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the drawing so much blood at first as a pneumonic inflammation might require; but, as the same persons are often found to bear after-bleedings better than the first, this allows the second and subsequent bleedings to be larger, and to such a quantity as the symptoms of the disease may seem to demand.
363. It is according to th,e state of the symp. toms that bleedings are to be repeated; and they •will be more effectual when practised in the course of the first three days then afterwards; but they are not to be omitted although four days of the disease may haye already elapsed. If the physician shall not have been called in sooner; or if the bleedings practised during the firs,t days shall not have been large enough, or even although these bleedings shall have procured some remission j yet, upon the recurrence of the urgent symptoms, the bleeding should be repeated at any period of the disease, . especially within the first forpiight; and even afterwards, if a tendency to suppuration be not evident, or if, after a seeming solution, the disease shall have again returned.
364. "With respept to the quantity of blpo$ which qu,ght, or which with safety may be taken, away, no general rules can he delivered, as it must be very different, according to the state of the disease, and the constitution of the patient. In,
an adult male of tolerable strength, a pound of blood avoirdupois is a full bleeding. Any quantity above twenty ounces is a large, and any quantity below twelve a small bleeding. A quantity of from four to five pounds, in the course of two or three days, is generally as much as such patients will safely bear; but, if the intervals between the bleeding and the whole of the time during which the bleedings have been employed haive been long, the quantity taken upon the whole may be greater. . %
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365. When a large quantity of blood has been
already taken from the arm, and when it is doubtful if more can with safety be drawn in that manner, some blood may still be taken by cupping and scarifying. Such a measure will be more particularly proper, when the continuance or recurrence of pain, rather than the difficulty of breathing, becomes the urgent symptom; and then the cupping and scarifying should be made as near to the pained part as can conveniently be done.
366. An expectoration takes place sometimes very early in this disease: but if, notwithstanding that, the urgent symptoms should still continue, the expectoration must not supersede the bleedings mentioned; and, during the first days of the disease, its solution is not to be trusted to the expectoration alone. It is in a more advanced stage only, when the proper remedies have been before employed, and when the symptoms have suffered a considerable remission, that the entire cure may be trusted to a copious and free expectoration.
367. During the first days of the disease, I have not found that bleeding stops expectoration. On the contrary, I have often observed bleeding promote it; and it is in a ihOre advanced stage of the disease only, when the patient, by large evacuations and the continuance of the disease, has been already exhausted, that bleeding seems to stop expectoration. It appears to me that even then bleeding does not stop expectoration j so much by weakening the powers of expectoration, as by favouring the serous effusion into the bronchia* (348), and thereby preventing it.
368. While the bleedings we haVe mentioned shall be employed, it will be necessary to employ also every part of the antiphlogistic regimen (i SO, 132), and particularly to prevent the irritation which might arise from any increase of heaU For this purpose it will be proper to keep the patient out of bed, while he can bear it easily; and* when he cannot, to cover him very lightly while he lies in bed. The temperature of his chamber ought not to exceed sixty degrees of Fahrenheit's thermometer ; and whether it may be at any time colder, I am uncertain.
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369. Mild and diluent drinks, moderately tepid, at least never cold, given by small portions at a time, ought to be administered plentifully. These drinks may be impregnated with vegetable acids. They may be properly accompanied also with nitre, or some other neutrals; but these salts should be given separately from the drink.
It has been alleged, that both acids and nitre are ready to excite coughing ; and in some persons they certainly have this effect; but, except in persons of a peculiar habit, I have not found their effects in exciting cough so considerable or troublesome as to prevent our seeking the advantages otherwise to be obtained from these medicines.
370. Some practitioners have doubted if purgatives can be safely employed in this disease; and indeed a spontaneous diarrhoea occurring in the beginning of the disease, has seldom proved useful: but I have found the moderate use of cooling laxatives generally safe ; and have always found it useful to keep the belly open, by frequent emollient glysters.
371. To excite full vomiting by emetics, I judge to be a dangerous practice in this disease: but I have found it useful to exhibit nauseating doses; and, in a somewhat advanced state of the disease, I have found such doses prove the best means of promoting expectoration.
372. Fomentations and poultices applied to the pained part have been recommended, and may be useful; but the application of them is often inconvenient, and may be entirely omitted for the sake of the more effectual remedy, blistering.
Very early in the disease, a blister should be applied as near to the pained part as possible. But as, when the irritation of a blister is present, it renders bleeding less effectual; so the application of the blister should be delayed till a bleeding shall have been employed. If the disease be moderate, the blister may be applied immediately after the first bleeding; but, if the disease be violent, and it is presumed that a second bleeding may be necessary soon after the first, it will then be proper to delay the blister till after the second bleeding, when it may be supposed that any farther bleeding may be postponed till the irritation arising from the blister shall have ceased. It may be frequently necessary in this disease to repeat the blistering: and, in *hat case, the plasters should always be applied somewhere on the thorax ; for, when applied to more distant parts, they have little effect. The keeping the blistered parts open, and making what is called a perpetual blister, has much less effect than a fresh blistering.
373. As this disease often terminates by an expectoration, so, various means of promoting this have been proposed: but none of them appear to