DIGITALIS IN THE FIRST AND SECOND STAGES OF PNEUMONIA. BY J. W. CARHART, M.D., C.M., D.D., MEMBER OF AMERICAN MEDICAL ASSOCIATION, TEXAS STATE Ziemssen gives 50 per cent. of deaths from pneumonia following measles. He lost one-half of his pneumonia patients under one year of age; two-fifths of those from one to three years; and one-fourth of those above three. The ratio of deaths from pneumonia among those of advanced years, and enfeebled by age is even greater. The disease prevails to an alarming extent in the State of Texas, particularly at certain seasons of the year; and as a consequence, I have been led to make somewhat careful investigation into the nature and treatment of the disease, and the cause of the very large death rate amongst us, which, I have no doubt, will equal that reported by Ziemssen. Whilst there are many factors that contribute largely to swell the mortality record in this disease, such as insufficient cloth ing, uncomfortable dwellings, exposure in camplife, improper sanitation, inefficient nursing, bad habits as it regards the use of tobacco and alcoholic stimulants, the one I have chosen for discussion in this short paper is not the least of them all. I am persuaded that the use of digitalis in the first and second stages of this disease is responsible for the death of multitudes in my State, Texas; and I hope, through this means, to call the attention of the profession to the subject, and thus save many valuable lives and relieve much suffering. In order to a clearer comprehension of our subject, it will be well for us, in the first place, to consider the physiological action of the drug in the condition of health. Here we find, not only a variety but a decided conflict of opinion among writers; a conflict which is unfortunate, not to say unjustifiable. There are many established facts, however, upon which most, if not all, writers are agreed. "Fish placed in a weak infusion of the plant die in spasms, with the ventricle of the heart contracted. Digitalin used hypodermically in frogs occasions a tetanoid rigidity of the muscles and an irregular, tonic contraction of the left ventricle of the heart, with slowness and unsteadiness of its rhythm. The auricle does not seem to participate in this action of the ventricle, but becomes distended as the capacity of the ventricle diminishes. At the same time, the pulse rate declines and the blood-pressure in creases. Experimental investigation has demonstrated that large doses of digitalin produce marked contraction and even a complete closure of the capillary vessels, a condition which necessarily involves an increased blood pressure in the larger arteries. . . . . The auricle does not participate in the contraction affecting the ventricle, but becomes distended by the accumulated blood. . . . Digitalis is held to act on the vaso-motor centre, and thus to produce contraction of the peripheral arterioles." In small doses, digitalis and its preparations primarily increase pulse-rate and tension, and if continued will lower the pulse-rate without diminishing the tension. The supply of arterial blood is everywhere diminished under the influence of the drug, owing to the tonic contraction of both the left ventricle and of the arteries themselves. All the heart-muscles are not subject to contraction in an equal degree, under the influence of digitalis, but chiefly those of the left ventricle. It thus tends to obstruct cardiac circulation; and by preventing free passage of blood through the heart tends to produce death from syncope. It certainly depresses the entire nervous system, if administered in sufficient doses to produce anything like its physiological action; impairs digestion, diminishes urination, retards respiration and interferes with the nutrition of the heart itself. Digitalis as an antipyretic is valueless. If any antipyretic effects should be produced it would be accompanied by disquieting results, and a tendency to heart paralysis. The result of various experiments proves that digitalis does not in the least modify favorably any acute inflammation, and especially pneumonia, pleurisy and pericarditis; but that, on the contrary, it exposes the patient to the risk of sudden death. It is now in order for us to get as clear an idea as possible of the pathological conditions in pneumonia that we may understand the effects of digitalis in the first and second stages. It will not be necessary, for our present purpose, to discuss the fine distinctions that are made in this disease, such as bronchial pneumonia, catarrhal pneumonia, and lobular pneumonia. The term broncho-pneumonia will sufficiently indicate the form adapted to our purpose in this discussion. The lungs are made up of bronchi, air-passages, alveoli, pulmonary pleuræ, and connective tissue stroma, containing blood-vessels, lymphatics and nerves. In pneumonia, of the type under consideration, the common course is for the inflammatory invasion to proceed from the larger to the smaller air tubes, thence to advance into the finest, to the capillary bronchi, whence it communicates the inflammation to the terminal air passages, and alveoli. This process of invasion may be almost simultaneous and rapid; or it may take several days or weeks. The result, sooner or later, is the involvement of the bronchi and more or less lobules of pulmonary hepatization and possibly atelectasis. I am aware that from a strictly pathological standpoint we may not speak of the three stages of the disease as the stage of inflammation and engorgement, the stage of infiltration and red hepatization, as the result of engorgement; and the final or third stage of resolution, in favorable cases; or that of gray hepatization and possibly atelectasis premonitory of dissolution; and yet, clinically, this division would seem to be correct, and to be very serviceable. In order to a fuller understanding of our subject, let us consider the condition and function of the lungs in the first and second stages of the disease; and the resultant effect upon the circulatory apparatus. In the early stages the bronchi contain more morbid secretions in the form of clear viscid mucus, whilst in subsequent stages they are filled with creamy pus. There are sometimes found subpleural accumulations of somewhat inspicated, yellow secretions, contained in dilated alveoli, or in small globular dilatations of terminal bronchioles. They are probably caused by the secretion of particles of bronchial secretions into the alveoli in the forcible inspiratory effects which follow paroxysms of cough. |