Antiphlogistic Treatment. Half a century ago bloodletting was considered the remedy par excellence for pneumonia and it seemed justified by the marked relief to breathing and pulse which usually at once followed a free bleeding. In a short time, however, the fever would rise anew and the distressing symptoms reappear, which led the school of Broussais to repeat the bleeding, coup sur coup, as often as the exacerbation appeared. There was no respite for either age or condition, the debilitated city toiler, the babe at the breast, and man of eighty tottering into the grave had alike to submit to the lancet, and when the oppressive symptoms returned, the blood had to flow anew. Broussais himself, however, recognized his error in his later life, and remarkably enough, his conversion was effected through veterinary practice. His two carriage horses were successively attacked by pneumonia: the first was treated by bleeding coup sur coup and recovered: the second was put under a more conservative treatment and also got well, but while the first remained soft, flabby, debilitated and susceptible for a length of time, the second was on convalescence at once able to go into active work. The enormous abuse of bleeding, led to its more complete abandonment than would otherwise have been probable, and the contrast between the high mortality of cases treated by excessive bleeding, and the lower fatality in pneumonias treated without phlebotomy on the expectant (let alone) plan of Dietl or the stimulating method of Todd, Bennett and others, served to hasten its abandonment. Yet in bloodletting we have an instrument for good or evil which is not to be judged on slight evidence. The mere lessening of the blood pressure is to be little considered, as it requires the abstraction of nearly one-third of the entire mass of blood to visibly affect this. The vascular walls at once adapt themselves to the lessened amount. Nor is the mere lessening of the volume a vital point. After moderate bleeding this is made up in a few hours: after severe bleeding in 24 to 48 hours. The loss of adult red globules is more lasting. Bleeding to the extent of one per cent. of the body weight may have the number restored in seven days. The young red globules though rapidly produced have individually less hæmoglobin, and they can convey less oxygen to the tissues. This should mean less oxidation, less heat, less waste, less urea, uric acid, hippuric acid and other poisonous products in the tissues. Yet Baur says that in anæmia there is a greater metabolism of proteids and more excretion of urea. How easy it is to blunder in looking from one single point of view. Again after bleeding there is a great relative increase of the various forms of white blood globules, most of them young and therefore with somewhat altered functions. The paucity of red globules and excess of white are brought about by the pneumonia and independently of bleeding, so that it is difficult to say whether the phlebotomist is enhancing an evil, or helping a natural therapeusis. It seems hopeless to estimate the effects of these and other changes in the blood after bleeding, upon the metabolic processes of nutrition, secretion and sanguification. This digression has not been made to elucidate the results or the modus operandi of bleeding, but rather to illustrate the complexity of the problem involved and to warn against broad and unwarranted generalizations from insufficient premises.
Even today practitioners of the soundest judgment meet with a limited number of cases in which they resort to bleeding with advantage. These occur mainly in strong, robust constitutions, in individuals accustomed to an invigorating, open air life, liberal diet and abundant exercise. Even in these this measure is chiefly resorted to, to relieve an acute pulmonary congestion with a dangerous distension and over charging of a fatigued and overworked heart. In short the condition is one closely allied to acute congestion in which the value of bleeding is all but universally admitted. It is especially warranted early in the disease, though it may still be adopted with caution in a similar condition which has supervened at a later stage. A strong pulse and bright red mucous membranes, are not as has been supposed, essential prerequisites to its employment. The mucosæ may be pale, or more likely cyanotic, and the pulse small and weak, from the over charging of the heart and its tendency to failure, and it is to relieve these conditions that we adopt this most potent of all measures for securing a temporary lessening of the blood pressure in the right heart and pulmonary circulation. Even the transient relief may allow this to right itself and then less radical or dangerous measures may be relied on. Bleeding should very rarely be resorted to save at the outset of the disease; extensive exudation into the lung tissue strongly contra-indicates it; it cannot be safely employed in the very young or old, in weak or debilitated subjects, when the pneumonia has relapsed or supervened on another serious malady, or when occurring in an unhealthy district. Delafond met with a very high death-rate from bleeding in a damp undrained locality. Where bleeding is permissible, the blood should be drawn from the jugular in a full stream, from a large orifice, the finger being placed upon the pulse, and the flow arrested as soon as the blood is felt to pass along the vessel in a fuller, freer current, and the breathing is seen to be relieved. It can rarely be repeated with profit or safety, and in the vast majority of cases can be well dispensed with altogether.
Antipyretic Treatment. When the temperature runs dangerously high, a temporary use of antipyrin, acetanilid, phenacetin, or other potent antithermic remedy may be resorted to. But agents that so profoundly affect the heat centres are not devoid of danger and should not as a rule be continued after the dangerous excess of temperature has been overcome. They may be looked on as valuable to temporarily obviate an extreme danger rather than as a form of regular treatment.
The modern resort of applying ice bags to the chest may be similarly disposed of. In very high fever they have been apparently beneficial, but the danger of chill or injurious reaction is so great that they must be employed with the greatest possible consideration and care.
Refrigerant Febrifuge. Neutral salts such as saltpeter in 2 drachm doses every six hours may be given in the drinking water. These are valuable for their cooling and eliminating action, and possibly in counteracting the viscidity of the blood and exudations. Acetate of potash, bicarbonate of soda, iodide of potassium or muriate of ammonia may be substituted.
Stimulants. In debilitated subjects or with low fever or oppressed heart the stimulating diuretics like sweet spirits of nitre or liquor of the acetate of ammonia are to be preferred, and this is especially the case during convalescence. They at once sustain the flagging heart and aid in the excretion of morbid products. Digitalis is often of great value in the same sense, and as a heart stimulant nux vomica.
Some follow Todd and Bennett in seeking stimulation from alcohol, ammonia and its salts, ether, etc. When the circulation is weak or flagging these are often of value and they may even act directly on the pathogenic microbe. The inhalation of oxygen, or the solution of peroxide of hydrogen given by the mouth has often an excellent effect.
Sedatives. Aconite has become too much of a domestic remedy, nevertheless it may be used with advantage in high fever with excited heart action, to moderate the circulation and relieve the breathing. Veratrum, hydrobromic acid, bromide of sodium or ammonium, or chloral hydrate may be used as alternates or substitutes.
Compresses. Fomentations. Poultices. No measure is safer nor more promising, especially in the early stages, than the poultice jacket or compress. A blanket wrung out of hot water is wrapped around the chest, covered with a thick dry one, and held firmly attached by elastic circingles. Or soaked cotton wool is applied and covered with a dry blanket or a rubber sheet. The more acute the inflammation the more valuable is this measure.
Derivatives. As a derivative the mustard pulp rubbed in and covered with thick paper or rubber is especially valuable. In one hour it may secure a free exudation and material relief to the breathing. It may be replaced by ammonia and oil, with or without a covering, by hot water or by cantharides. This must however be used with judgment. In the early stage with a high type of inflammation and fever the surface irritation may aggravate this through sympathy; in such cases therefore the severity of the inflammation should first be moderated before using an active counterirritant. In debilitated conditions, too with an altered or depraved state of the blood and during the prevalence of a low type of the disease, sloughing may ensue from incautious blistering.