treatment may be discovered suddenly to supplant all 
pievious plans and immediately reduce mortality. 
The more successful treatment of typhoid fever is an 
illustration of the first; diphtheria is an instance of 
the second. A number of specific treatments of pneu- 
monia are claimed each year, but improvement is still 
confined to the elaboration of a better technique. 
I will touch upon four topics-feeding, the preven- 
tion of delirium, hydrotherapy, and stimulation. 
As to diet. In acute lobar pneumonia it has al- 
ways seemed to me that the tendency was rather to 
overfeed. It is questionable whether, in the acute 
stages of the disease, with the undoubted accompany- 
ing congestion of the abdominal organs, harm is not 
often done by stuffing the stomach with milk to the 
production of large quantities of gas and upward 
pressure on the diaphragm. Now and again a feeble 
voice is raised against overfeeding in pneumonia. 
The lesson of feeding in other febrile diseases has 
been so well learned that the shortness of the course 
of pneumonia is not enough considered. There are 
undoubted benefits in restricted diet in a disease so 
acute. Overfeeding means a consumption of physi- 
ological force in the digestion and assimilation of 
food. It means the diversion of so much energv from 
the reparatory forces of the body to the digestive 
foices. It means throwing into the circulation a 
quantity of crude food products that must be taken 
care of. It means the presence in the intestinal canal 
of the waste matter of the food that must be gotten rid 
of. 1 he patient dying of acute pneumonia does not 13 
die from a lack of reserve force such as might be pro- 
duced by a system of stuffed feeding, but rather from 
the failure of the development when needed of the 
latent force already existing. If by a system of over- 
feeding, such as would produce this more remote 
force, part of our stock of immediately available energy 
is used up, more injury than good is done. It is as if 
the captain of a ship with an important and pressing 
commission should stop to replenish the coal supply 
on the wharf when he should be on his journey, 
burning that in his well-filled bunkers. Diet should 
be bland and moderate in quantity. It would seem 
that only a misconception of the conditions of pneu- 
monia leads to stuffing. 
There is no disease in which it is more important 
to discount future events. An acute delirium in an 
alcoholic patient, when fully developed, frequently 
means a fatal termination. The feeble power of drugs 
to control this delirium, short of paralyzing the patient 
with dangerous doses, is only too well known. If at 
the outset of pneumonia in an alcoholic case we fore- 
see that the day of delirium is bound to come, we can 
by the free use of safe sedatives avoid, or at least limit, 
this delirium. 
The bromides are not sufficiently appreciated for 
their good qualities in acute disease. Their harmless- 
ness has been so impressed upon me by the experience 
of treating a large number of epileptics, who took con- 
tinually enormous quantities, that it has seemed desir- 
able to consider their usefulness in other conditions. 
The reason that the bromides have so little reputation 
in emergencies, compared with morphine, chloral, 
hyoscine, and the hypnotics, is that they have been 
given in too small amounts. Other drugs get more 
fair treatment. We push them until we accomplish 
the result aimed at, or until the appearance of some 
danger symptom. With bromide, single doses of 
from five to thirty grains are too often given, and then 
resort is had to some other expedient. A solution of 14 
bromide well diluted is not irritating to the stomach. 
It resembles very closely in its chemical and physical 
properties the saline salt solutions that we do not 
hesitate to put directly into the veins. It is not poi- 
sonous in any dose that any one would possibly ap- 
ply. Its most glaring defects are the size of the 
dose and the slowness of the results. The fear of 
bromism that is constantly before the mind rests upon 
a foundation chiefly of tradition. It occurs in patients 
who have been taking large quantities fora long time, 
and is the result not simply of the drug itself, but of 
mixed causes, such as gastric irritation and deficient 
elimination. 
If the alcoholic pneumonia patient is brought from 
the beginning of the disease under the influence of 
bromide in efficient quantities, the use of the more 
powerful and dangerous sedatives at a later period 
may be avoided. After delirium is once thoroughly 
established in pneumonia, bromide is a drug too mild 
to be efficacious. It should be begun in the very com- 
mencement of the disease in alcoholics and given free- 
ly, so that the patient shall get from two drachms to 
one ounce in the twenty-four hours. Lives seem to 
have been saved in alcoholic cases by the free use of 
bromides from the beginning. 
The third point in the treatment of pneumonia that 
can well be discussed is the value of hydrotherapy. 
In going over the recent literature of pneumonia as 
found in the later text-books and systems of medicine, 
a restlessness and reaching out for new methods is 
perceived that is not found in the older ones. While 
we do not find among the conservative men who are 
usually selected as the authors of these books one who 
definitely recommends the exclusive use of hydrother- 
apy, still nearly all point to it as a possible, or even 
probable, improvement, and quote some other man in 
support. 
The great problem that confronts us in this disease 
is the maintenance of the circulation in spite of the 15 
obstruction due to the consolidation of the lung. To 
get the best results of management, we must regard 
the circulation as a whole, not concentrating our 
attention entirely upon the heart, or the pulmonary 
circulation, or the systemic circulation ; but always 
remembering that what benefits one part of the cir- 
cuit cannot but affect favorably the other. The stimu- 
lation of the heart, and the use of vasodilators to re- 
lieve its burden, are important, but hydrotherapy is not 
frequently enough employed in combating prostra- 
tion and blood stasis. The difficulties and prejudices 
to be overcome before it can be generally adopted in 
pneumonia are so great that it is with some diffidence 
that one undertakes to break ground. Hydrotherapy 
has been so much the property of men who have 
prostituted medical science to the ends of mere per- 
sonal profit that much of value has been lost to more 
conservative practitioners. 
No one who has once witnessed the splendid results 
of systematic cold bathing in typhoid fever would be 
willing to be cut off from this resource in a severe case. 
In the same way, in pneumonia, the effect of hydro- 
therapy properly adapted to the condition of the 
patient would reduce mortality as much as in the case 
of typhoid fever. It can never be emphasized enough 
that the value of hydrotherapy extends far beyond the 
limits of the mere reduction of temperature. The 
effect is a general tonic to the nervous system, reha- 
bilitating the heat-controlling forces of the body and 
restoring the tone of the circulation. To accomplish 
these results, the temperature and duration of the bath 
must be adapted to the case and the conditions pres- 
ent, but there is one element in the application of 
bathing that is of so much importance that one is 
almost tempted to speak of the treatment as tub rub- 
bing, instead of tub bathing. While in the bath, the 
patient must be properly rubbed in every part of his 
body by a sufficient number of trained attendants. 
Without the rubbing properly carried out, the tub 16 
bathing in an acute disease is indeed the fearfully 
dangerous procedure that it is often supposed to be 
by those who have not given the subject mature con- 
sideration. 
The Brand method of treating typhoid fever gives a 
standard-the bath of 65° F., the rubbing by strong 
attendants during the whole time of immersion, the 
immediate removal to a dry bed, the precautions that 
a patient should never be bathed when the feet are 
cold, and that cold feet after a bath should be treated 
by application of warmth. 
Every man, before undertaking the treatment of dis- 
ease by the application of cold water, would do well to 
follow a few cases of typhoid treated by this method. 
Then he would be in a position intelligently to depart 
from the set system, according to the demands of each 
case. Thus the bath may be advantageously modified 
by only half covering the patient, and trusting to the 
attendants to apply water to that part of the body not 
covered. 
A very suggestive paper by Dr. F. Gundrum of 
California, in the Therapeutic Gazette of last year, 
emphasizes the importance of hydrotherapy in pneu- 
monia. He found that by placing a blanket in the 
bath under the patient, the treatment was rendered 
less objectionable. He states that in his experience 
packs were found a useful adjunct when for any rea- 
son frequent baths were difficult to give, but when- 
ever the temperature went above 1030 F., he resorted 
to the baths. With all other writers, he emphasizes 
the fact that equal in value to the reduction of tem- 
perature is the general nervous stimulus of the cold 
water and the rubbing. The effect of cold water in 
health, as a refreshing and stimulating agent, needs 
to be remembered. 
Without detriment to the treatment, the baths may 
be commenced at a temperature of 8o° or 900 F., and 
then, while the patient is being thoroughly rubbed, 
the temperature may be reduced by the addition of 17 
cold water. This lessens the shock somewhat with 
sensitive persons. 
In the discussion of the hydrotherapy of pneumonia, 
curiously enough, we come upon the old question of 
heat or cold in the treatment of disease, emphasizing 
once again the only possible answer to this dispute of 
two thousand years' standing,-that there is good in 
both. The ground for belief is strong in the expe- 
rience of every one of you that in pneumonia, heat 
applied to the chest by poultices, hot-water coils, or 
other means, has a beneficial effect upon the morbid 
processes within the chest. It certainly benefits com- 
mencing oedema, from whatever cause, and is said to 
hasten the cycle of the pneumonic processes. That 
heat is good, I firmly believe ; on the other hand, 
there is good authority from some of the best observ- 
ers in the world that cold applied to the chest in 
pneumonia has also the power of influencing for good 
the course of the disease, cutting short the processes 
and hastening recovery. Thus between heat and 
cold we cannot decide absolutely, saying one is good 
and the other bad. It is even possible that there are 
times when the very hot bath might benefit a desper- 
ate case. In the Maternity Hospital, I have frequently 
studied the effect of such immersion in new-born 
children in whom vitality was at a dangerously low 
ebb. 
The effect of a properly adapted bath was beauti- 
fully shown in the case of a child of seven. The child 
had pneumonia, with a very high temperature and 
rapid pulse. There was much venous stasis, and 
everything seemed to be going wrong. This child 
was put into a bath at a temperature of 900 F., and 
thoroughly rubbed for a period of about fifteen min- 
utes. When the child was taken out of the tub and 
put back to bed, the temperature had fallen, the 
breathing was quiet, the pulse improved, and the 
whole picture had changed. The bathing without 
the rubbing would not have accomplished any such 
result. 18 
In a discussion in the section of general medicine of 
the New York Academy on the treatment of typhoid 
fever by cold bathing, the influence of the baths as a 
respiratory stimulant was dwelt upon by Dr. A. B. 
Ball. It would seem that in pneumonia this action 
should be advantageous. Its wonderful tonic effect 
upon the nervous system, equalizing the circulation and 
bringing about physical rest, has astonished every one 
who has had the opportunity of studying fever cases so 
treated. Increase in the secretion of urine, such as is 
a constant observation in fever patients who are taking 
baths, would suggest improved elimination of toxine. 
The reports of the treatment of pneumonia in which 
bathing was used as a tonic and supportive measure, 
as opposed to merely anti-pyretic baths, are very 
meagre. Professor Bozzolo says: "After a consid- 
erable number of observations: (i) Such baths are 
well borne in severe cases ; they never produce collapse. 
(2) They lower temperature rapidly and notably, and 
keep it down for a considerable length of time ; they 
may be repeated every three hours. (3) The mor- 
tality per cent, among patients treated thus with cold 
bath is among the lowest recorded under any form of 
treatment." * 
d he fourth and last topic is the management of the 
circulation. Every thoughtful physician has a philoso- 
phy of his own that guides him in the choice of means 
of stimulation. The direct care of the heart is equal in 
importance to the attention to delirium and the destruc- 
tive forces of high temperature. Every one who has 
watched a patient with pneumonia from the onset of 
the disease to a termination has felt that the heart was 
the organ upon which the brunt of the battle had 
fallen. There is no question of equal general import- 
ance or greater difficulty than that of heart stimula- 
tion. It is a problem to be approached with the utmost 
candor, because there are many points upon which it 
* Gazetta Medica Italiana, July 2, 1881. 19 
must honestly be confessed that definite facts are not 
known. The mechanism of the heart and circulation 
are admirably adapted to fulfil their functions. The 
heart has its wonderful nerve supply, both from the 
central nervous system and from the ganglia within 
itself. The blood-vessels are governed by the marvel- 
ous vasomotor system, with its millions of constrictors 
acting as a system of regulators whose perfection sur- 
passes the comprehension of man. The automatic 
action of the respiratory and cardiac nervous centres 
also elude our complete understanding. In health the 
slightest mental or physical exertion is followed by an 
increased effort on the part of the heart 'and a corre- 
sponding deepening of respiration. When anything 
happens to cause obstruction to the breathing or circu- 
lation, the heart immediately responds with a large 
increase of labor to overcome the obstruction, and the 
lungs increase their activity to an even greater degree. 
Now, nature having provided this wonderful plan of 
increased activity to meet emergencies, the question 
of stimulation resolves into an inquiry as to whether 
we can by artificial stimulants supplement with advan- 
tage the natural stimulus that comes from the nervous 
system. We come face to face with the possibility of 
injudicious stimulation, or stimulation at the wrong 
time, which may exhaust the natural resources so that 
they will not respond at a more critical period. On 
the other hand, leaving stimulation, pure and simple, 
out of the question, can we not control the action of 
the heart and conserve its forces to calm the excessive 
stimulation of an excited nervous system, and in this 
way reserve the force required to tide over a critical 
period? In addition to stimulation and control, it 
would seem that nutrition of the heart was of great 
importance. Particular drugs cannot be discussed at 
much length. The best general plan of management 
of the heart in pneumonia is to conserve its forces 
early in the disease by the control of delirium by the 
use of proper antipyretic but at the same time tonic 20 
system of bathing, and by the use of such drugs as 
will relax the general circulation and diminish the 
hyperactivity of the heart. Undoubtedly, with all its 
disadvantages the aconite group of drugs affords very 
valuable properties. 
The importance of the philosophical consideration 
that it is the right side of the heart instead of the left 
which is chiefly in danger of exhaustion seems to im- 
press itself with difficulty upon the profession. Dr. 
Andrew H. Smith has for a long time advocated the 
study of the pulmonic second sound as a guide to 
prognosis. Still it is not perfectly clear that we have 
any means at hand by which we can stimulate one 
part rather than another, nor, indeed, with all that has 
been studied and written, is the mechanism of the 
circulation so well understood that we can proceed to 
a very great degree in the treatment of particular parts 
of it with confidence. After all is said, when we re- 
call to mind the impression made upon us by a critical 
case of pneumonia at the critical period, it is of an 
effort to apply cardiac and pulmonary stimulants with 
the object of tiding our patient over. Before my mind 
is a patient surrounded by the paraphernalia of the 
sick-room and the anxious attendants, but more dis- 
tinctly there stands out in my imagination a picture of 
a struggling heart and certain alkaloids, notably 
strychnine, atrophine, digitalin, and cocaine, that must 
be applied hour by hour to keep this heart from fail- 
ing in its task. After one has cared for a case like 
this, it is often difficult afterwards to describe just what 
doses were given, as each was administered according 
to immediate indications. In Wood and Fitz's new 
text-book on practice, we find the following recom- 
mendation that appeals to our judgment of stimulation 
in a severe case, the drug to be given hypodermically 
if not well borne by the mouth : Strychnine, one-twen- 
tieth grain, every four hours, and cocaine, one-sixth 
grain, every four hours, alternating so that one or the 
other is given every two hours. The strychnine may 21 
be slowly increased to one-fourteenth grain and the 
cocaine to one-half grain. Dr. Wood thinks he has 
seen life saved by even larger doses. Certainly a 
well-thought-out and courageously-applied plan of 
stimulation offers the only hope for critical cases. 
Time compels the omission of the discussion of the 
place of alcohol, belladonna, nitroglycerin, and digi- 
talis in pneumonia. Nor can the place of bleeding be 
touched upon, but these will doubtless be taken up in 
the discussion. 
Faith in the value of hydrotherapy in pneumonia is 
more the gradual growth of time and thought than a 
belief founded upon any special line of experiment or 
the teaching of any single person. The literature, 
though curiously meagre considering the importance 
of the subject, is entirely favorable to the views ex- 
pressed above. Many occasions arise in the course 
of pneumonia when a tub bath of moderate tempera- 
ture, carried out with skilful rubbing, would benefit 
the patient more than a great deal of drug stimula- 
tion. To follow such a method requires courage, ap- 
paratus, and skill. In advocating it at this time we 
can only hope to stimulate thought, with the desire 
that means may be found to adopt this important 
measure in practical medicine. When reason is con- 
vinced, no valuable addition to therapeutics must be 
discarded on account of apparent difficulty or pre-ex- 
isting prejudice. It was my privilege to witness the 
introduction of the cold-bath treatment of typhoid fe- 
ver into a large hospital, and I have listened to all 
the objections that will be raised again in the appli- 
cation of hydrotherapeutics to pneumonia, and yet we 
have all seen this method accepted in typhoid fever 
by every one who has had the opportunity of observ- 
ing cases under treatment. 
Until an antitoxin is discovered, the treatment of 
pneumonia must be in its final analysis expectant, and, 
valuable though it may have been to review the 
various means by which the patient is protected from 22 
mortal injury by the disease and supported to resistit, 
still in the application of each and every one of these 
measures the judgment of the individual physician at 
the particular time must have influence greater than 
the voice of any authority. It is this quality of judg- 
ment that is found in its most excellent development 
in the general practitioner occupying the field a little 
removed from the atmosphere of theoretical teaching 
and extreme specialism. To such men it is a privi- 
lege and an advantage to bring the results of thought, 
study, and research, and from them I trust my conclu- 
sions may be reflected back with the additional light 
of well-digested experience. 
30 West Thirty-sixth Street. 
" One of the pleasantest courtesies that physicians can grant each 
other is the acknowledgment of the reprints of papers that they dis- 
tribute among themselves."