Alcohol should not lie withheld under these circumstances, and though still much difference of opinion maintains regarding its value as a routine agent in pneumonia, nevertheless it cannot safely be denied that in emergencies like the one under consideration this drug may be the means of saving life. It is wise, therefore, to reserve alcohol during the first three or four days of the disease till the first symptoms of cardiac failure threaten, and as soon as increased frequency with teduced tension of the pulse is apparent Whiskey or Brandy should be commenced in divided doses amounting to 5 or 6 oz. daily. Those habituated to its use may be permitted to take half the above amount from the start, but when in them urgent cardiac weakness supervenes, a daily quantity of to oz. may some times be necessary.
The action of alcohol as a food in pneumonia need not be considered as in the case of typhoid or other protracted continuous fever where along de mand is made upon metabolism. The confusion of these different actions accounts to a large extent for the conflicting opinions upon the value of the drug in pneumonia. In this hitter disease the effects of alcohol as a cardiac stimulant should only be kept in mind, and it should never be depended upon alone as an agent for strengthening or increasing the tone of the cardiac muscle, a cardiac tonic being always necessary to supplement its action. In the presence of profound toxemia or a full 'bounding pulse, alcohol in full doses is worse than useless, since it only increases the poisoning of the nerve centres, respiratory and cardiac.
The writer is satisfied by prolonged observation and clinical study that the alcohol which has been produced by the pot-still process and permitted to mature for a period of at least 4 or 5 years is better for medicinal use than the patent-still product, and that, therefore, a blended spirit, whether whiskey or brandy, into which the latter form of alcohol largely enters should be avoided. The stimulant should be given mixed with milk, and • as already implied in the statement regarding dosage, a table spoonful should be given every 3 hours, and in severe cases every 2 or every r hours. Considering that the period of free stimulation does not usually commence till the third or fourth day, these doses will only need to be kept up for 3 to 5 days.
Strychnine should always be resorted to in combination with the alcohol treatment. The divergence of the views regarding the value of this drug may be easily accounted for by the fact that some physicians who invari ably give it by the mouth seldom observe any marked cardiac tonic effects, whilst those who resort to hypodermic medication in full doses are satisfied about its strengthening the power of the ventricular contractions. It is
difficult to explain this difference in the action of strychnine, but the writer has long been convinced of the truth of the above observation. The drug is, moreover, commonly given in doses which arc useless; the tablets for hypodermic injection usually supplied vary from to gr.; less than gr. should not be relied upon, and often in emergencies gr. may be necessary.
Digitalis, as already remarked, is a most disappointing drug in the treat ment of cardiac failure in pneumonia. It may, however, be injected along with the strychnine; the B.P. tincture in i5-min. doses may be given by the mouth, whilst the strychnine is administered hypodermically. Notwith standing the writer's scepticism regarding the value of digitalis in pneu monia, he always administers it as a routine in every case when the pulse is failing in tension and becoming more frequent, though he never depends upon it. It is almost impossible to conceive that it can do harm, and the best routine is to commence with a combination like the following in which the dose of nux vomica is so moderate that it does not prevent resort to or gr. strychnine hypodermically as soon as the symptoms of failing heart power become unequivocal; when the nux vomica or strychnine is given by the mouth the effect of the fuller hypodermic dose is more certain.
it. Tr. Nucis_Vomico 3ij.
Tr. Digitalis 5iss.
Spt. Am»ton. Aront.
Aqua Chlorof. ad 5vj.
Ft. mistura. cpt. ass. ex aqua quarta q. Irora, p.p.a.
As in the case of the administration of alcohol, strychnine medication should not be commenced during the first few days unless specially indi cated, some authorities holding that the premature resort to strychnine is liable to induce a condition of cardiac irritability, but the writer has never witnessed such result. gr. in severe cardiac weakness may be injected three times a day, but when these large and frequently repeated doses are necessary the mouth administration of nux vomica should be stopped. The above mixture may, however, be continued, the night and morning doses being substituted by a gr. dose by the needle.