Leeching may be employed in sthenic patients for the relief of local pain, and cupping over the bites may be resorted to, though, as a rule, when blood-letting is indicated for the relief of severe pain and distress, it is better to open a vein.
Pyrexia.—This may be taken as a measure of the degree of toxemia present in the early stages of the disease, and when the temperature rises to 104.° or upwards, measures should be employed to reduce it. Antipyrine and other antipyretics of the same class, including Salicylates, will effec tually depress abnormal temperatures, hut their effect is so transient and liable to be followed by collapse or other untoward results that their administration appears to increase the mortality of the disease, and their use in pneumonia as a routine should be abandoned. Quinine is less objectionable, but as already remarked it often fails, and sometimes seriously embarrasses the respiration by drying up the sputum.
Cold sponging is always safe, and should be assiduously practised when the temperature reaches 103° or upwards. The cold or tepid bath is more reliable, but owing to the difficulty of employing it systematically it is better to resort to '• Cradling." This is carried out by placing a large surgical cradle over the naked or gauze-covered body of the patient; from the interior a number of ice-bags or pails filled with crushed ice are suspended, and the whole covered in loosely by a large thin linen sheet extending from the neck to the foot of the bed. This plan is very suitable for children, but any approach to hyperpyrexia is best met by the prompt use of the cold pack, over which cold water may be affused freely till the temperature falls. The cold douche should be reserved for those grave cases of hyperpyrexia in which cyanosis is threatening from retained bronchial secretion or from collapse of the lobules in bronchopneumonia.
Digitalis is recommended by Continental physicians, who quote statistics in which the mortality has been reduced to about 2 per cent. When it is remembered that the dose for antipyretic purposes consists of the daily administration of 6o to 18o grs. of the dried digitalis leaf, it is not to be wondered at that the treatment is rarely employed in this country, not withstanding the strong statements made that the exercises a specific action in neutralising the toxins of the disease.
The vaunted antipyretic action of digitalis in pneumonia is not to be confounded with its cardiac tonic properties. Thus fraenkel, who extols its efficacy, states that it should never be given in cases where cardiac weakness is present; his daily dose corresponds to i oz. B.P. tincture, and Jurgensen gives 15 grs. of the leaf at one dose to infants under a year old, and 77 grs. to adults. The writer confesses that lie has never possessed the courage to prescribe digitalis in this manner, and therefore cannot speak of its efficacy.
The action of digitalis as a cardiac tonic in pneumonia is most dis appointing. Whether this result be due to the high temperature or to the depressing action of the toxins on the cardiac muscle or nerve apparatus remains to be proven by the pharmacologist. Nevertheless in full cardiac tonic doses it can do no harm, and may be combined with any drug prescribed for the relief of other symptoms. Maragliano states that when a preparation of digitalis is mixed in vitro with a virulent culture of the pneumococcus the resulting combination is quite innocuous.
As a rule it may be said that little good is to be expected from the mere routine reduction of the fever heat in pneumonia unless when hyperpyretic temperatures are reached, and then the excellent results of the cold bath are attributable to its influence upon the heart and eliminatory organs. It is usually only necessary to keep the patient in the bath or pack till the rectal temperature falls to about too°, as the reduction of temperature proceeds after his removal to bed.
Dys jmcca and Cardiac Failure.—These symptoms must be considered together, as the first evidence of cardiac weakness may show itself by blocking of the right heart causing urgent respiratory embarrassment. When this occurs the best procedure is at once to open a vein, and when the pulse is full and bounding 15 to 20 OZ. blood may be permitted to flow out. As the engorgement of the ventricle has been relieved by venesec tion, remedies intended to strengthen the action of the muscular fibre should be administered.