When we turn to the nervous system we find evidence early in the disease that the medullary centres are affected. The rapid breathing so characteristic of the disease is not a sign of pulmonary embarrassment, but of stimulation of the respiratory centre. It is rapid, involuntary, unconscious, and diaphragmatic. There are no signs of pulmonary distress. The cardiac action also would seem to indicate stimulation of the medullary centre. It is slow in proportion to the pyrexia and the rapidity of breathing, a condition which appears to be the result of the inhibitory action of the vagus under stimulation. These are the changes seen in the early days of the disease when stimulation of the cardiorespiratory centres in the medulla by toxins is present. The pulse may be full and bounding. The later stages of an attack show a different picture. The breathing may still be rapid, but becomes laboured, conscious, voluntary, and costal, with all the accessory muscles of respiration brought into play. The check action is removed from the heart, and the pulse runs up to 120, 140, 160, or more, with marked weakening of the cardiac action. These signs point to increased poisoning of the cardio-respiratory centres in the medulla, to gradual failure, and to complete paralysis in one or both when a fatal result follows. Why the cardiac failure should precede respiratory failure appears to be due to the fact that a patient possesses accessory muscles and methods of respiration, while he has no such means of aiding the circulation.

The second assumption, that alcohol is in the majority of cases a stimulant to the medullary centres, is one based on the clinical experience of many observers.

In any given case of pneumonia we must take into consideration (1) the proper time for giving alcohol, (2) the indications for its use, (3) the contra-indications, (4) the form and dosage, and (5) the conditions of the patient, apart from the pneumonia, which may affect the treatment.

(1) The Proper Time For Giving Alcohol

At the beginning of an ordinary attack of pneumonia in a previously healthy, or moderately healthy subject, there is no occasion to give alcohol. Some commence the routine treatment of pneumonia with 3 or 4 oz. of brandy a day, and assert that cardiac debility must be averted by early treatment with alcohol. A special characteristic of alcohol is that it acts quickly, so that one has not to wait a few days for its effects to be perceptible, as in the case of digitalis. In the early days of a pneumonic attack alcohol should be withheld, and the patient's strength should be sustained by suitable food. After the fourth day, or when the signs of the pre-critical stage present themselves, alcohol may with advantage be given and continued through the exhausting period of the crisis, until recuperation has set in. The period during which alcohol may be beneficially given will thus be limited in ordinary cases to from three to six days.

Its action is strictly comparable to that of the other stimulants which may be used at the same time. After the crisis has passed, the amount of alcohol may, as a rule, be rapidly diminished.

(2) The First Indication For The Use Of Alcohol

The First Indication For The Use Of Alcohol is given by the pulse. When the pulse becomes small or irregular or compressible, and runs up to 110 or more per minute, alcohol is called for. The more suddenly this change takes place, the more urgent is the call for alcohol, as the whole system is injuriously affected by a sudden impairment of the circulation. Confirmatory evidence will be found on examining the heart, when the first sound at the apex may be found to be weakened or blurred, and some dilatation of the left ventricle is present. Unless some evidence of cardiac weakness is recognized it is not advisable to give alcohol. Other associated disturbances of the system may indicate a case for stimulation, for instance sleeplessness. This can often be relieved by a full dose of alcohol. Again, the cardiac weakness may induce a disturbed state of the secretions, as shown by a dry mouth and tongue. Here also alcohol may afford relief. There may be low muttering delirium, with restlessness, owing to the weakened circulation through the brain, a condition which is often benefited by alcohol.

Having decided to use alcohol for one or other of the above indications, one must give it a fair trial and watch the result closely. The stimulant is not to be continued on any general principles, but on the indications which the progress of the patient affords as to whether it is acting beneficially or not If the pulse is slowed and the cardiac action improves, if the secretions become re-established, and if the delirium or restlessness or sleeplessness is removed, then the alcohol is probably doing good and is to be continued as required. If, on the other hand, one fails to perceive any improvement under the use of alcohol in sufficient amount, it is better to discontinue it and trust to other forms of stimulation. It should be kept in mind that many cases of pneumonia can be successfully treated without alcohol at all, and that the indications for its use should be as clear as in the case of any other powerful drug.

(3) There Are Certain Contra-Indications

There Are Certain Contra-Indications which must be referred to. In the presence of a full and bounding pulse it is folly to give alcohol as a cardiac stimulant, or for any symptom such as restlessness or sleeplessness, or delirium, or loss of appetite. If there is reason to suppose that pneumococcal myocarditis or endocarditis or pericarditis is the cause of the cardiac weakness, alcohol will not be called for in large doses, and it is questionable whether under these conditions stimulation by alcohol will benefit the heart. My own experience has been that in acute inflammation of the heart the less alcohol one gives the better. If there is considerable blockage of the pulmonary circulation, and embarrassment of the right side of the heart, these conditions should be relieved by other measures, cupping, leeching, etc., before alcohol is used. The place of alcohol is to strengthen the action of the left ventricle after the state of the pulmonary circulation has been relieved. If there is much pulmonary oedema or bronchial catarrh, the free use of alcohol will rather tend to aggravate the condition unless it is traceable to weak action of the left ventricle. If the patient is prostrated by profound toxaemia, any attempt to revive him by large doses of alcohol will probably prove useless. His blood and tissues, already saturated with the poison of pneumonia, will neither be purified by means of alcohol, nor rendered more capable of throwing off the toxins. As already stated, it is the collapse produced by failure of the cardiac centre, and not that caused by general toxic infection, which will be benefited by alcohol. If the effect of alcohol is to excite and disturb the patient, to increase the distress, or to fail in producing an improvement in the cardiac embarrassment, it is advisable to reduce the amount or to discontinue it altogether.

(4) The Form In Which The Alcohol Is Supplied

The Form In Which The Alcohol Is Supplied is important. Some have advised the use of the stronger wines, port and sherry, because of the special ethers they contain, and of the added nutritive effect as compared with a plain spirit such as brandy. The ethers can hardly be determined beforehand by the doctor, and the chief point to be considered is the stimulating effect of alcohol. In the case of wines the strength in alcohol varies so much that one cannot regulate accurately the amount of alcohol which is to be given. A sound brandy or whisky is to be preferred as allowing of exact alcoholic dosage, and as supplying the stimulant in a form which is suited to most stomachs. If the patient or his doctor has a preference for rum or gin, equally good results may be obtained from either of these. On the grounds of palatability and quickness of effect champagne has also distinct claims, and it may sometimes act better than brandy in disturbed states of the stomach. After the crisis has passed and the stage of convalescence has been entered on, port or sherry or Burgundy may be employed in place of the spirit.

The question of dosage is one to be determined by the special requirements of the case. Speaking generally, one may say that a mild amount of stimulation will be secured by 3 oz. of brandy or whisky in the day, a moderate amount by 6 oz., and a full amount by 9 oz. If it be said that these would be large amounts for a person in perfect health it may be replied that the conditions in pneumonia are quite different. It is well known that many patients suffering from pneumonia can take large quantities of alcohol without the production of those symptoms which would certainly follow from the same amount taken in a condition of good health. The object of the stimulation is to raise the force of the circulation as nearly as possible to that existing in health, and the dosage is to be regulated on this principle. Again, it may be said that the effect of large doses of alcohol on the tissues generally has been found to be injurious. To this it may be replied that such an effect depends upon the length of time during which the absorption of alcohol has been going on. The question of alcohol in pneumonia differs from that in most other affections in that it is a self limited disease, and in that the period of stimulation may be put down as from three to six days. It is a case of treatment during a critical period, and we are justified in pushing our remedies in a way which would not be possible or advisable in a case of prolonged illness. From this point of view the above-mentioned amounts are not excessive, and if the stimulating effect is beneficial, no permanent harm can be done to the system by the alcohol. These amounts will not, in the vast majority of cases, require to be exceeded. At the same time, if the physician is convinced that the alcohol is benefiting the patient, and that more is called for, he should have the courage of his convictions and increase the quantity.

It is advisable to give the brandy or whisky in doses of from 2-4 drachms, at regular intervals, and diluted with at least twice the amount of water. The aim is to produce a steady and continuous stimulative effect. Larger doses tend to upset the digestion and to produce a temporary over-stimulation followed by a reaction. Sometimes, however, a condition such as sleeplessness or delirium may be best treated by one full dose of from 1-2 oz.

(5) Certain Personal Factors In The Patient

Certain Personal Factors In The Patient modify the treatment by alcohol. Age is one of these. In the majority of cases of lobar pneumonia in infancy and childhood alcohol is not called for. In certain cases the threatening of cardiac failure, at or about the crisis, may be best met by alcohol. As a rule from half to one ounce of brandy in the twenty-four hours will be sufficient. In elderly people the pneumonic poison tends to affect the cardiac action at an early stage so that alcohol is called for early. There is more general agreement about the benefit derived from alcohol in the pneumonia of advanced life than at any other age. While alcohol is called for early, it is seldom required in such full doses as at the more robust period of middle life. The reserve powers of the nervous centres and of the heart are weakened by age, so that they cannot respond to stimulation to the same extent as in earlier years, and the full amount of stimulation possible is produced by smaller doses.

The chronic alcoholic patient is a bad subject for pneumonia, but he must be treated with alcohol freely. To discontinue the alcohol by which his nervous system has been sustained, and to allow the poison of pneumonia to take its place, is not a wise policy. He cannot be fed up during acute illness, and the omission of his accustomed stimulant will probably precipitate a fatal termination. It is not much use ordering 3 oz. of whisky in the twenty-four hours to a person who has been in the habit of taking a pint or more daily, so that the amount of stimulant which is required will depend largely on the quantity which the patient has been in the habit of taking. It is not necessarily as much, but it will probably be considerably in excess of that which would be considered sufficient for a previously abstemious subject.