THE MANAGEMENT OF PNEUMONIA 
PATIENTS. 
SIMON BARUCH, M.D., 
BY 
OF NEWYORK. 
FROM 
THE MEDICAL NEWS, 
January 2, 1897. [Reprinted from The Medical News, Jan. 2, 1897.] 
THE MANAGEMENT OF PNEUMONIA PA TIE NTS.1 
SIMON BARUCH, M.D., 
My chief reason for bringing so trite a subject 
before you is that the fatality of pneumonia and the 
frequency of the discussion of its treatment indicate 
that it is very far from being settled in the minds of 
the profession. Another reason is a desire to sum- 
marize a personal experience extending over one- 
third of a century in city and country, private and 
hospital practice, and which represents a therapeutic 
evolution, a consideration of which may contribute an 
humble stone to that therapeutic structure which can 
be reared only by the aggregation of individual ob- 
servations. It is hoped that the discussion of this 
subject to-night may furnish some clue to a better 
management of patients suffering from this very 
prevalent and fatal malady. The most effective 
therapeusis may be evolved only from the most thor- 
ough comprehension of the nature of disease. Whether 
stumbling upon it accidentally, as in the case of 
quinin for malarial diseases, or by a gradual evolu- 
tion, as in the Brand bath for typhoid fever, or by a 
process of reasoning, as in the thyroid-gland treat- 
ment for myxedema, our therapeutic achievements 
are in proportion to our mastery of the nature of the 
disease. 
OF NEW YORK. 
The history of pneumonia illustrates this idea. I 
will not weary you with the recital of its historical 
1 Read before the New York Academy of Medicine, December 3, 
1896. 2 
stages, but confine myself to personal observations. 
The teaching of the schools and text-books in 1859- 
’62, and the practice in the military hospitals in which 
I served as interne, were clearly antiphlogistic, be- 
cause the conception of lobar pneumonia at that time 
was a pure inflammation of the lung, whose tendency 
was to destroy life by apnea (Watson). Delirium, 
pyrexia, and other threatening manifestations were 
regarded as “direct evidence that the pectoral mis- 
chief is telling through the circulation of venous blood 
through the brain.” It was but a legitimate deduc- 
tion from this view that the chief agents to bring 
about recovery were the so-called antiphlogistics, by 
which it was hoped to throttle the local disease. It 
would be a bootless task to review the contending 
opinions prevailing before and at the time mentioned. 
Long before this period Dietl of Vienna had learned 
from the homeopaths (who were genuine Hahne- 
mannians, and not the mongrel breed met with to- 
day) that pneumonia is a self-limited disease, tend- 
ing to terminate favorably if the patient’s vital forces 
be not despoiled by blood-letting, mercurials, and 
starvation. 
Although he combated the prevailing “ hemato- 
mania ” with energy, he failed to make any perma- 
nent impression. In the first decennium of my 
active practice, Hughes Bennet and Austin Flint 
labored to inculcate similar doctrines. Their efforts 
were more successful, because the medical profession 
was beginning to emancipate itself from the thraldom 
into which that bloodthirsty monster phlogosis had 
cast them. In Vienna, a therapeutic nihilism at- 
tained ascendency, which, though not as fatal, did 3 
not fill the full measure of the physician’s duty. 
Then came the quinin, aconite, and digitalis, and, 
later, the antipyretic era, from which the profession 
has not yet quite emancipated itself. 
We stand to-day on the threshold of a view of 
croupous pneumonia which will contribute more to 
the saving of lives than all the doctrines and reme- 
dies suggested since the days of Hippocrates. The 
student is no longer taught, as I was taught, that the 
pneumonia patient dies from apnea. Heart failure 
is the specter that now stands at the bedside of the 
patient in this and, for that matter, in most other 
acute diseases. But we are, fortunately, not lapsing 
into the Brunonian theory of asthenia, which de- 
manded enormous quantities of alcoholic and other 
stimulants. To-day it is an almost universal axiom 
in the therapeutics of croupous pneumonia to pre- 
vent and combat heart failure. The view that this 
is an infectious disease, whose chief recognizable lesion 
is in the lungs, but whose lethal tendency is in the over- 
whelming of systemic force and vigor, is obtaining 
more and more recognition. 
I would go further than this, even. Careful 
clinical observation and a judicious sifting of the tes- 
timony of reliable practitioners have brought us to 
the belief that croupous pneumonia is no more a lung 
disease than is typhoid fever a bowel disease. When- 
ever this doctrine shall receive universal acceptance, 
we will cease to treat the disease, and we shall be 
prepared for a more effective management of patients 
suffering from it. 
It may be said that this idea is obtaining adherents 
in certain quarters. All of our recent text-books in- 4 
sist upon maintaining the patient’s vital powers as 
the main indication. That great American clinician, 
Austin Flint, read a paper before the State Medical 
Society in 1877, on “Pneumonic Fever,” in which 
he referred to the analogy to typhoid fever. My in- 
terest being aroused, I discovered that, 200 years 
ago, Huxham had insisted upon the infectious char- 
acter of pneumonia. Thus history has repeated 
itself in this as in other diseases, before the micro- 
organisms assigned to them had been discovered. 
As to etiology : The present state of our knowl- 
edge may be briefly stated to be, that while cold may 
be a predisposing factor which diminishes the pa- 
tient’s resisting power, the Sternberg-Fraenkel dip- 
lococcus is an important factor in the production of 
croupous pneumonia, because it is present in about 
seventy-live per cent, of cases, although in some cases 
there are doubtless other organisms present. Stern- 
berg and others have found the diplococcus in the 
mouths of healthy persons. Its mode of entrance 
into the lung and its pathogenic course are not yet 
clearly determined; its aspiration from the mouth 
seems to be claimed by most observers. The pres- 
ence of some constitutional depression is a potent 
etiological factor. Age is a predisposing and ex- 
empting factor, inasmuch as young children are 
rarely attacked; while it is most prevalent among 
adults, and liability to it diminishes with advancing 
years. 
Typhoid fever presents analogous conditions. The 
Eberth bacillus enters through the mouth and is 
lodged and developed in Peyer’s glands. The chief 
differences are that the Eberth bacillus is not, like 5 
the diplococcus, capable of producing other diseases, 
and that the life period of the former is three to four 
weeks, while that of the latter is five to ten days. 
The analogy certainly holds with regard to the in- 
fluence of depreciated constitution and age as etiolog- 
ical factors. 
Analogy in Symptoms.—ln pneumonia we have an 
increased leucocytosis, pyrexia, and more or less over- 
whelming of the nervous system, which is reflected to 
the heart, lungs, and other organs. The dyspnea is, 
I believe, more the expression of a special toxemia 
than of the crippling of the lung, because it is not 
always in proportion to the extent of the lesion, and 
it disappears at the crisis, while the lung is still 
greatly obstructed by the exudates. In addition, we 
have cough, which of course is due to the disturbance 
of the lungs and bronchi. 
We have practically the same manifestations in 
typhoid fever, differing only in regard to the habi- 
tat of the microorganism, diarrhea taking the place 
of cough. The fever runs a different course because 
of the difference in the life-period of the organisms 
involved in each disease. 
The most striking and important similarity is that 
the chief point of attack, in both diseases, is upon 
the nervous system; the toxemia resulting from the 
life and death of the microorganisms spends its chief 
force upon the nerve centers. This explains the well- 
recognized clinical fact that the general symptoms 
are rarely a correct index to the local lesion. Dys- 
pnea and fever, especially, may be extreme, and the 
case may terminate fatally, with slight involvement of 
the lung, just as we may observe the most serious 6 
general condition, in typhoid, without evidences of 
local lesion. 
Crisis in croupous pneumonia is signalized by com- 
plete cessation of all the general symptoms, because 
the life-period of the microorganisms is terminated. 
And yet the lung remains more or less solidified by 
exudates, as is evident from the physical signs con- 
tinuing. So do the general symptoms of typhoid 
fever cease with the cessation of the life-period of 
the Eberth bacillus, although the intestinal lesions 
are still so far from being removed that great care 
needs to be exercised with regard to diet, rest, and 
other preventive measures. 
The prognosis of croupous pneumonia and typhoid 
fever bears close resemblance in many respects. The 
effect of previous mode of life, habits, and environ- 
ment, before and during the illness, upon the issue 
of the case, is very much alike in both diseases, as is 
the influence of childhood upon the prognosis. 
Having as briefly as possible in the time at my 
disposal traced the close analogy in the etiology, 
symptoms, and prognosis of these diseases, I propose 
to deduce from this analogy the expediency of fol- 
lowing in pneumonia, as nearly as the differences in- 
dicated above may admit, the line of management 
which has afforded the best results in typhoid. We 
have learned from sad experience that the chief in- 
dication in typhoid fever is to enhance the patient’s 
resisting capacity to the lethal agencies evolved by 
the infection-process. 
It is my aim to emphasize a similar cause of 
action in pneumonia. The management of the pneu- 
monic patient, which I propose to present to your 7 
consideration, is the result of an evolution from the 
methods, which some of you, like myself, have been 
taught, and which, doubtless, some of you, as I, have 
practised for years. 
A distinct mental picture of my first case of croup- 
ous pneumonia rises before me. The patient was a 
young soldier, a hardy mountaineer, in whom a large 
portion of the right lung was consolidated. The chief 
surgeon of the hospital directed, as was the custom in 
1862, flax-seed poultices to the chest, and a mercurial 
purgative, to be followed by nitrous powders, a prep- 
aration which is happily unknown to our recently 
graduated colleagues, consisting of 8 grains of nitrate 
of potassium with y2 grain of calomel and y grain of 
tartarized antimony, these powders to be adminis- 
tered every three hours until the gums were touched; 
i. e., until ptyalism ensued. Wet cups to the chest 
were added to emphasize the doctors’ blows upon the 
enemy—inflammation of the lungs—with a view to 
deplete the latter. . The inflammation was resolving 
beautifully when the left lung was attacked. The 
same treatment was resorted to, with the exception 
of a blister being substituted for the wet cupping as 
a concession to the evidently enfeebled condition of 
the patient. This lung also was beginning to resolve, 
but the vital powers had been so exhausted by the 
depleting measures, that the system was unable to 
furnish the necessary conditions for restoration. The 
result was that the disease was practically cured, but 
the patient died from sheer depletion, as evidenced 
by a necrotic gray deposit on the blistered surface. 
This result of what was the classical treatment at 
that time (1862), made a deep impression on my 8 
youthful mind as a crucial test, and I say it with some 
satisfaction that no patient of mine has ever been 
salivated or cupped, and very few blistered since that 
time. I continued for a long time to commence 
the treatment with a mercurial purge, to give vera- 
trum to reduce the pulse, to poultice the chest for 
comfort to the patient, and to give small doses of 
tartar emetic as an expectorant, and morphin to allay 
the cough. But the teachings of Hughes Bennet 
Austin Flint, and Horatio C. Wood, gradually 
weaned me from this mildly spoliative practice. 
Until a few years ago I felt as helpless in a case of 
pneumonia as I did at that time in typhoid fever. 
Recovery in both diseases seemed to be the result 
of conditions over which my control was feeble or 
lacking. The patient’s constitution, the type of the 
disease, and his environment played the chief role. 
Treatment was symptomatic in both diseases—ex- 
pectant it was termed—and not inaptly, for I always 
expected something to happen which I seemed power- 
less to prevent. When I learned the true principles 
and value of the Brand method in typhoid fever, a 
positive treatment was at my command by which, if 
called early, serious and fatal complications, against 
which I had formerly felt impotent, could be pre- 
vented. For the comfort and the sense of security 
derived from this method, since I mastered its 
technic, I shall ever be grateful to its author. And 
herein I was recently corroborated by Gilman 
Thompson, Uelafield, Ball, and Northrup in the 
‘ ‘ Section of Practice. ”1 
It has been my ardent desire to reach a similarly 
1 Med. Record. November 7, 1896. 9 
comforting attitude in pneumonia. Weary of the 
expectant plan, and observing its enormous fatality, 
especially in those depreciated by faulty modes of 
life and habits, I looked to hydrotherapy for succor. 
While I cannot say that the latter has been reached 
to an entirely satisfactory degree, observation and 
reflection have produced a method of management 
whose clinical value deserves to be tested further. 
The prevailing type of the disease should be care- 
fully considered. It has been demonstrated by care- 
ful observers that the vaunted success of certain 
methods of treatment may be attributed to a change 
of type in the disease and the previous conditions of 
the patient. Any new treatment should therefore be 
approached with caution and judgment. 
Dr. Learning, whom many of you remember as a 
practical, safe clinician, gives a graphic delineation 
of this idea in his little book published in 1884. 
‘ ‘ When I began my professional career, I believed, 
as I had been taught, that active interference was 
necessary in every step of this disease, to prevent 
destructive inflammation. But I soon found, and by 
accident, that cases would get well without active 
treatment; that the expectant plan and wise man- 
agement was the best ; simple medication, with 
stimulants and supporting alimentation. The mor- 
tality was so small that it seemed unnecessary for an 
uncomplicated case to reach a fatal result. When 
the fatal form of pneumonia began to occur in New 
York, I, with other physicians, was surprised at the 
failure of the managing method. The failure of the 
latter rendered a resort to the heroic method a ne- 
cessity. ’ ’ The type of pneumonia in this city appears to have 
remained as grave as it was in the time of which 
Learning wrote. We still see and hear of cases dying 
rapidly. As recent sad illustrations in our own ranks 
may be cited the deaths of the lamented Loomis and 
of the brilliant young clinician Roosevelt. In hos- 
pital and private practice this disease is more fatal 
than any other acute disease of adults. In the New 
York City Board of Health statistics it ranks next to 
phthisis in fatality. I apprehend that the chief rea- 
son of this great fatality may be sought for and found 
in the helplessness of physicians in the presence of 
this fearful disease. 
It follows, therefore, that the first consideration in 
the management of these cases is a due regard for 
the prevailing type. 
Complete rest of body and mind, and good nur- 
sing, are essentials in furthering recovery. This 
cannot be too earnestly urged upon the patient and 
his family. The ventilation of the sick-room, too, 
which is much opposed by the laity, should be anx- 
iously watched by the medical attendant, who is too 
prone to yield to existing prejudices, and thus to 
become an unwilling accomplice in depriving the 
patient of this greatest pabulum in infectious dis- 
eases—fresh, pure air. The patient and family 
should be positively assured that there is no danger 
of taking cold if the body temperature is elevated to 
any considerable extent. In summer and winter the 
air of the sick-room should be constantly renewed, 
even at the cost of reducing its temperature in win- 
ter to an extent which may be uncomfortable to the 
nurses. During the late war, cases of pneumonia 11 
treated in tents in rigorous weather did far better 
than those treated in improvised hospital buildings. 
The diet should be restricted to milk and farinaceous 
broths, administered with precision, while the pa- 
tient is awake, every two hours, in quantities ranging 
from four to eight ounces. Ido not share the horror 
of asthenia in this disease, which is only too preva- 
lent, and leads to undue feeding. The disease is of 
short duration ; it not infrequently suddenly attacks 
well-nourished persons in the midst of comparative 
good health. It seems an unphysiological pro- 
ceeding to stuff these patients with concentrated 
foods, in large quantities, which they cannot assimi- 
late, and thus to impose an additional tax upon the 
system. Stimulants, also, are rarely so necessary 
to the same extent as formerly, since the course of 
management here outlined was adopted. In alco- 
holic subjects whose consumption of liquor has been 
a daily habit and requirement, to 2 ounces of good 
whisky every two or three hours may be useful, es- 
pecially while resolution is going on, but not as a 
spur to a failing heart, as is commonly the practice. 
I am not quite sure on this point, hence still feel 
myself under the dominion of this idea. It would 
seem that inasmuch as a large part of alcohol is elim- 
inated through the lungs, the latter are needlessly 
overburdened while they are straining to the utmost 
their functionary capacity. I should like to hear the 
experience of the fellows of the Academy upon this 
point. 
Of medicinal agents I use but very few. Besides 
an opening dose of 10 to 20 grains of calomel, 
strychnin, and an occasional dose of morphin for pain, are the only medicines I have found of any 
real value. When the first sound of the heart be- 
comes muffled or feeble, hypodermics of strychnin, 
sV to tV Sr-’ every three or four hours, offer a valu- 
able aid to tide the patient over a trying period. 
Given even to the production of trismus, if necessary, 
it is far superior to digitalis or brandy. Ido not 
fear an occasional dose of phenacetin when the pa- 
tient is restless, with high temperature, but it should 
not become a routine practice for temperature re- 
duction. It is rarely required. Quinin, aconite, 
veratrum, digitalis, and other drugs, I have discarded 
after a prolonged trial. 
The administration of calomel requires some de- 
tail. It should be placed, as Learning and Cammann 
direct, dry upon the tongue and allowed to gradually 
disappear, being swallowed with the saliva, or, if 
necessary, washed down with a small quantity of 
water. These experienced practitioners tell us that 
‘‘ the inefficiency of the expectant method rendered a 
“ resort to the heroic a necessity, and with very en- 
‘‘ couraging results. Cases, such as had proved fatal by 
“ the mild treatment, were saved by the prompt exhi- 
“bition of sedative doses of calomel, which are less 
“ depressing to the system than smaller doses. ” To- 
day we are able to give a more rational explanation 
of the action of calomel in pneumonia than that of a 
“ sedative.” Its effect is twofold. First, it is a 
fact clearly established by Sternberg and others, that 
the diplococcus of Fraenkel, found most abundantly 
in the saliva, is destroyed by very feeble mercurial so- 
lutions. This may explain why the effect of calomel is 
so much more striking when allowed to slowly mingle with the saliva. Thus, the supply of microorganisms 
is at once cut off, together with toxins which would 
continue to be evolved from these, so long as they are 
living. This is not an unreasonable explanation of 
the remarkably rapid change in the symptoms of even 
desperate cases which are reported by Learning, and 
which I have observed. 
Secondly, a large dose of calomel removes pto- 
mains that may have lodged in the gastrointestinal 
canal. Calomel is the only agent to which investiga- 
tions (made before guaiacol was discovered) have con- 
ceded internal antiseptic properties. Moreover, it 
clears the primce via, as we older practitioners were 
taught to do; it clears the ship for action, as it were. It 
also disgorges the portal circulation, and probably thus 
relieves the stasis existing in the pulmonary circula- 
tion indirectly. Be the explanation what it may, 
clinical observation in typhoid fever, pneumonia, 
tonsillitis, diphtheria, and other infectious diseases 
has convinced me of its value when given in one large 
dose in the beginning of the case. It very rarely 
produces serious purgation. Even when diarrhea ex- 
ists, it does not salivate as readily as smaller doses, 
and it certainly requires no repetition. It is more 
easily retained by an irritable stomach than other 
medicines. It is my custom to direct the patient to 
rinse the mouth frequently with a saturated solution 
of potassium chlorate to insure against ptyalism, and to 
keep the mouth in a clean condition. Juergensen 
recommends weak mercurial solutions as a mouth- 
wash for the purpose of destroying the diplococci, 
whose favorite habitat is in the mouth. 
Hydrotherapy, judiciously adapted to the indica- 14 
tions of the case, has proven a valuable auxiliary in 
the management of these patients. In the croupous 
pneumonia of children, who are more easily handled, 
without great disturbance, the tub-bath is very use- 
ful when administered alongside of the bed, as in 
typhoid fever. The temperature should, however, 
rarely be below 85° F. Beginning with 95 °, each bath 
may be reduced a few degrees, until the patient be- 
comes accustomed to it, repeating every four hours 
until the temperature remains below 102.5°. Friction 
is a sine qua non, because chilling is more apt to occur 
in these patients than in typhoid fever, and for this 
reason the duration of the bath should be short—eight 
to ten minutes. The toxic agents which are opera- 
tive in pneumonia appear to affect the heat-center 
quite differently from those evolved in typhoid fever. 
A bath of Bo° F. often reduces the temperature in 
the former disease two to four degrees, while in the 
latter one degree would be a large reduction. Upon 
this clinical fact I have based a diagnostic bath 
which materially aids in the differentiation of typhoid 
fever from other diseases which so strongly resemble 
it during the first week. The value of the full bath 
in the pneumonia of children has been confirmed by 
the highest authorities, such as Penzoldt and Baginsky 
in Germany, Hutinel of Paris, our own Jacobi, and 
others. 
In adults, however, I have given up tub-baths, al- 
though very cold baths (so°-6o°F.) have been lauded 
by Juergensen and commended (65° F.) by chief-sur- 
geon Yogi of Munich in a letter to myself. While 
they proved useful in many cases, I am convinced 
that the disturbance and agitation incident to a cold tub-bath increase the lung disturbance. If the pa- 
tient is very dull, cyanotic, and presents great nerve 
prostration, resembling the typhoid state, I do not 
hesitate to choose between the two evils, an increase 
of the local disturbance and a decrease of nerve 
prostration, by plunging the patient into a bath of 
Bo° F., or less, or seating him in water at xoo° and 
and pouring several basins of water at 65° to 750 F. 
over his head and shoulders. This is a valuable 
heart tonic. It serves, by deepening the inspirations, 
to dislodge accumulations in the bronchi, which have 
crippled the healthy as well as the affected lung. 
The most useful hydriatric procedure in pneu- 
monia is the wet compress. This consists of three 
folds of thin old linen stitched together at the edges, 
which has slits corresponding to the axillae, so that it 
may be wrapped around the patient’s chest snugly. 
The slits are made sufficiently deep to allow the up- 
per edge of the compress to reach above the clavicles, 
and admit of the junction of the flaps thus formed on 
each side to cover the shoulders. Two such jackets, 
and two pieces of closely woven thin flannel of the 
same shape, but an inch wider and longer, should be 
provided and fitted to the patient. One of the former 
is rolled up and soaked in a basin of water at 6o° F., 
and wrung out so that it remains quite damp without 
dripping. The flannel is now spread out upon an 
even surface and the wet compress put upon it, so that 
there remains an edge of flannel about an inch wide 
all around. Both are rolled together half-way. While 
the patient is gently turned upon his left side, with 
the precaution of not allowing any exertion on his 
part, the compress is so placed upon the bed that the 16 
rolled part lies in close proximity to the left side of 
the patient, and the lower edge of the left slit is un- 
der the left axilla. Now the patient is quietly turned 
upon his back, so as to release the rolled-up portion. 
The latter is now unrolled, and both edges of the 
compress are brought forward upon the front of the 
chest and are thus made to envelop the latter snugly. 
The flannel cover, which has been allowed to lie 
upon the bed during the application of the wet com- 
press, is now brought forward so as to quite cover the 
latter. It is secured by two safety-pins in front, and 
one upon each shoulder. 
The well-known oiled silk jacket may serve as a 
model for the shape and manner of applying this wet 
compress. The latter should be changed every half- 
hour, unless the patient’s temperature is below 
102.50 F.; every hour unless it be when it 
is discontinued. The removal is accomplished by 
preparing the second compress just like the first, 
paying attention to the water temperature being 
6o° F. When it and the flannel covering are rolled 
up in readiness, the first compress is removed and the 
second is applied. Thus a rotation is kept up every 
half-hour or hour as the case may require, night and 
day, unless the patient be asleep. The water in the 
basin should be renewed each time, and the compress 
rinsed off in another basin before it is rolled up for 
soaking, in order to insure thorough cleanliness and 
prevent furnuncles by furthering asepsis. 
The technic of the procedure has been entered into 
with a detail that may seem needless. As will be 
shown later, these details insure precision, and upon 
their exact execution may depend success or failure. The physician should himself supervise the first ap- 
plication, just as he should supervise the first Brand 
bath in typhoid fever. A skilled nurse can apply 
these compresses with a minimum of disturbance. 
There is need, too, of individualization. In the 
average case a temperature of 6o° F. will be appro- 
priate. Should the patient evince stupor or mutter- 
ing delirium, a lower temperature should be adopted, 
and the chest should receive one or more dashes of 
colder water, before renewal of each compress. The 
same procedure is useful in bronchopneumonia, when 
the bronchi are blocked by secretions, or cyanosis ex- 
ists. In a case which I had the privilege of seeing with 
Dr. E. J. Ware, this application proved its worth. The 
patient had passed through an attack of typhoid fever 
lasting some ten weeks ; her condition was so pre- 
carious that when I entered an adjoining room she 
was bidding her relatives adieu. By skilful manage- 
ment she had been sustained up to this time. The 
right lung in its entire posterior aspect was solidified. 
The temperature was usually below 102° F., and the 
pulse exceedingly rapid. There was no dyspnea. 
In this case the modified procedure referred to 
was extremely valuable. Inspiration soon deepened, 
the heart slowed, and in a few days the patient rallied 
from a most desperate condition. 
A higher temperature than 6o° F. may be used if 
there be much jactitation, insomnia, or excitability. 
In the latter event great benefit will accrue from 
allowing the compress to remain two hours and 
moistening it more thoroughly, which converts the 
compress into a soothing fomentation that is not 
relaxing like a poultice. In a colleague, whom I had the privilege of seeing 
with Dr. Palmer Cole, there was complete involvement 
of the entire right lung, with temperature ranging from 
103° to 105° F., the heart action being fair. The 
patient being a morphin habitue, there was a decided 
neurotic element in the case, involving insomnia and 
great jactitation. The compresses were only applied 
hourly, despite the high temperature, but they were 
allowed to be quite moist, in order to obtain a calm- 
ing effect. Although the left lung became involved 
later, Dr. Cole informed me that the patient recovered 
from his desperate condition, and that, in his opinion, 
his life was saved by the management here outlined. No 
remedial measure deserves adoption by the profession 
unless the rationale can be satisfactorily explained. 
According to my view of pneumonia crouposa, the 
therapeutic indications are (1) to stimulate and in- 
vigorate the nerve centers with a view to enhancing 
the patient’s vital powers, (2) to prevent and con- 
trol heart failure, (3) to reduce temperature, (4) to 
eliminate toxins. 
The nerve centers are well stimulated and rehabili- 
tated by the repeated gentle shocks and subsequent 
reactive stimulation of the sensory fibers in the skin, 
both of which are conveyed to the central nervous 
system and thence reflected to the organs, upon whose 
functionating capacity depends the patient’s ability 
to resist the toxic agencies circulating in the blood. 
We aim here to accomplish precisely the same object 
as with the Brand bath in typhoid fever. The milder 
form of shock is better adapted to pneumonia, be- 
cause it is less disturbing, and because the toxemia, 
induced by the diplococcus, is less intense in the average case, and certainly has only one-third of the 
life period of the Eberth bacillus. 
After a few compresses the patient grows more 
calm, the inspirations, which are deepened by each 
application, continue deeper, dyspnea is markedly 
relieved, sleep ensues, appetite improves, and the skin 
and kidneys begin to act more freely. These clinical 
evidences demonstrate the correctness of the rationale 
enunciated above. 
The maintenance of the heart action is accom- 
plished by the wet compresses in the following man- 
ner : When the cold compress is applied, there is a 
rapid contraction of the cutaneous vessels, which 
raises the tension at once, but gives way to a tonic 
dilatation of these vessels, which is evidenced by a 
ruddy hue of the skin. This dilatation differs very 
decidedly from that relaxed condition of the cutane- 
ous vessels produced by warm poultices. The latter 
relax the vaso-constrictors, producing a paretic con- 
dition of the vessels, or a stasis, while cold applica- 
tions stimulate the vaso-dilators, giving rise to an 
active dilatation, with maintenance of the tone of 
the vessels, an active hyperemia, by reason of which 
the blood is propelled more vigorously through them. 
The heart is thus relieved ; not by a vis-a-tergo, as 
is the case after digitalis, but by a vis-a-fronte, 
formed by broadening of the blood-stream in the cu- 
taneous capillaries, whose enhanced tonicity aid at 
the same time in propelling the blood onward. Ar- 
terial tension is increased, as is evidenced by the 
better filling of the radial arteries. The right heart 
is indirectly aided by this enhancement of the gen- 
eral tone in the vascular apparatus, and may thus 20 
expend more force upon the pulmonary circulation, 
whose vessels contract more firmly by reason of the 
dilatation of the superficial vessels. 
Romberg1 has recently confirmed what I have, 
several years ago, and repeatedly since that time, 
insisted upon, that in acute infectious diseases we 
encounter disturbances of the circulation which man- 
ifest themselves clinically as reduced tension and 
diminished filling of the arteries, and which are com- 
monly described as heart failure. Undoubtedly the 
condition of the peripheral vessels bears a very large 
share in the production of cardiac atony, as I have 
sought to impress when explaining the rationale of 
cold applications in typhoid fever and pneumonia.2 
Romberg has shown by experiments with injections 
into rabbits of Fraenkel’s diplococci that the circu- 
lation is damaged by a paralysis of the vasomotors, 
while the heart itself remains unaffected. It is true 
that the right ventricle is overloaded because of lung 
infiltration, but that this does not so seriously cripple 
the heart as is generally supposed is proved by the 
fact, referred to above, that when crisis ensues, the 
compression due to the exudates is not removed at 
once, and yet the respiration and circulation are re- 
lieved as if by magic. This can only be accounted 
for, if I may be allowed to reiterate so important a 
statement, by the nervous system being suddenly re- 
lieved of the toxic elements generated by the diplo- 
coccus, whose activity ceases at once when it has 
reached the end of its natural life-period. It is prob- 
able that crisis ensues when the antitoxins evolved in 
1 Berlin klin. Wochenschrift, 1895, Nos. 51 and 52. 
2 “ Uses of Water,” vol. ii, p. 166. the natural course of the disease have attained an 
overbalance of power. The battle between the diplo- 
coccus, with its allies, and the patient’s vital powers, 
is at an end. The most important effect of cold ap- 
plications in pneumonia is, therefore, the aid and 
sustenance they furnish to the nervous system, which 
bears the brunt of the fight. The improvement of 
cardiac action is one of the results of this effect. 
Reduction of temperature is an important thera- 
peutic element in these cases. Persistent high tem- 
perature may enfeeble the heart, and certainly de- 
preciates the nerve centers. Some good clinicians, 
like Juergensen, claim that high temperature is the 
chief danger to patients suffering from pneumonia, 
and he advises in his latest work1 that very cold 
baths, some below 6o° F., are demanded to meet this 
‘ ‘ great danger. ’ ’ I shall not discuss this doctrine 
fully to-night. Since my argument against it before 
the New York State Medical Society in 1889, I have 
repeatedly expressed adverse views in this and other 
societies to this unfortunately too firmly established 
error, an error which has given unhappy prominence 
to the coal-tar antipyretics in the therapy of fevers. 
If any further testimony is needed to lay this ghost, 
which has so long affrighted timid practitioners, to 
rest, the discussion on fever in the Fourteenth Con- 
gress of Internal Medicine in April, 1896, demon- 
strates that we should cease to regard elevation of 
temperature as the cardinal symptom for therapeutic 
attack. While, however, these conclusions fully cor- 
roborate my own views expressed eight years ago, I 
may say that high temperature, though not actually 
1 Penzoldt and Stinzing, “ Allgemeine Therapie,” 1896. 22 
and directly a lethal factor by inducing fatty degen- 
eration of the cardiac muscular fiber, as claimed by 
Ziegler and others, does seriously cripple the work 
of the heart by imposing upon it more rapid action, 
and it does seriously interfere with the patient’s com- 
fort. High temperature, therefore, demands careful 
attention by measures that are not harmful like the 
routine use of coal-tar antipyretics. As I said else- 
where, I do not hesitate to use the latter occasionally 
when high temperature is associated with sleepless- 
ness or great jactitation. They give great comfort to 
the patient, and are less annoying and disturbing than 
the wet compresses. But the latter are not used by 
me for their antithermic effect, which is only inci- 
dental. 
The susceptibility of pneumonia patients to cold 
baths, and the great facility with which their tem- 
perature may be reduced, renders great care in the 
application of these measures imperative. For this 
reason I have abandoned cold baths, and have dwelt 
so minutely upon the method of application. That 
so mild a procedure as the wet compresses should be 
capable of reducing high temperatures in pneumonia, 
I have numerous charts to demonstrate. The decline 
is not as rapid as after cold baths, but it is pronounced 
and steady. It does not ensue after one or more com- 
presses, nor does it follow the course of temperature 
reduction observed after cold baths in typhoid fever. 
It decreases day by day one or more degrees. It 
is not the result of direct refrigeration; such an effect 
is neither aimed at nor obtainable. When a com- 
press at 6o° F. covered with flannel is applied around 
the chest of a pneumonia patient who presents a 23 
temperature of 102° to 106° F., there is an imme- 
diate cooling of the surface covered by it, which is 
followed by a gradual reaction with a more or less 
rapid rise of the surface temperature, until the latter 
is nearly the same as it was previous to the applica- 
tion. The surface is now bathed in a vapor produced 
by the heating of the compress. If the latter be 
allowed to remain sufficiently long, the flannel cover- 
ing receives the vaporized water, and passes it out- 
ward until the compress becomes dry. But if the 
compress is changed as indicated above, the vapor is 
more slowly removed, and the skin and compress are 
found to be cooler than the flannel covering. Thus 
the gradual cooling process is continued until a fresh, 
cold compress is applied, when the skin, more sensi- 
tive by reason of having been bathed in this warm 
vapor, feels the shock more distinctly and reacts more 
fully. The error is not infrequently committed of 
covering a wet compress with oiled silk. While this 
would protect the bed and clothing of the patient, it 
would defeat the object of the compress by convert- 
ing it into a poultice. If the body temperature is 
103° F. or over, the compress applied as above be- 
comes warm in half an hour, although evaporation of 
the moisture through the flannel renders the skin 
under it cooler than other parts of the body. When 
it is renewed, the repetition of the gentle shock and 
tonic dilatation occurs. Thus a slow cooling process, 
not relaxing or in any way depreciating, is main- 
tained,which gradually lowers the general temperature, 
calms the patient, and contributes much to his re- 
covery. 
How far this cutaneous hyperemia acts as a revul- 24 
sive, it is impossible to ascertain, but it is a well- 
known fact that such hyperemia is always accompanied 
by contraction of the blood-vessels in the parts un- 
derlying. Thus may a favorable effect be produced 
also upon the inflamed lung tissue, and its circulation 
be improved. 
The elimination of toxins is promoted by the wet 
compress, as by all cold hydriatric procedures. It 
has been proved by Roque and Weil that the urotoxic 
coefficient of the urine is trebled after cold baths in 
typhoid fever. All the secretions of the body are in- 
creased by cold applications. The alkalinity of the 
blood is also enhanced by the latter, as demonstrated 
by Alois Strasser. Tassinari (quoted by Winternitz) 
says that after septic infection of rabbits, the alkalin- 
ity of the blood is reduced about one-half. And it has 
been shown by others that in all infectious diseases 
the blood is less alkaline. Since alkalinity of the 
blood is a prerequisite for the existence and activity 
of phagocytes, it is not unreasonable to assume that 
cold applications further the phagocytosis, and elim- 
ination of toxic products, by rendering the blood 
more alkaline. Hence Buchner is correct (as Win- 
ternitz claims) in asserting that by cold-water treat- 
ment the powers of resistance to infectious agencies 
are enhanced. 
This antitoxic-eliminating effect is increased by 
copious libations of water. It is my custom to ad- 
minister in pneumonia, as in typhoid fever, 6 ounces 
of water every two hours, alternating with the same 
quantity of milk, night and day, when the patient is 
awake. The enormous increase of urine is scarcely 
credible. I have charts showing from 60 to 122 25 
ounces in twenty-four hours. Some of the well- 
trained nurses, who have seen much hospital service, 
have volunteered an assurance of the correctness of 
their reports, under the impression that I would dis- 
credit such large quantities. 
There is a striking peculiarity impressed upon the 
regular course of croupous pneumonia by the method 
here outlined to which I desire to call attention. Al- 
though the fever, dyspnea, and other distressing 
manifestations yield, to a remarkable extent, in a large 
proportion of cases, in one or two days, the phys- 
ical signs do not change in a proportionate degree. 
Indeed, I have observed a distinct crisis in only 
about forty per cent, of the cases so treated; in the 
remainder, the disease ended by lysis of a very slow 
type. Improvement of the general symptoms goes 
on, the patient seems well, and is anxious to rise, 
but a dull percussion-note, muffled breath-sounds, 
and bronchial whisper bear testimony to lingering 
exudates for many days. 
As an example, I may cite the case of H. E., who 
sickened on December 8, 1895. His temperature 
ranged from 102° to 104° F. for four days, without any 
pronounced physical signs in the lungs, which were 
examined every day. On December 12th, consoli- 
dation of the entire posterior lower half of the right 
lung was made out. The mouth temperature was 
104° F. at three p.m.; cough had been distressing sev- 
eral days ; there were now rusty sputum and increased 
dyspnea. The family being greatly alarmed, Dr. A. 
A. Smith was called in consultation, but did not see 
the patient until the next morning. Calomel having 
been administered, the wet compresses were now ap- 
plied, with the effect of bringing the temperature 
down two degrees in five hours. During the night, 26 
the compresses were, by a misunderstanding of the 
nurse, renewed every hour. The patient sleeping 
soundly for the first time since his illness, com- 
plained to me of the frequent disturbance. After 
twelve compresses, the temperature was ioi° F. at 
eight a.m. When Dr. Smith saw him, at ten 
o’clock, he found him so comfortable that he ex- 
pressed surprise at being called, and concurred in 
the treatment. Physical signs of consolidation were 
distinct. There had been no other treatment except 
5 drops of dilute hydrochloric acid every two hours, 
as a placebo, followed by 6 ounces of water. Tem- 
perature reached normal point once every day for two 
days, and remained normal for ten days, when the 
patient was dismissed. Physical signs continued dur- 
ing Dr. Smith’s attendance of five days, and dulness 
of the percussion-note had not entirely cleared up 
when I last saw him. 
Clinical results confirm the rationale of this treat- 
ment, and attest its value. A quarter of a century 
ago the greatest living German clinician, Professor 
Niemeyer said : 1 “I have made extensive employ- 
ment of cold in the treatment of pneumonia, and, 
relying upon a large number of very favorable re- 
sults, can recommend the procedure. In all cases, I 
cover the chest of the patient, and the affected side 
in particular, with cloths, which have been dipped in 
cold water, and well wrung out. ... In the hos- 
pital at Prague, every pneumonia is treated with cold 
compresses and, according to the statement of Smoler, 
it is exceptional for a patient not to feel material re- 
lief from the treatment.” 
Why has a treatment which has received high com- 
1 “ Text-book of Practical Medicine,” vol. i, p. 185, translated by 
Humphreys and Hackley. 27 
mendation by so eminent a teacher not become an 
established practice in a disease which so often baffles 
the physician under other management ? 
To the student of the history of hydrotherapy this 
question is not difficult. Although water is an or- 
thodox remedy, to which Hippocrates devoted al- 
most an entire book, and although it has been highly 
commended by eminent physicians at various times, 
it has not become the common property of the pro- 
fession, because most of those who taught its use and 
value most earnestly failed to give definite directions 
for its application. Niemeyer illustrates this point. 
He simply advises “ cloths wrung out of cold water 
to be applied to the chest” of the pneumonic pa- 
tient. The temperature of the water, the duration, 
technic, frequency of repetition are left to the discre- 
tion and good or bad judgment of his hearers and 
readers, and yet these are far more important in hy- 
drotherapy than are the dose, time of administration, 
frequency, etc., in prescribing medicinal agents. 
In a paper on pneumonia, published several years 
ago by an eminent American teacher, the following 
sentence occurs: “If the temperature in pneumonia 
“ rises to 104°, 105°, or 1060 F., I use cold baths or 
“ cold packs.” Such indefiniteness is to be greatly 
deprecated when coming from one who is highly re- 
garded as a teacher and guide. A cold bath, without 
stated temperature, is generally understood to be a 
bath to which neither hot water nor ice has been 
added. Such a bath would have a temperature of 
750 F. in August, and 450 F. in December, in this 
city. Thirty degrees in the temperature of a bath are 
capable of producing an immense difference for good 28 
or evil; in pneumonia it would react very unfavorably, 
according to my personal observation. Just as Nie- 
meyer failed to create a permanent following for the 
practice which he so highly lauded, so has the justly 
famous teacher referred to failed to impress upon 
the profession a practice which he had taught in 1870, 
as follows: “If there be anything I should rely on in 
“pneumonia, if the temperature is very high, it is 
‘‘ cold-water treatment. ’ ’ If this excellent teacher had 
been as explicit in giving temperature, duration, etc., 
of the “cold-water treatment,” as he was in giving 
the doses of digitalis, nitroglycerin, and camphor, 
the valuable lessons he endeavored to inculcate would 
not now (twenty-five years later) require to be taught 
anew; they would have served as a beacon-light to the 
vain searcher after reliable therapeutic methods in 
this fatal disease. Let me emphasize, therefore, that 
while I may have offered nothing novel or striking in 
this essay, its chief aim is to impress upon you the 
great import of giving definite prescriptions for all 
hydriatric measures in this as in other diseases, be 
they acute or chronic, for only by such precision may 
we obtain definite results. 
Statistical evidence to prove the value of the 
measures here advocated, or of any other method of 
management, is indeed very difficult to produce. The 
type of the disease differs very much; in private prac- 
tice the number of cases is too meager, and observa- 
tions are too inaccurate and unreliable. I may say, 
however, that I have not lost a case of uncomplicated 
croupous pneumonia in private practice since the 
adoption of the management of patients suffering 
from it, here outlined. In hospital work the chief 29 
element of success with this method, viz., its applica- 
tion in the early stages of pneumonia, is unfortunately 
absent. Its favorable influence upon the progress of 
the disease is attested, however, by the statistics of 
156 cases in the J. Hood Wright Memorial (formerly 
Manhattan General) Hospital, in which the total 
mortality from pneumonia has been reduced one- 
half, since the method here advocated has been 
adopted by the entire staff; while in the cases ad- 
mitted before the fifth day the mortality has been 
twelve per cent, against thirty-seven per cent, under 
the formerly prevailing expectant plan. These cases 
were under the observation and treatment of my col- 
leagues, Urs. Daniels and Knickerbocker, and my- 
self. The method described above is, with slight 
modifications, equally favorable in catarrhal pneu- 
monia. 
The ice-pack method recently advocated by Dr. 
Mays of Philadelphia, which claims a mortality of 
3.58 per cent, in private practice, is worthy of men- 
tion in this connection, because its success is applica- 
able upon the theory that it fulfils all the therapeutic 
indications almost as well as the cold wet compresses. 
Ice is applied in bags which are wrapped in towels 
and placed over the affected area, with a view to reduce 
the inflammatory process in the lung by direct cold. 
That the latter is an erroneous idea has been proven by 
the experiments of Silex,1 who has shown by experi- 
ments on animals, that ‘ ‘ ice applications increase the 
“ temperature of the organs over which they were 
“ placed and which were to be cooled.” This effect 
of local cold has long been recognized by hydrothera- 
1 Miinchener mediz. Wochenschrift, 1893. pists, who know that intense cold applied externally 
produces a compensatory hyperemia in the parts be- 
neath, thus protecting the latter against destruction 
if carried too far. The rationale of the favorable in- 
fluence of the ice-compress treatment, however, is 
not difficult to explain upon recognized principles of 
hydrotherapy. 
The towels which envelop the bags of ice soon be- 
come thoroughly wet by condensation, and thus the 
application is practically a continuous wet compress. 
This together with its unevenness prevents the com- 
plete reaction which is so useful in arousing the nerve 
centers, but its being applied upon parts of the chest 
only prevents serious results from this source. The 
objection to ice compresses would seem to be their 
uneven surfaces, which renders them uncomfortable 
when applied to the posterior portions of the lungs, 
the patient lying on the back; and also that their 
weight when applied anteriorly must render them in- 
convenient. In consideration of these facts I have 
not felt justified in applying this method of ice packs 
so long as good results were obtained from the wet 
compresses. 
i. Pneumonia is, like typhoid fever, an infectious 
disease whose chief attack is upon the nervous system, 
as manifested by heart failure, and other signs. 
In conclusion I hope to have shown that 
2. The treatment should be applied, not to the 
disease, but to the patient, whose resisting capacity 
should be enhanced by all useful remedial agencies. 
3. Calomel in a large dose, followed by wet com- 
presses, adapted in duration and temperature to each 
case, with fluid diet, and an abundance of water in- ternally, aided, if need be, by mild alcoholic stimu- 
lation and hypodermics of strychnin, offer at the 
present time the most favorable, yet not perfect, re- 
sults in the management of patients suffering from 
pneumonia. 
DISCUSSION. 
Dr. Charles B. Folsom of Boston opened the dis- 
cussion. He said that at the Boston City Hospital he had 
tested the cold-bath treatment in thirty-six cases of pneu- 
monia, all of a severe type. The method consists in plac- 
ing the patient in a sheet, and rubbing him with a towel 
and water at a temperature varying from 70° to 950 F., for 
about ten minutes. The patient is then wrapped in a 
blanket and allowed to rest for half an hour. Of these 
thirty-six cases, eight died, a mortality of 22.2 per cent. 
The mortality in that hospital for croupous pneumonia 
averaged about thirty-five per cent. Of the fatal cases, 
one had typhoid fever, one had pleurisy, three were vic- 
tims of chronic alcoholism, one had general diplococcus 
infection, as shown by the presence of endocarditis, peri- 
carditis, and cerebral meningitis; one had chronic nephritis, 
and one had phthisis. As death was only hastened by an 
intercurrent pneumonia in the case of phthisis, the pa- 
tient dying on the thirty-first day, and as the case of chronic 
nephritis was fatal on the second day, these might fairly be 
excluded. If this were done, the mortality would be 17.6 
per cent. He had been convinced from the observation 
of these cases that the cold baths were very effective, and 
he was more than satisfied with the results. In marked 
contrast with the bath treatment of typhoid fever was the 
fact that all these patients said that the baths were grate- 
ful to them. In conclusion, he would say that these baths 
controlled the fever, diminished the cough, lessened dili- 
rium, and induced sleep. 
Dr. E. G. Janeway said that his experience had led 32 
him to dread the afebrile pneumonias of old people more 
than the highly febrile pneumonias of the young. In the 
former, neither cold baths or cool compresses had any 
place; all our efforts must be directed to sustaining the 
failing strength of the patient. These cases were ex- 
ceedingly fatal notwithstanding the comparative absence 
of symptoms. We must look at pneumonia in several 
different aspects, and must take into consideration, not 
only the toxemia and the inflammation of the lung, but the 
individual reaction. Although the prognosis was neces- 
sarily very grave in cases in which as much as three lobes 
were involved, he had seen a number of these cases re- 
cover, and in these the treatment had consisted chiefly 
in the use of oxygen, alcohol, and the so-called cardiac 
stimulants. Oxygen was of special value when the 
breathing capacity was markedly diminished, and we 
could not afford to overlook this fact even though we 
called pneumonia an infectious disease. Heart stimu- 
lants might be required, either early or late, in this disease, 
and when such a contingency arises as edema of the sound 
lung, cardiac stimulants must be given hypodermically. 
He thought the cold compresses made the patients about 
as comfortable as any other measure, yet he was bound 
to admit that he had seen a number of pneumonia 
patients do very well with nothing but a flannel shirt. 
He was not one of those who believed in decrying the coal- 
tar series of drugs, simply because a number of physi- 
cians, following more particularly the example of the 
Germans, had observed bad results from their use in 
unnecessarily large doses. When administered judiciously 
in proper cases and in moderate doses, they would be 
found to be of very great value. For example, he had very 
recently seen a severe case of pneumonia with a tempera- 
ture of io6° F. The patient had had but little sleep, was 
slightly delirious, and had a rapid pulse. In this case he 
had recommended giving five grains of phenacetin, and 33 
repeating it, if necessary, in two hours. As a result of 
this the temperature remained low for about six hours, and 
the patient slept well that night. True, the temperature 
rose the next day to about ios°F., but the next night a 
dose of six grains of phenacetin was sufficient to secure an- 
other good night, and after this the temperature remained 
low, and the patient made an uninterrupted recovery. 
He mentioned this case because cold applications had 
been used to no purpose, while phenacetin had accom- 
plished the desired result. Morphin might have done 
the same thing, but it would probably have also caused 
constipation and disturbance of the liver. Our rule in the 
use of these particular drugs, as with all others, should be 
to give the smallest dose which will accomplish the de- 
sired result. Much had been said about the responsibility 
of aborting pneumonia. Years ago he had been skeptical 
about the possibility of calomel doing this, as had been 
claimed, but since then he had occasionally observed cases 
which seemed to prove that this might sometimes occur. 
It was, however, decidedly exceptional. It was right and 
proper to make an effort to abort the disease, and hence if we 
saw a case in the chill stage, we should direct that the pa- 
tient’s feet should be kept in a warm bath for half an hour, 
and that he should be given hot drinks, sweet spirits of 
niter, liquor ammonii acetatis, and aconite, and subse- 
quently, a large dose of quinin. 
Dr. W. P. Northrup referred to a case in which he 
firmly believed that by the use of similar measures at the 
onset of the first symptoms he had succeeded in prevent- 
ing the development of a genuine pneumonia. He said that 
he too had met with many cases of afebrile pneumonia in- 
old people; but he was unable to say much about their 
treatment, as they had invariably proved fatal. In all 
cases of pneumonia he was particular about securing am 
abundant supply of fresh air to the sick room, if necessary,, 
by keeping the patient near an open window. He had 34 
not the slightest fear of these patients catching cold so 
long as the feet were kept warm, and there was a high 
fever. He also gave oxygen in pneumonia, but usually, 
as he had said, by way of the window. He had learned from 
Dr. Baruch that a bath of 90° F. would often calm a very 
excitable patient with an alcoholic pneumonia, and would 
at the same time improve his general condition. He had 
proved by experience the benefits of hydrotherapy in pneu- 
monia, and believed that in this disease the effect of such 
treatment could be briefly summed up by saying that it 
quieted the mental excitement, improved the quality of the 
pulse, increased the depth of the respirations, and pro- 
moted sleep. 
Dr. Alfred Meyer said that he had tried the effect 
of the “digitalis treatment” of pneumonia in his service 
at Mt. Sinai Hospital, with the result that only two 
out of twelve patients died. According to the author of 
this treatment, the daily dose of the drug should be as 
high as 60 to 120 grains of the digitalis leaves. 
Dr. Baruch, in closing the discussion, said that he 
had not observed any of these cases of pneumonia occurring 
in old age without fever, and with but few other symptoms. 
He could not subscribe to the recommendation of oxygen 
gas, for it seemed to him that according to the law of 
the diffusion of gases it could not be taken into the system 
in any quantity. He, however, approved very highly of 
the principle of this treatment, and made it a point to sup- 
ply the patient with as much oxygen as he could absorb 
by giving him an abundant supply of fresh air. He ap- 
proved of the use of digitalis as a heart stimulant in the 
early stage of pneumonia, but in the later stages, when 
the heart was working hard to overcome the contraction 
of the peripheral blood vessels arising from the action of 
the toxins, the administration of digitalis did not meet 
with his approval; it seemed too much like spurring on a 
jaded horse. The failure of the cold applications in the 35 
•case in which Dr. Janeway had found phenacetin so effica- 
cious could in all probability be explained by the manner 
in which they had been made. As he had said in his 
paper, everything depended upon the exact manner in 
which the cold compresses were used. It was for this 
reason, he believed, that the profession had been so long 
in recognizing the great value of this method of treating 
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