Delirium.—This may, like high temperature and other symptoms, be regarded as a measure of the toxaemia present, and it should be met when the temperature is high by the use of the cold pack and ice to the head, saline solution hypodermically, and saline purgatives in sthenic cases. Alcohol may be tried often with benefit, hut its effects must he watched and the drug stopped if the delirium does not speedily yield.
Insomnia is often associated with the previous symptom, and in some cases it may be the cause of the delirium. Smart counter-irritation at the nape of the neck is often useful. When sleeplessness resists the ordinary antitoxic remedies already mentioned, the serious question of the selection of an hypnotic arises. This is often best met by the administration of a full dose of Whiskey at bed-hour; a small wineglassful (2 oz.) may be given provided the general toxaemia is not severely marked, but insomnia accom panied by a low muttering delirium is liable to pass into coma if alcohol in large doses is pushed. The best all-round hypnotic is a full teaspoonful of Paraldehyde administered along with 1- to r oz. whiskey diluted with water. Trional is also comparatively safe, but sulphonal and chloral should be avoided. Morphia, though recommended highly by several authorities, should be reserved for cases where alcohol and the simple narcotics fail, and even then it should be avoided in the late stage of the disease, as undoubtedly lives have been sacrificed to the injudicious use of the hypodermic syringe.
Coma is usually a terminal symptom, but nevertheless sometimes if the pulse is not too low in tension and very quick the letting of blood followed by the injection of 3 or 4 pints or normal saline by the veins or skin may save life. Counter-irritation to the extremities, and when meningitis is present lumbar puncture, should be employed.
Abdominal distension in some cases becomes a prominent symptom from the onset, and seriously embarrasses the heart's action. The best treatment will consist in flushing out the entire colon by large enemata of normal saline solution followed by a small dose of Castor Oil and one full hypodermic gr.) Strychnine. A large sinapism over the transverse colon may also be applied, but the ordinary carminatives are useless, as they never reach the paralysed bowel unless when given by the rectum. The use of the long tube in these cases only aggravates matters; the best procedure is to get up as much fluid as possible by the ordinary enema apparatus, pausing at times to inject a few drs. of Oil of Turpentine mixed with Tincture of Asafoetida by placing the terminal tube of the apparatus in the mixture without withdrawing the nozzle from the anus.
raerine Therapy has failed, and probably there is no hope for it in a disease of such short duration and complex causation as pneumonia.
Nevertheless some physicians believe they get good results by injecting a stock polyvalent vaccine as soon as the case conies under observation, following this up afterwards by using 20 million of the killed autogenous cocci obtained by lung puncture or from the sputum.
Serum Thera Ay, on the other hand, holds out some prospect of a success ful method of treatment. The first fact to realise in this connection is the mixed nature of the infection in severe cases. Four different types of pneumococci are now identified: types i and 2 supply the majority of cases. Il immunising horses with the first type a scrum has been obtained and utilised in the Rockfeller Institute by Cole which reduced the mortality from 3o to 6 per cent.
The treatment of complications as empyema, ulcerative endocarditis, joint suppuration, &c., is to be carried out on general principles, and here vaccine treatment should always be resorted to when possible, autogenous pneumococci being injected.
After the crisis has occurred and the temperature has fallen and the immediate danger seems to have passed, the greatest care should be exercised, as the heart may still require assistance. Stimulants should be continued for a little time in gradually diminished amounts, but all anti pyretic or depressing remedies must be carefully avoided, and the horizon tal position maintained during convalescence. The most liberal diet is to be kept up. and the following tonic, or anything possessing similar action, may be safely administered. Fellows' and Easton's Syrups are valuable.
R . Liquor. ,Strychnine Acid. Nitro-hydrochlor. Ili!. 5iv. Quinine Sulphalis 5ss.
Infusi Calumba ad 5viij. Misce.
Fiat mistura. Capiaf cochlearc magnum ex pauimio aqua ter in die ante cibos.
The treatment of the acute pneumonia occurring during influenza will be carried out on the above lines as mentioned in the article on Influenza. As there can hardly be a question about the contagiousness of this type of pneumonia apart entirely from the infectiousness of the influenza rigid isolation is imperative. Nothing has been said above regarding the neces sity of disinfecting the sputum and isolating the patient in ordinary pneumonia, as the disease cannot he regarded as infectious in the ordinary sense. In some epidemics of pneumonia the disease is highly infectious, and at the commencement of an outbreak this type cannot be distinguished clinically from the purely pneumococcal form : it is always wise to take precautions, and common cleanliness demands that the sputum in all cases should be passed directly into a vessel containing some disinfecting liquid.