A system of practical medicine. By American authors. Vol. 3

by Unknown

Not only does indiscriminate bleeding increase the death-rate and have no influence over the progress, course, or severity of pneumonia, but it postpones crisis and convalescence, and in the old, young, and enfeebled is very often nothing less than a fatal procedure. In a robust, vigorous individual, in spite of the fact that a free bleeding at the very onset will temporarily relieve the urgency of some symptoms, it nevertheless diminishes by so much the chances of recovery, lessens the power to fight against the disease, and makes the patient far more pregnable to subsequent dangers and complications.

Venesection has no influence upon the temperature. It may sometimes postpone imminent death from asphyxia; and the fact that there is one condition in which bleeding may be practised is no contradiction to the foregoing statements, for venesection is then resorted to on account of conditions that must be treated independently of the coexistent pneumonia, such as sudden engorgement of the heart with blood, attended with all the signs of sudden and extensive pulmonary oedema and congestion. When the patient is vigorous and the above-mentioned emergencies exist, free bleeding gives prompt relief. In no case should more than ten ounces of blood be taken.

A careful study of the pathology of pneumonia not only leads one to the conviction that venesection must do harm, but it strongly contraindicates the employment of all those remedial agents which have been used to arrest a simple pulmonary inflammation. Hence tartar emetic, veratrum viride, aconite, and all other cardiac sedatives which at one time were used so extensively have now fallen almost entirely into disuse, as by their effects they can only add to the burden of a heart already overtaxed by the venous stasis and the lack of arterial blood. They may for a time lower the temperature and diminish the pulse-rate, but they will accomplish this at the expense of heart-power, and will almost certainly favor the earlier and more certain development of that heart-insufficiency which must be regarded as the most powerful death-producing agent in pneumonia. Dangerous collapse has frequently followed the free use of these drugs.

Veratria is claimed to be a cardiac depressant; and this fact should make us hesitate before we administer it in pneumonia. It acts promptly in slowing the pulse, but its effects are only temporary, and when used for a couple of days the larger doses that are necessary to bring about the desired results interfere with the nutrition of the patient, often causing vomiting and diarrhoea. Aconite is also a cardiac sedative, but my experience with it has convinced me that it is in all respects inferior to veratria. Digitalis, which may be regarded as a cardiac stimulant, is to be preferred to either veratria or aconite. It not only lowers the temperature, but lessens the frequency of the pulse, steadies it, and produces in the majority of cases its well-known tonic action upon the heart. Its use in children is sometimes followed by an intermittent pulse, but it is a symptom of no dangerous import.

Calomel and antimony have been almost entirely discarded from the therapeutics of pneumonia: there is no evidence that the former has any influence either upon the progress of the disease or the absorption of the pneumonic exudation. Those who advocated its use believed it to be most advantageous after the patient had been freely bled and large doses of tartar emetic had been given. The latter was also a part of the treatment where bleeding was practised. It exercises a depressant effect upon the heart, and hence, although it may diminish the frequency of the pulse and lower the temperature temporarily, it is an exceedingly dangerous relief, as it is obtained at the expense of vital power. It is absurd, with our present knowledge of the pneumonic process, to discuss what was once claimed for tartar emetic—namely, that it had the power of arresting the pneumonic process as well as preventing pulmonary congestion in the unaffected portion of lung. These drugs, while they at best afford only temporary relief, require most careful watching to guard against their dangerous and prostrating effects.

Expectorants have no place in the treatment of pneumonia, as only a very small portion of the exudative matter in the lung is removed by expectoration. If mucus or other secretions accumulate in the bronchial tubes in sufficient quantities to cause inconvenience, it is in consequence of the exhaustion and a loss of muscular power which attend the disease, for which expectorants will afford no relief.

Counter-irritation, by blisters or other irritants applied to the surface of the chest in the earlier stages of pneumonia, is of questionable utility. Occasionally, blisters may be applied during the third stage to hasten the process of resolution and promote the absorption of plastic exudation. The application of leeches, followed by a linseed poultice or some other soothing fomentation, will often relieve the pain in the side which is so urgent at the onset of a pneumonia. If extensive pulmonary oedema occurs, dry cups applied to the chest will afford relief to the dyspnoea and temporarily remove the oedema.

It has come to be a quite universal practice in this city to encase the chest in a layer of cotton batting or flannel covered with an oil-silk jacket. While this procedure has no direct influence on the course of the pneumonia, it promotes diaphoresis and protects the surface from sudden changes of temperature, and is always grateful to the patient. It is especially serviceable in children.

A pneumonic patient should be kept in bed, as nearly as possible in a horizontal position. Every appliance for promoting rest should be employed. He should be cautiously moved for the necessary examinations of the chest, and should be kept as short a time as possible in a constrained position. If there are evidences of heart-failure, the sitting posture should be avoided and talking should be prohibited. The sick-room should be large, cheerful, and well ventilated, and its temperature should range between 65° and 70° F. In acute febrile disease there is no danger of catching cold from draughts, and the idea of the laity that the moment a person is sick or has a fever he must be put in a dark, close room is one of the superstitions of ignorance. Pneumonic patients always demand air, and the cooler the more grateful it is. Pure fresh air has a marked antipyretic power. It is a good rule to allow adults to regulate the temperature of the sick-room to suit their feelings.

One of the most important things in the successful treatment of pneumonia is a carefully-regulated diet. The food should be fluid or semi-fluid and highly nutritious, such as milk, eggs, beef-tea, and concentrated meat-broths. Milk is to be preferred to all other forms of nutrition. It should be given in small quantities at short intervals.