This section is from the book "Materia Medica And Therapeutics Inorganic Substances", by Charles D. F. Phillips. Also available from Amazon: Materia medica and therapeutics.
A simple pneumonia usually terminates favorably, independently of medicine, and requires at least no active interference; but, under certain conditions and complications, phosphorus has proved, in my experience, a valuable adjuvant. Thus, if at the commencement of an attack adynamia is very pronounced, this medicine is indicated. It is curious that the most amenable to its action seem to be adult subjects previously robust, and old persons. It is a matter of common observation that the nerve-power fails more rapidly in severe illness attacking such subjects, than it does in the young or the simply delicate. Some degree of biliary disturbance usually accompanies the early stages of pneumonia, and so long as this does not assume a very aggravated form, 1 have found it a good indication for phosphorus treatment, and especially if prostration be extreme. Again, it is good in ordinary cases with difficult muco-sanguineous expectoration and very marked lowering of strength and evening exacerbations; also in later stages, when either pyrexia has subsided and the patient is left very feeble, and does not progress toward convalescence; or again, when red hepatization is complete, fever and prostration increase, and suppuration is imminent- although, when pus has actually formed, phosphorus is contra-indicated.
Dr. A. Thompson, speaking highly of the value of phosphorus in pneumonia, remarks that success depends much on the dose given, and in his opinion the better results of older practitioners were traceable to their use of full doses, toxic effects being less known and consequently less feared by them. He says that "no caution need limit the quantity of such a preparation as the tincture, the only limit to be recognized being improvement in the patient." He commonly orders 1/12-gr. dose in the cases referred to, but I cannot agree either with this theory or practice; my best results have been obtained with 1/200 to 1/100 or 1/50 gr. given every two to four hours.
I have also had good results from phosphorus in chronic pneumonia; but when it occurs in tuberculous subjects with tendency to hemorrhage, this drug should be avoided. In acute or chronic cases, complicated with bronchitis, phosphorus is less appropriate than other remedies.
The proper treatment of this disease has long been a crucial question, and opinions have varied as to the amount of influence possessed over it by antimony. Very much depends upon the time and mode of administration. Rasori, with his "contra-stimulant" method, aimed at exciting, in or near the inflamed part, an artificial irritation, more powerful than the original disease, and gave from the commencement large doses, which he rapidly made enormous. Thus, one adult was ordered on the first day about 24 gr., and by the eighth, 144 gr. per diem; the amount was then reduced up to the twelfth day, when death occurred: the same patient was bled several times in the course of the attack, this being considered to favor the special action of the drug; there was no evidence of its irritant effect, but such a mode of treatment could not be sanctioned at the present time; and although the mortality in the practice of the Italian physician was less than that of his contemporaries, it was yet very large, and must not be taken as illustrating the results of a judicious use of antimony.
Laennec usually recommended 1 gr. every two hours till 6 gr. had been taken, and then an intermission for the same period; sometimes, however, he increased the dose gradually to 30 gr. in the twenty-four hours. His mortality was about one in twenty, reckoning only well-marked cases; that of Louis, following a very similar method, was about three in twenty. Trousseau and Grisolle, who have treated the subject fully, agree in speaking highly of this antimonial treatment, the former, indeed, so highly, that he foresees "a future generation will tax him with exaggeration." The latter observer has specially analyzed forty-four cases, showing some strikingly good results as to relief of signs and symptoms and as to brief duration, but these reports must be read in the light of our later knowledge of the natural history of pneumonia, which would explain some of the rapid recoveries by the occurrence of a natural crisis: vomiting and purging were often caused to a serious extent (cf. Sturges: "On Pneumonia," Appendix G, "Treatment Statistics").
Dr. W. Stokes was one of the earliest British physicians to report favorably of this remedy in pneumonia; he stated that it acted better when given before hepatization had commenced than afterward. Sir Thos. Watson also commends it, specially in the stage of engorgement, and Dr. Walshe lays stress upon its value when it is not given to emesis. Dr. C. J. B. Williams uses 1/8 to 1/2-gr. doses every two, three, or four hours during the early stages, combining them with citrate or nitrate of potash (Lectures, Medical Times, i., 1872).
Three grains is the minimum, and 16 the maximum daily dose recommended by the German Codex, and these quantities nearly accord with those already mentioned: with them vomiting has generally been observed at first, and is said to have proved useful rather than otherwise, and, later on, tolerance has become established so that irritant effects have not been marked; nevertheless, smaller doses are to be preferred. I have found the best results from those ranging between 1/50 and 1/4 gr. given every two to three hours, beginning with the smaller amount and increasing gradually so as to produce general effects without vomiting or even nausea. In severe cases, with high temperature, small frequent doses of aconite are valuable in combination or alternation with antimony (v. Vegetable Kingdom), and I believe by this treatment may be effected all the good Rasori expected from preliminary bleedings. In moderately severe attacks, with less pyrexia, antimony alone is a good and sufficient treatment from the first, although its special value is shown best when "resolution" begins; it assists the clearing up of consolidated lung. Another indication for the remedy is to be found in the presence of various complications, such as bronchitis, or whooping-cough, or when the malady deviates from an ordinary course, or occurs after influenza or in emphysematous subjects; then I have reason to express the greatest confidence in it. It is true that Nothnagel, Nobiling, and others, hold a different opinion, but this may be attributed partly to giving larger doses than the patients could bear, partly to the indiscriminate use of the medicine in all stages and phases of the disease; for Nobiling speaks of emetic doses which induced cardiac collapse, and of small doses being continued till intestinal ulceration occurred, results of which I have never seen any indication under the method above recommended. I must, however, guard myself from seeming to imply that it is the only or the best treatment for every individual case: in exhausted broken-down subjects the appropriate time for it is but short, and ammonia, bark, phosphorus, and alcohol must soon replace it, while in septic forms of the disorder, which indeed are not infrequent, tinct. ferri-perchloridi is rather indicated.
In the serious lobar pneumonia, as it commonly affects young children, many authors - Stille, for instance - question the propriety of giving antimony in any dose, because of the risk of sudden depressing effects; this must be borne in mind, but yet I have myself seen the remedy so efficient that I advise its employment very much as in the lobular form connected with capillary bronchitis.
Dr. George Buchanan, while hesitating to recommend antimony as a usual treatment, records that he has seen more benefit from emetic doses of it given at an early period (1/6 to 1/4 gr. every quarter-hour till vomiting occurred), than from any single remedy; it seemed to control the severe symptoms, and secure a favorable after-progress (Lancet, i., 1868); this is, of course, one mode of using the drug, but I prefer minute continued doses.
In cases of phthisis with intercurrent acute pneumonic attacks, the remedy is often as useful as in the idiopathic malady, but special care must be taken to avoid emetic or irritant effects, because of the possibly tuberculous condition of the intestine. In "incipient phthisis," during the stage of cachexia with febrile reaction, small doses lessen irritation and congestion; and even, in the developed malady, when there is general pyrexia, and constant irritative cough, it often relieves, rendering the cough "softer" and expectoration easier.
In the early stages of acute pneumonia, formerly treated by calomel and antimony, I cannot recommend mercurials, but the time for using them with advantage is when secondary fever arises, and there is reason to fear purulent degeneration. So far as I can judge, they have seemed to exert some power in preventing this, for certain cases of the kind have improved on commencing the use of sublimate, and others have relapsed on its omission. In pleuro-pneumonia, with copious effusion, the same remedy is still more clearly indicated, and in chronic interstitial pneumonia it sometimes has excellent effect. Sometimes a syphilitic or strumous deposit occurs in the lung, rendering it partially solid, and giving the physical signs of a pneumonia, and these deposits, especially when of the former nature, seem to "melt away" under the moderate action of mercury: but careful diagnosis of such cases is required, for in true tubercular deposit the drug is injurious. Graves speaks highly of mercury "in scrofulous inflammation of the lung."
Under the use of lead acetate, a good proportion of success in the treatment of pneumonia has been reported by Brandes, Strohl, Leudet, and others (British Medical Journal, i., 1863).
The nitrate of potash is said to be valuable in the early stages (Dublin Quarterly Journal, July, 1873), but as Dr. Jones, who commends it, used also antimony and ipecacuanha, we cannot verify its precise effects.