being usually in a great measure, and sometimes in its earlier stages entirely, wanting; and its presence being only ascertainable, with certainty, by a carefully-conducted physical examination of the chest ; which, as it is the posterior part of the lungs that are always affected, it is exceedingly difficult, in the majority of cases, to institute; it being obviously impossible to place a patient suffering from the effects of a severe injury or capital operation, in such a posture as to enable the posterior part of his chest to be examined by the ear. When, however, this can be done, the usual physical signs that occur in typhoid Pneumonia will be found in this variety of the disease, namely, absence of the respiratory murmur, dullness on percussion, with sibilous, and large mucous rhonchus, and bronchial respiration. The crepitation being either entirely absent, or, when present, existing but for a short space of time, being, as Dr. Hudson observes with regard to typhoid Pneumonia, quickly lost by an accumulation of blood in the surrounding vessels compressing the air-cells. As the symptoms of congestive Pneumonia are frequently rendered latent by the low condition of the patient, or masked by the existence of some severe injury that chiefly attracts the surgeon's attention, it behoves him to watch, with the utmost care, any appearance, however slight, of the supervention of a chest affection. He must not wait for the marked symptoms of active acute Pneumonia to show themselves; but if the breathing be at all hurried and shallow, if there be any dyspnea, lividity of the lips, and occasional short hacking cough, with thirst, increased heat of skin, and rapidity of the pulse, he should immediately be on his guard, and, if possible, examine the chest with the ear, in order to ascertain if there be any of the well-marked and easily-recognized signs of Pneumonia present, and if so, to have recourse to as active and prompt measures as the circumstances of the case will admit of. As this form of Pneumonia has usually existed for some time before the surgeon's attention is directed to it on account of the obscurity of its early symptoms, it becomes exceedingly difficult to determine the precise period at which the disease commences. In some instances, it is probable that death supervenes very rapidly on its occurrence; but in other cases, more particularly when solidification of the tissue of the lung has taken place, which happened in seventeen out of the twentyeight cases of the first class, it must have existed for a considerably longer period, as time is required for those changes to take place, however imperfectly, that constitute the second stage of Pneumonia. On the subject of treatment I have but a few words to add. If the views that have been taken, in this paper, of the causes of that form of Pneumonia which occurs after surgical operations and injuries, be correct, it will be more consistent with a rational therapeia to aim at remedying that condi tion of the nervous system which has been the immediate cause of the diseased state of the lungs, and to prevent the congestion of these organs from increasing, by changing the position of the patient, when practicable, from the recumbent to the sitting posture, than to direct our efforts immediately to these organs themselves. themselves. With this object in view, the energies of the nervous system should be supported and increased by such stimuli and tonics as the patient may be able to bear; as, for instance, carbonate of ammonia, decoction of senega, quinine, and, in extreme cases of depression, wine and brandy. The inflammatory condition of the lungs should, at the same time, be combated by means of calomel, combined with minute doses of opium, and by counter-irritation in the form of dry-cupping, blistering, stimulating embrocations, or turpentine epithems. Blood-letting in any form, whether general or local, is not only contra-indicated by the already enfeebled condition of the patient, but would, to say the least, be perfectly useless; for we might, as Dr. Williams justly observes in speaking of typhoid Pneumonia, stop the action of the heart by this means before we could unload the congested condition of the lungs. This remark applies, if possible, with more force to the treatment of the surgical form of the disease, as the patient has, before the supervention of the pulmonary affection, already been, in most instances, much lowered by profuse discharges and irritative fever. Upon the whole, however, the curative treatment of this form of Pneumonia is but little satisfactory, the best-directed efforts being but seldom crowned with success. The prophylactic measures that must be had recourse to, in order to prevent the occurrence of the disease in question, are obvious. Patients who have suffered much from the consequences of capital operations and severe injuries, or who are worn out by irritative fever and profuse discharges, should be placed in a room or ward that is as freely ventilated as possible, care being, however, taken to prevent draughts of cold air from playing upon them; they should be warmly clothed, so as to promote, as much as possible, the freedom of the circulation, and all depressing causes of disease must be carefully removed. The supine position should also be occasionally changed for the lateral one, or, if the patient have sufficient strength, he may be seated partly upright. And I may take this opportunity of stating, that the starched or dextrinated bandage, the immovable apparatus, as it is called, may here be of most essential service, by enabling the surgeon to place patients, with injuries of the lower limbs, in such a position, and in such an atmosphere, as. shall remove two of the most active predisposing causes of the form of Pneumonia now under consideration, namely, the recumbent position, and the comparatively impure air of a hospital-ward or sick room. |