The Philadelphia Polyclinic, 
Vol. VII, Jan. 22, 29, 1898, Nos. 4, 5.] 
[Reprinted from 
ON THE NATURE AND TREATMENT OF PNEUMONIA.1 
SOLOMON SOLIS-COHEN, M.D. 
Professor of Clinical Medicine and Therapeutics in the Philadelphia Polyclinic, Clinical Lecturer on Medicine in the 
Jefferson Medical College, Physician to the Philadelphia Hospital, etc. 
By pneumonia, I mean croupous or acute 
lobar pneumonia, a disease which in most 
cases is to be ranked among the infectious 
fevers, having adefinite locallesion. The old 
name “lung fever” is much more appropri- 
ate than the designation pneumonitis, which, 
for a while, held sway in our modern patho- 
logic nomenclature. There are cases of in- 
flammation of the lungs, pneumonitis 
properly so-called, which result from trau- 
matism, from exposure to cold, from inhala- 
tion of smoke, steam, overheated air, and 
the like, just as similar causes excite inflam- 
mations elsewhere. But the disease to which 
I refer at present is caused by infection, the 
barriers of normal resistance having been 
broken down by general disease or by special 
accident. It exhibits many varieties to which 
I can refer only in passing. Whether or not 
the so-called pneumococcus is the infective 
agent lamby no means satisfied; much of our 
modern bacteriologic etiology and pathology 
is vitiated by sweeping conclusions from in- 
sufficient evidence, and by the logical fallacy 
of petitioprincipii-—begging the question, or 
reasoning in a circle. But be this as it 
may, normal resistance being at fault, infec- 
tion takes place in some way and through 
some agent, and is followed by intoxication; 
concomitantly with which, structural changes 
take place in and around the pulmonary alve- 
oli, involving a greater or lesscontinuous area; 
usually, but by no means invariably, in a 
lower lobe. These changes, while analogous 
to those which we call inflammatory, will, I 
think, in the further course of science be 
classed together with those changes which 
take place in the intestine in typhoid fever, 
in a distinct species, if not genus. 
testinal lesions of typhoid fever, as constitut- 
ing not the disease itself to which the febrile 
and other general symptoms are secondary, 
but merely the anatomic expression of a 
special form of infection which likewise 
manifests itself by general intoxication, giv- 
ing rise to fever, dyspnea, and disturbed 
action of the heart. The dyspnea and the 
cardiac disturbances are increased by the fact 
that this anatomic lesion of which we have 
spoken involves an important portion of the 
respiratory apparatus, and mechanically inter- 
feres with the balance of circulation. We 
have, therefore, two main conditions to deal 
with ; First, the intoxication with its fever, 
prostration, delirium and other nervous con- 
comitants, including dyspnea and circulatory 
imbalance ; and secondly, the mechanical re- 
sults of pulmonary consolidation—diminution 
of air space in the lungs, blocking of a larger 
or smaller portion of the vascular canal, and, 
as results of the action and interaction of 
these conditions, imperfect purification of 
the blood, and opposition to the action of 
the right heart, increasing the respiratory and 
circulatory disturbance. 
While, therefore, intoxication and its re- 
sults must receive primary attention, the 
mechanical phenomena spoken of, involving, 
as they do, two physiologic systems of the 
highest importance, must receive proper con- 
sideration. In a strong patient seen early, 
I have no hesitation in commending resort to 
venesection. The removal of, say, sixteen 
ounces of blood, removes considerablepneu- 
motoxinm&, likewise, relieves the mechanical 
congestion of the lung, favoring the early 
termination of the local process. So, too, 
in a case not in its earliest stage, in which 
the right heart is laboring against pressure 
which it can scarcely overcome, the relief 
The point to which I desire to direct your 
attention now, is their analogy with the in- 
Remarks made at the Polyclinic Hospital. afforded to this viscus by depletion of the 
general venous circulation is sometimes suffi- 
cient to turn the scale in favor of recovery. 
cian. An average temperature of 102.50 to 
104° F. is the most favorable. 
Cases with what we may call the tempera- 
ture of depression, need more than usually 
careful watching in respect to diet and to 
general environment, and call for the ad- 
ministration of supporting and stimulating 
remedies, such as strychnin, camphor, am- 
monia, and in some instances alcohol, to- 
gether with the early and sufficient use of 
' oxygen by inhalation, and the most scrupu- 
lous avoidance of those sudden changes of 
posture and the like which are likely to 
add to the disturbance of the vascular equi- 
librium. In the aged, the application of 
external heat is sometimes useful—not merely 
to raise temperature, but to counteract the 
depressing effects of the causes of lower 
temperature. In cases showing violent tem- 
This fact is not to be proved either by the 
relation of individual cases or by the mass- 
ing of statistics. No case-description can 
convey to another the impression made upon 
the observer either of the dangers threatened 
or the relief afforded ; while statistics, includ- 
ing as they do cases of great variety in causa- 
tion, course, complications, environment, 
including season and weather, to say nothing 
of age, sex, temperament, personal idiosyn- 
crasy and the like, are utterly without value 
to the thinking mind. 
However, it is in the smallest proportion of 
cases of lung fever that venesection will find 
an appropriate place. In the majority of 
cases other measures will be more rational or 
more successful. I do not agree with my 
friend, the distinguished teacher, who in his 
great treatise on the practice of medicine in- 
timates that the mortality of pneumonia, taken 
by and large, is at all events not diminished 
by any method of treatment hitherto em- 
ployed. Nevertheless, I believe that we can 
trust much to nature—that is to say, to the 
inherent recuperative tendencies of the human 
organism; seeking to discover the course 
which these take and interfering only when 
that course seems to be departed from in the 
individual case. On the other hand, if by 
any means in our power we can facilitate 
the natural evolution of the disease toward 
recovery, such measures are eminently ap- 
propriate. 
perature, cooling applications may be neces- 
sary to counteract the effects of excessive 
heat upon the nervous system; and these 
may take the form of the cold bath, the wet 
pack, the ice pack to the chest, frequent cold 
sponging or cold compresses, as advised by 
Dr. Baruch, according to the circumstances 
of the case and of the nursing. 
In the moderate cases my own preference 
is—apart from the necessary sponging for 
cleanliness and stimulation of the skin—for 
the external application of heat and moisture 
over the chest, as accomplished by the old- 
fashioned jacket poultice, although in these 
cases, the compresses advised by Dr. Baruch 
also seem to serve the purpose admirably. 
This purpose is neither the elevation nor the 
reduction of temperature, but action upon 
the vascular system—upon the “ skin heart” 
—relaxing the opposition to cardiac action, 
increasing the tone—not the tension—of 
the vessels both by local and reflex effect 
and thus directly or indirectly relieving a por- 
tion of the mechanical difficulty of circulation. 
The febrile temperature is one of the most 
important indications in this connection. 
When, in acute infective pneumonia, the 
temperature is low, the usual inference is that 
intoxication is profound and vital reaction 
imperfect; while, on the other hand, an ex- 
cessively high temperature indicates a severe 
infection with violent reaction and corre- 
sponding danger. Both extremes, therefore, 
awaken solicitude on the part of the physi- 
In these cases, also, the internal administra- 
tion of strychnin is useful, though alcohol is 
rarely necessary. 3 
In all cases, careful attention to the excre- 
tions is required. Free diuresis, diaphoresis, 
and purgation are to be encouraged, if neces- 
sary, by the use of calomel, of saline cathar- 
tics and diuretics and by external applica- 
tions to the skin, the nature of which is to be 
determined by considerations previously re- 
ferred to—that is to say, warm or cold spong- 
strychnin separately, so that the size and fre- 
quency of doses may be varied according to 
circumstances; and as regards the latter 
drug, I seldom use it in the treatment of 
pneumonia. There are cases, however, in 
which it is useful as a cardiac tonic, espe- 
cially in the middle period of the disease and 
again after resolution has occurred. 
ing, poultices, or moist compresses. 
I am in the habit of administering a stimu- 
Of drugs designed to act upon the heart I 
prefer aconite and nitroglycerin ; the first has 
usefulness only before consolidation, as in- 
dicated by bronchial breathing, has taken 
place. It is, however, undoubtedly useful 
during the preliminary stage of congestion 
in which the crepitant rale is heard. It 
probably acts mechanically. Nitroglycerin 
finds its use during the stage of hepatization, 
to relax the vascular channel generally, both 
pulmonary and systemic, and in that way, 
in some measure obviates the necessity of 
venesection. It should be given as spirit of 
glonoin in drop doses every hour at first, 
until the patient’s susceptibility is ascertained, 
when the size of the doses and the intervals 
should be regulated accordingly. One judges 
by the effect upon the tension, force and 
frequency of the pulse, and by the condition 
of the right heart. 
lant expectorant mixture in somewhat of a 
routine fashion to most patients with pneu- 
monia, and I think the practice is a good 
one, though rather on empiric, than scientific 
grounds. In other words, observation shows 
the practice to have good effect, though I 
cannot frame a theory to explain this effect 
capable of successful defense against all as- 
saults. By experience I refer not to my in- 
dividual experience only, but to the tradi- 
tions of the profession. The formula I use 
most frequently is about as follows: 
Ammonium chlorid . , . .10 grains. 
Ammonium carbonate ... 5 grains. 
Ammonium salicylate ... 5 grains. 
Fluid extract of coca . . . . 1 fluidram. 
Essence of pepsin ..... 1 fluidram. 
Sirup of tolu I fluidram. 
Water I fluidram. 
Mix. 
To make a tablespoonful, which is to be given with 
or without water every second to fourth hour. 
I have referred to the use of oxygen by- 
inhalation. Let me now repeat and empha- 
size the recommendation. It undoubtedly 
saves life in many cases; but to do this it 
must be given promptly and persistently. To 
wait until a patient is moribund and then 
attempt to revive him with a few cubic 
feet of oxygen forced into his lungs would 
be ludicrous, were it not so serious. Oxygen 
to be useful must be given so soon as the 
thought that it may be necessary enters the 
physician’s mind. That thought will be 
suggested by the respiratory distress, and by 
the extent of local lesion as demonstrated by 
physical signs. Observe, please, that these 
are not identical conditions, nor conditions 
invariably associated. It is true that exten- 
sive lesion will usually cause great embarrass- 
The object of the coca is to disguise the 
taste, of the pepsin to prevent nausea, of the 
sirup to render the dose a little more smooth 
and palatable ; and any of these, therefore, 
can be substituted by whatever individual 
fancy or experience may suggest. Licorice, 
as all know, is often an acceptable means 
of disguising the taste of the ammonium 
salts and acacia frequently serves better than 
sirup. Coca has, however, some action 
upon the heart and kidneys, which is addi- 
tionally useful; and spirit of nitrous ether 
may be added for diuretic effect if deemed 
needful. One can, if he chooses, add nux 
vomica and digitalis to this mixture, though 
as regards the former drug I prefer to give 4 
ment of breathing j but frequently there is a 
dyspnea of nervous origin, with comparatively 
restricted local lesion. Often after the crisis, 
resolution not having occurred, local lesion 
remaining, extensive dyspnea will have van- 
ished ; an evident proof that it was not of 
merely mechanical origin. 
in the vast majority of cases, the gas is al- 
lowed to flow over gently but continuously, 
no attempt being made to check the current 
synchronously with expiration. Oxygen is 
thus wasted, but life is often saved. 
The administration of oxygen is kept up 
for from ten minutes to thirty-six hours or 
more, uninterruptedly, according to circum- 
stances. If begun in time, it will usually be 
found that one-half hour’s continuous inhala- 
tion, repeated every second hour, will suffice. 
I have known it to be ordered for 10 minutes 
at a time, three times daily, or perhaps every 
fourth hour, in a serious case. This is 
simply tomfoolery. In a desperate case the 
oxygen must be given as nearly continuously 
as possible until relief is manifest. When 
the patient is unconscious, nasal delivery is 
usually the better method. Hard-rubber 
nozzles are preferred to avoid danger of 
breakage by unconscious movements of the 
patient. The apparatus should be thoroughly 
disinfected after each case, so that it goes 
not only mechanically, but medically clean 
to the next case. 
Now either condition, whether severe 
nervous dyspnea—pneumoparesis—which is 
especially associated with the pneumonia of 
influenza, or great mechanical difficulty of 
breathing, or their combination, calls for the 
timely and sufficient use of oxygen. 
The air-current, doubly necessary in a 
condition of intoxication, is diminished, oxy- 
gen is not supplied in necessary quantity, the 
necessity for a more concentrated respiratory 
pabulum is manifest. Pure oxygen is usually 
best ] in some cases its combination with a 
small proportion of nitrous oxide answers. 
It has been advised to heat the oxygen, but 
personally I have seen no better results with 
the heated gas than with the unheated gas. 
Recently-evolved oxygen is preferable to 
stored oxygen, and there are in the market 
some quite readily available forms of apparatus 
for its production, of which Wallian's seems 
the most convenient. The compressed gas, 
however, is usually better managed by nurses, 
and will serve the purposepn most cases. 
Conjointly with the inhalations ot oxygen 
in severe cases, it is usually necessary to give 
strychnin nitrate hypodermati ally. say -jL 
grain, every second to sixth hour, according 
to results. These cases,too,usually call for the 
sufficient use of nitroglycerin or amyl nitrite. 
Not rarely I use a mixture containing am- 
monium carbonate five grains, with amyl ni- 
trite three drops, in a fluidram each of gly- 
cerin and alcohol, every second or third 
hour, as suggested by B. W. Richardson. 
In these bad cases, too, time for natural re- 
covery is sometimes gained by temporary 
stimulation of the heart, as with cocain, 
musk or camphor, preferably under the skin. 
In the apparatus that I employ, the gas, 
which is chemically pure, but diluted with 
about 5 per cent, of air, owing to the method 
of storage, is furnished in cylinders contain- 
ing i oo gallons. From the cylinder outlet, 
which is controlled by a key, it passes to a 
small rubber bag and from this to a quart 
wash-bottle, about one-third filled with water. 
Bubbling continuously through the water, 
as it overflows the bag, it passes through rub- 
ber hose and hard-rubber mouth- or nose- 
piece into the patient’s throat, by way of 
the mouth or nasal chamber. When the 
patient is comparatively strong the pressure 
is so adjusted tnat a Slight inspiratory effort 
is necessary to bring the oxygen over, and 
daring expiration the current ceases. But 
In regard to the various complications that 
may occur in pneumonia it suffices to say 
that they are to be met, as they arise, on 
general principles. That means that there is 
to be no unnecessary interference; but when 
interference is needed it is to be prompt and 
bold.