When not contraindicated wine may always be administered with milk. Such administration of wine is not a part of the stimulating plan of treatment hereafter to be considered, but it is a means of increasing the digestive power of a feeble stomach.
If expectoration becomes difficult, it may be from a loss of muscular power in the bronchial tubes, when stimulants are indicated; or from extreme viscidity of the sputa, when alkalies will be of service. Just here it may be mentioned that alkalies and neutral salines possess a diuretic and diaphoretic power which often affords relief from the pungently hot skin, and may aid the elimination of effete material by the kidneys.
It should be remembered that in the treatment of croupous pneumonia we have to do with a self-limited, acute febrile disease, which usually runs a cyclical course.50 Routine treatment is therefore always harmful.
50 Fernet ("De la Pneumo. franche aigue," etc. Arch. gén. de Méd., 1881, pp. 5–155) has demonstrated the regular and cyclical course of pneumonia. The evolution of the malady is represented by the march of the fever and is figured by the thermometric curve.
The nervous shock which attends the ushering in of a severe croupous pneumonia is greater than in any other acute disease, unless it may be peritonitis, and the important question presents itself at its very onset, What measures shall be employed to overcome or mitigate the impression made upon the nerve-centres by the morbific agent which is operating to produce the pneumonia? The experience of the last few years leads me to the conclusion that during the developing period of the disease, when the pneumonic blow is first struck, and until the pneumonic infiltration is completed (usually for the first four days of the disease), if the patient is brought under the full influence of opium, and held in a condition of comparative comfort by hypodermic injections of morphia repeated at regular intervals, he is placed in the best condition not only for resisting the shock, but also for combating the activity of the pneumonia. Opium does not, when thus administered, interfere with a stimulating or antipyretic plan of treatment which may be demanded, but it does very greatly diminish the chances of heart-failure, cases often recovering under its use which from age and condition of life seemed hopeless. Then the great relief and comfort which it gives to the sufferer in the first four days of his struggles are sufficient to commend it, especially in those cases where pain is severe and the restlessness of the patient is exhausting.
After the pneumonic infiltration is completed opium should be administered with great caution, for paralysis of the bronchi (which it induces), and the consequent accumulation of secretion in the bronchial tubes, may greatly increase the already existing difficulty of respiration.
In all severe types of croupous pneumonia there are two prominent sources of danger: heart-insufficiency and high temperature. There are consequently two prominent indications for treatment—viz. to sustain the heart and reduce temperature.
A large proportion of deaths from pneumonia result directly or indirectly from heart-failure. Alcoholic stimulants, judiciously employed, are the most efficient means which we possess for sustaining a flagging heart, but their indiscriminate use is more dangerous than indiscriminate venesection. It may be that only a few ounces of brandy will be required to carry a pneumonia patient through a critical period, or it may be that its free administration will be required to save life. In the old and feeble, and in those who have been accustomed to the use of alcohol, stimulants may be indicated from the commencement of the attack, and their free use required throughout the whole course of the disease. Each case demands careful study. In no other disease is so much discretion and judgment required in the administration of stimulants as in croupous pneumonia. The pulse, being the indicator of the condition of the heart, must be carefully studied. A frequent, feeble, irregular, or intermittent pulse always indicates heart-insufficiency. The quantity of stimulants to be administered in any case must be determined by their effect upon the pulse. It is advisable to commence their use in small quantities, and carefully watch their effects. If the effect is beneficial, a favorable result will follow within a few hours, and then the quantity to be administered can be increased according to the necessities of each case. It is seldom necessary to give more than six or eight ounces of brandy in twenty-four hours, yet if the necessity of the case demands it may be given in much larger quantity, twelve or twenty-four ounces often being required in twenty-four hours. A dicrotic pulse is a certain indication for the administration of stimulants.
The period immediately following the crisis is the one in which stimulants are usually most serviceable. Delirium is a symptom which calls for their administration, whether it is due to asthenia, pyrexia, or is an expression of blood-poisoning. When muscular tremor and subsultus tendinum are present, alcohol may usually be freely given. A critical collapse in the aged and weak, attended by great prostration and a subnormal temperature, is a condition in which alcohol shows its best effects, and the amount of asthenia will determine the amount of stimulation required.
It has been claimed that carbonate of ammonium in large doses stimulates the heart and prevents the formation of heart-clots by its action on the blood. The cause of heart-clot is the heart-failure, and there is no evidence that carbonate of ammonium prevents the coagulation of the blood when the blood-current is slowed. Besides, large doses of carbonate of ammonium irritate the stomach, and on this account interfere with nutrition, and thus diminish the chances of recovery. As a diffusible stimulant it is inferior to champagne. Moreover, champagne can be administered for a much longer period without causing gastric disturbances.