ment for pneumonia. We had all hoped at one time that the serum treatment of pneumonia might give us a specific, but we are dealing with a microorganism that carries its poisons within its body and does not seem to set free a soluble toxin, and thus allow the formation of a definite antitoxin such as we see in diphtheria. We are dealing with a serum that is bactericidal in its actions; we are pouring into the blood of the patient a so-called immune body which requires the combination of the so-called complement to make it an effective deadly substance to the bacteria, and it is just this complement, this one essential substance in the body, which seems to be lacking in many of the infectious diseases. We have no means at present, or method of immunization, by which we can increase this complement. The body must move on in its own way; we do not seem to be able to help it, and, if you will pardon my expression, we must stand on the side lines. and watch the opposing forces fight out the game. I do not mean that we are helpless and hopeless, but I do mean that we can only help and assist the organism to keep life intact, and must let the organism work out its own salvation. There is one feature in pneumonia which I think is very prominent, and that is the low arterial pressure which develops in the course of the disease. In mild cases, this is not a prominent feature, but in severe cases it is very noticeable and is, I believe, due to the effect of the poison on the vasomotor system. In general it seems to me that in our endeavors to sustain the heart we have to try to help the right heart do extra work and to assist the left heart to keep up its muscular contractions, and besides we must endeavor to keep as near as possible the normal tone in the circulation. In mild cases strychnin seems to be sufficient for the purpose, especially when given by the hypodermic, both for cardiac stimulation and for keeping up the tone of the blood pressure. In severer cases the question arises of the use of alcohol. Formerly we were taught to believe that alcohol was a heart stimulant, but the stern, unyielding facts of scientific investigation and proof have shown that it does not stimulate the heart. It dilates the capillaries and small arteries and

tends

not hesitate to say that my personal opinion is that, even in alcoholic patients, most patients are more benefited by cutting off their whisky than by giving it to them. The use of glonoin in this country in pneumonia is very extensive. It is a pure arterial dilator, and I think has been altogether too freely used in a disease such as pneumonia, in which the low arterial tension is part of the poisoning. It has its uses in patients who have arteriosclerosis with high tension and in whom we desire to assist the heart by reducing the blood pressure. Digitalis has been much vaunted, especially abroad, but the most favorable reports concerning it have come from those who have used it in large military hospitals, where their cases of pneumonia are in young adults in whom the prognosis is good, and their apparent good results seem to be more due to the general tendency of youth to recover than from any specific character of the drug. It does raise blood pressure, and is a most useful drug for this end and for cardiac stimulation, but Lauder Brunton has pointed out that it loses its effect on the vagus endings in the heart when the temperature is over 103, and this may account for the fact that it often fails us in pneumonia, when we need it most. One often obtains excellent results in sustaining the blood pressure and in preventing cyanosis and congestion by using ergot hypodermatically. This drug acts especially well in alcoholic patients and prevents the reaction produced by cutting off their alcohol. Adrenalin has also been recommended for this purpose. To obtain the best results with this substance one must use it intravenously or by well-diluted rectal injections. tions. When given subcutaneously it causes a local contraction of the vessels, and is too slowly absorbed to give much effect. Henry Elsner, of Syracuse, recommends in desperate cases the treatment by diffusible stimulants. He gives fifteen drops each of aromatic ammonia and Hoffman's anodyne in two drams of tokay wine every twenty minutes. This seems to be most excellent treatment in many severe cases, but unfortunately there is a tendency for the Hoffmann's anodyne to cause vomiting, and in alcoholic patients I have seen after a few hours "coffee-ground" vomiting from this treatment. Some desperate cases have, however, recovered in my hands, with this treatment. In the beginning stage of pneumonia, I think we make a favorable impression on the disease by limiting the congestion of the lung. This I think will sometimes result from the large dose of calomel which is sometimes given. The same results are obtained with one-quarter grain of tartar emetic with five grains of Dover's powders and repeated once at the end of an hour. The

to prevent a congestion in the splanchnic areas, and tends to keep the blood in the peripheral circulation, where it will be of most use to the patient. It gives the patient a sense of wellbeing, it benumbs reflex irritation and tends to keep the patient quieter, and in not too excessive an amount it stimulates digestion. Although the use of alcohol is not as widely extended as it was formerly, the consensus of opinion to-day among the best clinicians seems to be that in moderation its effect is good, rather than harmful, but there is no question that in excessive doses it dilates the vessels too much, and will increase or cause delir

ium.

What is excess and what is moderation in

the use of alcohol differs for different individuals, and I think that it requires the most careful judgment to decide this in each individual case. I do

drug which has best accomplished this limitation of congestion at my hands is the hypodermic use of Livingston's solution of ergot in thirty doses every two hours for six or eight doses. This solution is a drachm of the watery extract of ergot dissolved in one ounce of sterile water and three minims of chloroform and three

5

grains of chlorotone added. The whole solution is then filtered through sterile filter paper. This solution should be given direct into the deltoid or gluteal muscles, sending the needle at right angles through the skin into the muscular tissue, not subcutaneously. For the relief of the pleuritic pain, cold or heat is the usual procedure, and the old-fashioned flaxseed poultice, when properly applied, can be further kept warm by hot-water bags on the outside, and is of the greatest comfort to the patient. Manges, of New York, recommends the Paquelin cautery over the area affected by the pleurisy, and says that in his hands it has been much more efficient than any other method. If the pain is great we have to resort to morphine, sufficiently to dull its intensity, though benumbing the patient by morphine is, I think, a dangerous practice. Often five or ten grains Dover's powders is an excellent method of giving this drug. Cough is often a distressing symptom, and we must treat it directly in the pneumonias in which the bronchitis is the predominant feature. The administration of terpine hydrate and of creosote carbonate will often materially diminish the bronchitis. In old people, however, with chronic nephritis I believe I have seen creosote cause suppression of urine with fatal results. In the influenza pneumonia, with an excess of bronchitis, ten or twenty drops of tincture of nux vomica will often diminish the excessive secretion. Osborne, of New Haven, recommends ipecac and ammonium chloride in acid vehicles, such as dilute phosphoric acid as being very efficacious and least objectionable to the stomach. There is one symptom in pneumonia which is very distressing and equally dangerous to life, and that is excessive distension of the abdomen, due in severe cases to paralysis of the muscles of the intestines. High turpentine enemas or copious warm saline irrigations, repeated every few hours, will often be sufficient to overcome this. These saline irrigations are excellent cardiac stimulants in themselves, and increase the action of the kidneys, and are often of great benefit. Here in my experience the hypodermic injections of ergot have aided in regaining the tone in intestinal musculature. Hyperpyrexia is another symptom which at times requires treatment. Temperatures from 103° F. to 105° F. are temperatures normal to pneumococcus pneumonia, and it is only when such symptoms as increased delirium and restlessness or stupor and prostration occur with the high temperature that the hyperpyrexia needs treatment. Personally I do not believe here in the use of coal-tar antipyretics or guiacol. I prefer cool sponging in adults and a warm bath with or without mustard for young children. When delirium tremens is also a complication a cold bath is best, and often quiets the delirium and induces sleep. An effective bed bath is obtained by slipping a rubber sheet under the patient, covering him with a cotton sheet from his neck to his feet, and then by forcibly sprinkling him on the sheet with very cold water

thrown from a whisk-broom one obtains the necessary cutaneous irritation to stimulate the circulation and reduce the temperature. From five to eleven minutes is sufficient length of time for the duration of such a bath, and I have never seen untoward effects from its use.

Manges has recently emphasized the necessity of obtaining sleep for pneumonia patients, and I think this cannot be too strongly insisted upon. By careful consideration in administering food and drugs at stated intervals and allowing undisturbed quiet between the necessary administrations much can be done in this regard. The careful choice among the newer hypnotics will usually suffice, and if morphine or codeine must be given to allay pain, one often obtains sleep at the same time.

This meager presentation must suffice for the consideration of treatment. An essay on the treatment alone in pneumonia could well occupy an entire evening's discussion of the disease. I have taken it for granted that all are agreed on the value of the most watchful nursing, of the necessity of a well-ventilated and moderately cool room, and of the fact that each patient requires rules and routine for himself. A robust young adult with an overcrowded right heart may require bleeding, but with a weak and aged patient one would refrain from this procedure. When one sees a partially consolidated lung cramped by a serous effusion one should never hesitate to aspirate the fluid, nor hesitate to drain an empyema. The only accurate method of differentiating the character of a pleural effusion is to draw off a small sample, and one must act according to the nature of the fluid found.

The most important consideration to the family of a patient is the prognosis. There are many factors which influence one in predicting the probability of recovery in any given case of pneumonia. É. F. Wells', of Chicago, has published the record of 465,400 cases of pneumonia, collected from the reports of many hospitals and from many physicians in private practice. There were 94,826 deaths in this collection of cases, a mortality record of 20.4 per cent. Preble concludes after reviewing the mortality rate over many years from a large number of statistics that the mortality varies greatly in short series of cases, such as occur in one hospital from year to year, but that in series large enough to counteract the influence of mere chance the mortality does not vary much from time to time. Sex seems to influence the prognosis, for while pneumonia is much more frequent in men than in women, the number of deaths in the last census year in men was 58,430 and in women 47,631, which would seem to indicate a distinctly higher death-rate for women than for men. These figures are for the entire United States, and are more significant than the statistics from various hospitals. Age exerts a great influence on the prognosis. In infants the death from bronchopneumonia is very high, but in childhood, be-·

tween 5 and 10 years of age, the mortality from lobar pneumonia is less than 4 per cent. From 10 years of age onward to old age the death-rate with each year rises steadily, until in old age it is exceedingly high. The extent of the pulmonary involvement influences the prognosis more than the site of the lesion, except in chronic alcoholics, in whom, in my experience, a right upper lobe pneumonia carries with it an especially bad prognosis. In the aged a temperature below 100, and in all ages temperatures above 105, a pulse above 130, and respirations above 50 are dangerous signs. Irregularity of pulse-rhythm is of bad prognostic significance; the earlier the irregularity develops the greater the danger, and Mackenzie states that he has never seen a young adult recover who had an irregular pulse in whom the temperature was 103 or over. Chronic alcoholism in a patient greatly reduces the chances of recovery. In 667 alcoholic patients with pneumonia in Bellevue Hospital in 1904 the deathrate was 50 per cent., in 334 non-alcoholic patients in the hospital during the same time the death-rate was 23 per cent. In patients suffering from previous diseases, as nephritis, myocarditis, anemia or tuberculosis, a pneumonia is always a very serious disease. Of the complications in pneumonia a meningitis or endocarditis developing from the pneumococcus infection are almost invariably fatal. Pericarditis shows a death-rate of 50 to 75 per cent. Serous effusion raises the mortality rate but little, while empyema directly reduces the chances of recovery.

Some sad experiences in our care of pneumonia patients has forced many of us to realize that pneumonia is a communicable disease, and that no one who hourly cares for a patient suffering from pneumonia is free from the danger of infection from the patient. Habit and custom have made us accept the chances and dangers of infection, and I fear that habit has usually made us careless in the necessary prophylaxis against the Spread

of this disease. Much, I believe, can be done to limit the numbers that are yearly sacrificed by this infection. It seems not improbable that the time is not far distant when careful disinfection of pneumonic sputum will become rou

tine.

several

THE HEALTH OF THE NATION.1
BY WALTER WYMAN, M.D.,

Surgeon-General United States Public Health and Marine
Hospital Service.

HE health of the nation seems rather a large

topic, yet not too large for hopeful and practical consideration, nor yet so large as would be a kindred topic, the health of all nations, which is likewise one for serious and hopeful consideration. Indeed, these two subjects have a direct bearing one upon another, and one cannot be adequately considered without considering the other.

It is a somewhat trite idea, but one whose significance is of great present import, that the nations of the earth to-day are more nearly related than ever before in the world's history. "Not only has the 'narrow frith' been practically abolished," says a recent writer, "but the wide ocean is traversed by passenger ships in five days, and by thoughts put into words in a few seconds. All the world has become one neighborhood so far as relates to distances." In no manner has this been more strikingly shown than in the warfare against contagious disease. But a few years ago a violent epidemic of yellow fever in Cuba would excite no more than passing notice, while to-day the news of two cases in the far-off neighborhood of Santiago is immediately wired throughout the United States and foreign countries. A few cases of bubonic plague in the Orient, which a few years ago would receive no attention, are instantly

reported and published throughout the United

States, and one case of cholera in a ship in the Mediterranean is likewise immediately telegraphed to the principal cities of the world. International congresses, conferences and conventions are frequent, bringing the nations together as one family in the struggle against these foes of mankind. As in 1892, when a case of cholera appeared in Jersey City, the New York Board of Health took active interest therein. so is the

United States Government interested when epidemic disease is reported in England, France Germany, Turkey, Egypt, or any port in the

1Read before the New York County Medical Association, at the Academy of Medicine, New York City, January 16, 1905.

and frequent. And so closely related are we in health matters to our neighbors of Mexico, Central and South America, that periodical international sanitary conventions have been agreed upon by the several republics, and a permanent international sanitary bureau of American republics has been established and is maintained. I need further to refer only to the international congresses of Medicine, of Hygiene and Demography, of Tuberculosis, Leprosy, and other allied subjects, to show how closely the nations are getting together in the efforts to prevent and suppress disease.

We hear much at the present time of international peace conferences and arbitration treaties. Is it too much to expect, as a corollary parallel movement, the cooperation of nations to prevent and suppress communicable disease? There is at present pending before the Senate of the United States a convention-practically a treaty-subscribing to the findings of the international conference of Paris, 1903, embodying the principles and practice necessary on the part of all nations for successful warfare against plague and cholera. The International Sanitary Conventions of American Republics, previously mentioned, were instigated by the obvious advantage of an agreement for the sanitation of all yellow-fever infected seaports. Seaports being the points of contact. between nations, would properly be the first objective points in international sanitation, and their undoubted consequent prosperity would cause the sanitary movement to extend to other cities.

International sanitation might well be considered as adjunctive to the movement for universal peace. I believe it would be less difficult of achievement than absolute arbitration, or at any rate it could be made a powerful influence in establishing the latter. A former President of the French Republic, Monsieur Casimir Perier, at the opening of the Hygienic Conference in Paris, in 1894, said: "The international principles which had their origin in the laboratory and are based on science are the only ones which bind nations together with strong ties and establish equitable and immutable laws."

This principle may be well considered by those who are seeking universal peace, and international responsibility with regard to disease is a subject worthy of the attention of those interested in the development of international law. So far as I know there is no mention in the treaties on international law of the responsibilities of governments to one another in matters of public health, but the time is ripe for adding such a chapter.

I quote from a recent writer: It seems "that nations are beginning to develop a conscience and a sense of justice for the rights of other nations. As a whole the peace movement is another step toward the actual attainment of the ideal perfection of government." With this growing sentiment of harmony and fraternity among the nations there should be developed an international sentiment regarding sanitation and suppression

of disease. If, as Tolstoi says, the only substitute for war is religion, international sanitation would be a powerful weapon in the hands of religion, if, indeed, it could not itself be made a substitute for war. It surely would furnish a plain upon which nations might meet. It suggests a common enemy-disease-against which all might combine without fear of international complications, and would furnish a more worthy object than war for the expenditure of energy and money.

As to the health of this nation, the subject may be considered under two heads, the exclusion of disease and the extinction of disease. The former, which embraces the subject of quarantine, I will not discuss, as it may be considered by the distinguished gentleman who is to address you on "The Health of the Port." As to the extinction of the ordinary communicable diseases, is the idea one that is visionary or has it a good basis in scientific achievements and in practical results already attained?

It is not my purpose to burden you with statistics, but surely enough has been published to show a marked diminution as the direct result of special effort, and to encourage the belief that in future most of these diseases may be as rare as they are now common. Their subsidence or disappearance will be due chiefly to good laws and effective administration. Good laws imply good organization, and it may be profitable to consider for a moment the health organization of the United States as it exists to-day.

In general, I believe, this organization is a proper one, but defective in many of its details. The United States Public Health and Marine Hospital Service has, under various acts of Congress, certain maritime quarantine functions and interstate quarantine functions. It has also a hygienic laboratory for the investigation of contagious and infectious diseases and matters pertaining to the public health. This last is generous and broad legislation, but is limited to laboratory investigations. Therefore, certain other investigations, which are desirable, cannot be made; for example, an investigation into the sanitary conditions at certain health resorts where tuberculosis patients are gathered in great numbers. I mention this as simply an illustration, but efforts will be made to meet this difficulty. The epidemic appropriation, under which investigations other than laboratory can be made, is limited to certain specified diseases, namely, cholera, yellow fever, smallpox, typhus fever, and bubonic plague. The laboratory has an advisory board, through which it is brought into relation with the medical departments of the Army and Navy, the Bureau of Animal Industry of the Agricultural Department, and through five distinguished scientists with the laboratories of leading institutions of learning. Thus the scientific work of the Service is brought in contact with the profession.

In the practical administrative work of a sanitary character, the Service is brought into relation with State boards of health and quarantine

officers, through annual conferences required by law, and occasional conferences called either by the Surgeon-General or on request of the State health authorities.

Every State and Territory has a health department, consisting either of health commissioner or State board of health, which has about the same relation to county and municipal boards of health as the national service has to the State organizations.

The chain of organization, therefore, seems theoretically a good one, and it would appear to be the part of wisdom to perfect or strengthen every link in the chain. This chain has not been forged all at once. Link after link has been added, and the several links strengthened as occasion seemed to demand. In a growing country this seems to be the natural and proper method. The other method has been tried and failed. So that our sanitary system must be one of gradual growth.

Thus far I have spoken only of the official health organizations, which are, of course, the most potent of all, based upon the statutes of the States and the nation, continuous in their operations and not dependent upon spasmodic effort or · ephemeral enthusiasm. Yet it is impossible to ignore the valuable results of auxiliary organizations, voluntary in character, but inspired by noble and patriotic motives. They are too numerous to mention in detail, but I may refer to such organizations as the great American Medical Association, the American Public Health Association, State, county and city medical societies, and the auxiliary sanitary associations that exist in so many of our States and cities. Through these public sentiment is developed, which crystallizes into statutory laws and organizations.

One of the most common pleas of the sanitarian of to-day is for a wider diffusion of knowl-' edge of hygienic and sanitary principles. It has been frequently said that sanitary science is far in advance of its practical application. The facts are known, but not to a sufficient number, and appeals are often heard for the introduction into schools and colleges of more instruction in these essential and easily comprehended subjects. The plea is justified by every consideration, but I should like to call attention to the necessity of the spread of sanitary information among intelligent adults, among the learned, and the wise; among the men who govern our cities and our States, and among our legislators. The knowledge I would seek to have impressed upon them is the value of sanitation in the advancement of individual happiness and national, State and, municipal welfare. Too many regard sanitation as an ideal matter, efficacious theoretically. They should be impressed with the knowledge that improved conditions can and must be attained, and that bad sanitary conditions indicate sloth, a willingness to endure and ignore, characteristic of the least civilized and cultivated communities.

The possibilities of sanitation in the advancement of civilization should be impressed upon them, so that in addition to their high ideals of civil government they may also entertain ideals of sanitary advancement far beyond their present standards. Their influence and aid will then be more readily given when measures are brought before them for consideration or action.

There is one method of popular diffusion of knowledge which I have referred to on previous occasions and which seems worthy of further consideration. It is the making of sanitation an issue in local politics. Issues might be made on efforts to suppress the ordinary diseases by municipal improvements, particularly in the worst portions of a city. I am aware that these improvements are liable to be unpopular among those whose excessive profits on investments would be unfavorably affected thereby, and even among those whose individual physical welfare is to be improved. But these difficulties can be overcome if the political movement is shrewdly and fairly managed; and these issues being the subject of popular discussion, hygienic and sanitary knowledge would be brought out and broadly diffused. This idea has already been given expression by an association great in numbers and influence. At a recent annual meeting in San Francisco (last November) of the American Federation of Labor three hundred delegates were present, representing one hundred national and international labor unions, with a membership of about two million. In that convention was passed the following resolutions, which seem to me significant of the earnest and laudable attitude of these unions toward the sanitary movement.

The resolutions were referred to the Committee on Resolutions and adopted by the convention on the tenth day of its sessions:

RESOLUTION NO. 157.

WHEREAS, In the proper embellishment of our towns and cities, by parks, monuments, ornamental buildings, boulevards, and driveways, there is too frequently an utter neglect in the removal of insanitary and unhealthful conditions in the less favored localities, and

WHEREAS, In our opinion one of the first duties of town and city governments is to make wholesome, by good drainage, paving, water supply, and correct tenement-house construction, those portions of cities and towns that are now neglected in these respects, thus imperiling the health and happiness of the working people;

therefore be it

Resolved, In the interest of the poor and wellto-do also, town and municipal councils should give greater legislative attention with adequate appropriations to the removal of these evil conditions in the less favored localities, and be it further

Resolved, That the labor unions, by supporting candidates pledged in advance to the support of necessary and wise ordinances, according with