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which an occasional additional problem is to sup- port it under the stress of a severe disturbing tox- ; seniia. Following are a few suggestions as to how to meet these therapeutic indications : Diminish the functional demand on the heart by absolute recumbency and quiet; make as few ex- aminations as possible ; toward the crisis, in bad cases, neglect even baths and bowel movements. Give fluid diet, chiefly modified milk and strained gruels. The diet in this disease, whose pericd is usually short, need not be regulated so much with reference to nourishment as to the condition of the gastrointestinal tract. It is better to starve the pa- tient for a little while than to expose him to the dangers of indigestion, intestinal toxaemia, disturb- ing abdominal reflexes, and especially abdominal distention. In prolonged cases and cases of de- layed resolution, however, the question casino crazy fruit machine tips of nourish- ment becomes more serious. Secure sufficient sleep in the early days of the disease, by bromides and opiates if necessary, never by chloral or pala casino slot winners the coal tar sedatives, for nervous ex- haustion from loss of sleep may fatally turn the scale in a critical case. Increase the elimination of toxines, both specific and secondary', by stimulating the kidneys. These organs, though always more casino slot winners 2013 or less disturbed in pneumonia, are not often seriously disordered, and usually can be made to do some extra work. The best diuretic is water, which should be given in considerable, but not in excessive, quantities. When trying to flush out toxines do not forget casino player development resume that the work of pumping the water through the kidneys falls on the play casino card game online free heart. In the beginning of the disease a simple salinu purge, or sucli a purge following a small dose of calomel, makes for lessened toxaemia ; but for more than moderate catharsis there seems to be no good reason. The lessening of the tox- aemia has been made $1 250 free casino bonus to play at casino action a frequent excuse for unnec- essary and excessive medication in pneumonia. In the regular cases maintenance of the bodily func- tions in as high a state of efficiency as possible I seems to be the best we can do along this line, and I in the cases with pronounced pneumococcus septi- cha-mia there seems to be nothing better to do. I while there are many worse things. To treat these scpticha;mic cases with assured success we will probably have to await the development of an ef- fective serum or vaccine, for no drug is likely to serve the purpose. If from the beginning of the disease casino free play no deposit usa we keep the patient in as good general con- dition as possible, we minimize the likelihood of his physiological barriers being overwhelmed by the septichasmic flood. Supply the purest air to the crippled lungs. This does not mean that every patient with pneumonia is best treated out of doors in the winter, though many patients, the young, the sthenic, and those with high fever, do well so treated. It does mean that the patient should lie in a place casino slot winners youtube where Ihe ven- tilation is free. The foregoing procedures indirectly support the heart. In addition to them it is often necessary to give it direct support by stimulation. casino free play no deposit required The hearts of aged patients, alcoholics, and those with preexisting free casino games play casino games here free no download myocardial disease, usually re- quire stimulation from the beginning. In young adults with healthy hearts stimulation can usually wait on symptoms of cardiac insufficiency, but it real casino slots play for fun should not wait too long. It is better to give it be- fore it is needed casino machines a sous gratuites than to lose important ground by delay. It is my custom to give no stimulation at all during the first two or three days of the disease, unless indications for it appear, but on the third casino free play no deposit or fourth day, even if the patient shows no signs of circulatory distress, it is reasonable to suppose that his right heart is beginning to get tired, and I order 1/60 grain of strychnine three or four times a day. This gentle stimulation may be all that is necessary. I increase it according to the requirements of the circulation, following especially the signs afforded by the right heart. The casino machine tips most important signs of a failing right ven- tricle are, diminution in intensity of the closure sound of the pulmonary valve and enlargement of the right side of the heart. It is possible that weak- ness of the pul.monary second sound may be con- cealed by a near by upper lobe consolidation which magnifies its audibility. Increase to the right of the area of covered dulness is evidence of enlargement of the right ventricle only when we can exclude other reasons for it, such as displacement of the heart to the right by consolidated left lung, fluid in the left pleural cavity, retraction of the heart to the right by pleuropericardial adhesions, or pericardial effusion of considerable amount. The interpreta- tion of extension to the right of the area of cardiac dulness is usually made easy by the contemporane- ous character of the pulmonary second sound ; if that has weakened along with the extension to the right of the area of dulness, dilatation of the right ventricle is suggested ; and after this has taken place the radial pulse softens and increases in rapid- ity. Also, if there is much dilatation of the right ventricle and failure of the pulmonary circulation, cyanosis and other signs of venous stasis appear. When the heart failure is due to paralysis of the vasomotor centre there may be a grayish pallor in- stead of cyanosis. Functional murmurs are quite often heard, especially toward the casino slot winners 2012 end of the dis- ease; they may be due to dilatation, myocardial weakness, and incoordination, or pressure of con- solidated lung on the indian casino slots tips great vessels at tiic base of the heart. 74 CORNWALL: HEART IN PNEUM0NL4. In describing procedures with heart stimulants in pneumonia we are unable to lay down a programme of general application because each case has its own peculiarities. There is certainly no acute disease in which heart weakness is a frequent ancl promi- nent symptom which calls more strongly for indi- vidual treatment. Pneumonia occurs at all ages choctaw casino slot winners and in people with all kinds of hearts ; in children and young adults whose hearts naturally possess much reserve power, and in old people in whose hearts disease conditions either obviou.= or latent are already present. The degree and virulence of the toxjemia varies greatly, and cannot be estimated in advance ; and it has no relation to the extent of the lesion — with a small lesion a fatal penumococ- cus septichaemia may develop, and with involve- ment of several lobes there may be no toxsemic symptoms. The amount of obstruction in the lungs varies within considerably wide limits and cannot be accurately estimated, though we have a partial index to it in the signs and symptoms which tell of lung involvement and respiratory embarrassment. Unable, then, to lay down any programme of gen- eral application for the stimulation of the failing heart in pneumonia, I will tell of the principal agents which I am accustomed to use according to my judgment in each case. There are other agents besides those which I shall mention which are in good use, but the ones mentioned have proved in my experience the most reliable and elTective. If more stimulation siems required than is sup- plied by the small amount of strychnine previously referred to, larger doses of that drug are given, but not more casino penny machine tips than 1/30 of a grain every four hours, which I believe is as much strychnine online casino reviews australia as it is ad-

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