If the high temperature in pneumonia is due to rapid tissue-metamorphosis, the result of the action of some morbific agent in the blood, it follows that we must look for an antipyretic which can check this rapid tissue-change. It is claimed with reason that the sulphate of quinia is a sedative to the arterial system, and has a stimulating effect, sui generis, upon the capillary circulation; that it can arrest cell-development, and also check the amoeboid movements of the white corpuscles. Theoretically, therefore, it is a remedy par excellence for the lowering of the temperature in this disease; and clinically and empirically it has been found to reduce temperature more permanently and with greater certainty than any other agent. None of the objections brought against the other antipyretics can be urged against this one, for it possesses the twofold power of reducing temperature and sustaining the heart-power from its action on the nervous system. To act antipyretically, quinia must be given in large doses. From twenty to forty grains must be given within two hours, or the whole quantity may be given at a single dose. The greatest reduction of temperature will be reached in about seven hours after the quinia is taken.52
52 When quinia is employed as an antipyretic in pneumonia it must be given in large doses. The administration of two grains every two hours, or a larger quantity administered in divided doses within a period of twenty-four hours, will not act as an antipyretic; but from twenty to forty grains must be administered within a period of two hours. If the stomach is irritable, ten grains may be given every half hour until the desired quantity has been administered. Usually in from four to six hours after the antipyretic dose has been taken the fall of temperature will begin, and in about twelve hours it will reach its minimum height; then it will remain stationary from twelve to twenty-four hours. After the temperature has once been reduced by the quinia, its administration may be discontinued until the temperature shall again rise to 105°. As a rule, the temperature does not reach as high a point as before the quinia was administered. This mode of administering quinia rarely produces any symptom of cinchonism other than transient deafness after the first dose. In a large proportion of cases the temperature by this method can readily be kept below 103° F.
In Ringer and Gill's experiments with quinia on temperature it took at least twenty grains to produce a fall of a degree. From fifty to eighty minutes were required before the fall occurred, and the effects lasted from forty-five minutes to three hours. Ringer states that in pneumonia the quinia does not readily pass out with the urine, but is delayed in the system for a considerable time.
Lately, antipyrine has been brought before the profession as a valuable and powerful antipyretic. I have used it in both private and hospital practice, and have found it a prompt and efficient means of reducing temperature. It has not seemed to me, however, to have any other beneficial effect either in mitigating the severity or shortening the course of the disease. In two cases its use was followed by collapse, which in one case terminated fatally. My experience has seemed to bear out the belief that this drug is a decided cardiac depressant, and I should for this reason consider it much less desirable as an antipyretic than quinia.
During convalescence tonics and restoratives—iron, quinia, the mineral acids, cod-liver oil, or strychnia—should be administered, and the highest degree of nutrition should be maintained. If bronchitis complicates pneumonia, it may be treated with muriate of ammonium, ipecacuanha, and senega. If severe gastric catarrh occurs, hot fomentations may be applied to the abdomen, and calomel, followed by a saline purgative, may be administered.
Diarrhoea is rarely so severe as to require treatment; five grains of Dover's powder usually suffices to control it.
In the delirium which occurs in alcoholic patients small doses of the tartrate of antimony and potassium are said to be useful. I have controlled this form of delirium best with small doses of hydrate of chloral.
By some, camphor, musk, and turpentine are recommended during the stage of gray hepatization, but it seems to me that the requirements are far better fulfilled by alcoholic stimulants.
In the first stage of senile pneumonia an emetic, when not specially contraindicated, is given in the Salpétrière Hospital. The physicians of the Montpellier General Hospital regard ipecacuanha as an heroic remedy in senile pneumonia. The English regard nitrate of potassium as the most efficacious, while the Germans prefer hydrochlorate of ammonium. Antipyretics are rarely necessary in senile pneumonia; the most important thing is to sustain the heart by stimulants and concentrated fluid nutriment combined with iron and quinia. In senile pneumonia the diarrhoea occurring with the typhoid form must be promptly checked by vegetable astringents.
In children, as in old age, leeches and blisters should never be used. The whole chest should be enveloped in a linseed-meal poultice, to which some anodyne may be added (opium, aconite, or belladonna) if there is severe pain.