CHAPTER X. DISEASES OF THE LUNGS AND PLEURA. (Part 2)

be removed or corrected. lodids and belladonna will give better results than any other form of medication. IJ Potassii iodidi gr. xl Tincturae belladonnse TIX xl Spiritus setheris corapositEe 3 ij Aquae q. s. ad B ij Misce. Sig. : Teaspoonful three or four times daily. Or: IJ Liquoris potassii arsenitis 3 j Tincturae belladonnae 3 j Potassii iodidi 3 ij Fluidextracti grindeliae (U. S. P.) . .3 vj Aquae q. s. ad § iv Misce. Sig.: Teaspoonful after meals. Or: IJ Potassii iodidi 3 iiss-3 iv Tincturae belladonna 3 j-3 ij Essentiae pepsini (Fairchild) q. s. ad 5 iij Misce. Sig. : Teaspoonful every three hours until relief is per- manent. BRONCHIAL ASTHMA EDEMA OF LUNGS. 179 Or: IJ Potassii iodidi 3 ij Liquoris potassii arsenitis 3 j Vini ipecacuanhae 3 i j Tincturae hyoscyaminse 3 iv Aquae chlorof ormi q. s. ad 5 viij Misce. Sig. : Tablespoonful after meals. Iron should be administered if anemia be present. J^ Quininae hydrocliloridi gr. xxv Ferri carbonatis gr. xxx Arseni trioxidi gr. ^4 Misce et fiant capsulae No. XV. Sig.: Capsule after meals. Diet of asthmatics should be simple, as an indis- cretion will often cause an attack. The bowels must be kept regular, either by the use of mineral waters or saline cathartics. An equable climate is to be recommended if the patient is able to afford it. If there is emphysema, high altitudes are not well borne and should not be recommended. Where chronic bronchitis is present, a warm, dry atmosphere is best. In such a climate the open air treatment, as used in pulmonary tuberculosis, will give best results. Edema of the Lungs. Remember that, in rare instances, the exudation of fluid into the alveoli may be so rapid and abundant that dullness, increased pectoral fremitus, bronchial breathing, and the signs of complete absence of air from the alveoli occur. 180 DISEASES OF THE LUNGS AND PLEURA. Remember that there are two forms — the inflam- matory and that due to engorgement. Remember that the onset is usually sudden, with rapid breathing, a feeling of oppression, and pain in the chest. Remember that dyspnea and cyanosis occur — the signs of the accumulation of carbon dioxid in the blood. Remember that rales, moist and bubbling, may be heard. Remember that the sputum is characteristic, and is copious, foamy, and serous (resembling soap suds), or it may be blood-tinged. Remember that the second pulmonic sound of the heart is accentuated, and in that form due to en- gorgement the pulse is small. Remember that it may prove fatal in a few hours, or it may pass off and the patient have recurrence of the attack. Remember that acute edema of the lung may fol- low aspiration of the thorax for the removal of fluid. Treatment. Bleeding is the first and most beneficial procedure to be adopted; 6 to 10 ounces of blood should be taken. Cardiac stimulants, those acting quickest, is the next step in treatment. Camphor, ether, or strophan- thus are to be given hypodermatically. Morphin and atropin are practically a specific in EDEMA OF LUNGS LOBAR PNEUMONIA. 181 many cases. Atropin is especially indicated and should be given in a rather large dose. Ergot is useful, and may be exhibited as follows: IJ. Fluidextracti ergotag TTL xlv Spiritus setheris 3 j-3 iss Aquae cinnamomi q. s. ad 5 v Misce. Sig.: Tablespoonful every half to one hour. Purging with croton oil iu ii-""! iij on the tongue will often assist in checking the transudation of fluid. Elaterium may be used. These drastic purga- tives should not be used in cardiac disease, and very cautiously if nephritis be the cause of the edema. Dry cupping and the mustard draft are useful adjuncts. Lobar Pneumonia. Remember that in no other infectious disease is a chill so constant or so severe. It usually begins suddenly, without any premonitory symptoms. Remember that the pain in the side follows close after the chill, and is severe, especially when the patient coughs. Remember that the hurried, shallow breathing is often accompanied by a short expiratory grunt. Remember that the fever rises rapidly, and reaches the fastigium in twelve hours or less. Remember that by the end of the second day there is the rusty sputum — scanty, viscid, and blood- stained. Remember that cyanosis and dyspnea occur early, due to pulmonary obstruction. 182 DISEASES OF THE LUNGS AND PLEUK-^. Remember tliat the respiration rate is greatly in- creased, reaching 40 to 60 per minute. Remember that the pulse is strong and full at the beginning, but later becomes feeble and small, run- ning 90 to 120 per minute. Remember that a pulse of 140 to 150 is an un- favorable prognostic omen. Remember that the pain may be referred to the abdomen instead of the chest — very common with children. Remember that any abdominal pain of sharp, lan- cinating character calls for examination of the chest for pneumonia. Remember that a red spot on the cheek of the affected side is very frequently seen in pneumonia, and that herpes at the junction of the mucous mem- brane and the skin of the lips occurs in nearly half the cases. Remember that inspection shows a decided differ- ence in the expansion of the two sides. Remember that marked movement of the chest- wall over the affected lung may be observed, due to the pulsation of the consolidated lung. Remember that pleural friction may be better felt than heard, and vocal fremitus on palpation is greatly increased in comparison with the corre- sponding point on the healthy side. Always ask the patient to cough, and thus clear the larger tubes, before palpation. Remember that percussion reveals pathologic LOBAR PIS^EUMOKTA. 183 changes — viz., Skoda's resonance — found in the stage of engorgement. The note is high-pitched and has a somewhat tympanitic quality. This may also be obtained over the lung tissue bordering a consolidated area. In the stage of hepatization the note is dull or flat. Remember that you never find the vrooden flat- ness of effusion; neither is the sense of resistance so great. Remember that on auscultation, early in the dis- ease, is heard a fine, crepitant rale — a series of minute cracklings heard close to the ear. Remember that the crepitant rale is heard at the end of inspiration and may not be heard until a full breath be drawn. Remember that tubular breathing is heard over the dull area of consolidation. It is heard first with expiration, but later it becomes more intense, of high pitch, perfectly dry, and of equal length with in- spiration and expiration. Remember that the second heart sound over the pulmonary artery is accentuated. Remember that increased cardiac dullness to the right of the sternum and the pulmonary second sound becoming less distinct indicate beginning of heart failure. Remember that the soft, easily compressed pulse, with a gray, ashy face, feet and hands cold, clammy perspiration, signifies a profound toxemia. Remember that there is a diminution of the chlo- 184 DISEASES OF THE LUNGS AND PLEUEiE. rids in the urine, and this does not occur in empy- ema or pleurisy with effusion. Remember that the continuous absence of leuco- cytosis is to be regarded as an unfavorable sign. Remember that in the old and debilitated the on- set is insidious, and the symptoms are ill-defined and latent. Remember that rapid pulse, rapid respiration, and fever call for a careful examination of the chest. Remember that in cerebrospinal meningitis there are muscular rigidity and retraction of the head. Kernig's sign is present and lumbar puncture gives a turbid spinal fluid. Remember that in a hemorrhagic infarct the blood is less thoroughly mixed with the sputum, absence of fever, circumscribed dullness, and the presence of a condition capable of giving rise to embolism. Remember that in edema the sputum is frothy and thin, and dullness, if present, is found over the base of both lungs posteriorly. Remember that broncho-pneumonia usually fol- lows some other condition, as measles or other acute infectious diseases; comes on gradually without a chill, runs an indefinite course and terminates by lysis. Remember that lobar pneumonia sets in abruptly with a chill in a person of previous good health, runs an acute course and terminates by crisis. Remember that in pleurisy with effusion the on- set is with chilliness, but no distinct chill; moderate LOBAR PlSTEUMOlSriA. 185 fever; the percussion note is flat, with a peculiar sense of inelasticity; vocal fremitus feeble or abol- ished, and bronchial breathing distant and faint; the S-shaped line of dullness, with a change on a change of position of the patient; finally the inser- tion of the aspirator needle and the withdrawal of fluid settles the diagnosis. Remember that in many cases acute tuberculo- pneumonic phthisis can not be differentiated until softening occurs and elastic fibers and tubercle ba- cilli appear in the sputum. The important points are heredity, previous cough, and loss of weight; ir- regular fever, corresponding to the remittent type rather than the continuous; circumscribed areas of high-pitched, ringing, coarse, crepitant rales, per- sisting with little change, and a mucopurulent, greenish sputum. Treatment. Remember that in the treatment of lobar pneu- monia the conservation of the heart is paramount. The patient should be isolated, the room should be well ventilated, and the temperature of 65° to 75° F. The fresh air treatment lessens cough, improves appetite, lowers temperature, and diminishes pulse and respiration rate. Rest in bed, with as little disturbance as possible, conserves the vital forces and relieves the heart of unnecessary work. 186 DISEASES OF THE LUNGS AND PLEURA. The diet should be nutritious and easily digested. Milk should constitute the larger portion. To this may be added eggs, meat broths, jellies, and gruels. Food should be given at stated, short intervals in definite amounts. Plenty of pure water should be given throughout the attack, unless evidences of cardiac failure develop, when it should be restricted. Calomel, either in fractional doses or in one dose of 2 to 3 grains, followed by one of the salines, is indicated in the beginning; subsequently the bowels should be kept free by the use of the salines. The skin should be kept active by sponging and the kidneys by use of water. Pleuritic pain at the onset may be relieved, in some cases, by hot or cold applications. Strapping of the chest on the affected side with adhesive strips gives great relief. Morphin gr. ^-gr. %, with atro- pin gr. Yioo, will be required to relieve the severe pain. Tympanites, when it occurs, can often be relieved by a careful revision of the diet. A colon tube may be used to draw off the gas, or hot turpentine stupes. Some of the cases are due to paresis of the muscu- lar coat of the intestines, when a hypodermic of strychnin nitrate gr. %o three or four times in twenty-four hours should be administered. At times a hypodermic of eserin will give prompt relief. In severe cases a hypodermic of aseptic ergot intra- muscularly is of the greatest value. Baths should be used. Tepid baths or sponging LOBAR PNEUMONIA. 187 is best. The cold bath should not be used unless the temperature is very high. Venesection is life-saving in many sthenic cases with signs of engorgement and failing right heart. The withdrawal of 20 to 30 ounces of blood will re- lieve the congestion and tide the patient over his critical period. Expectorants are not to be given indiscriminately, because they derange digestion. The dry, irritating cough is best relieved by co- dein, and ammonium chloridi will render the sputum less tenacious. They are best given in an acid mix- ture, as: I^ Codeinae sulphatis gr. ii j-gr. v Ammonii chloridi 3 iss-3 ij Syrupi acidi citrici o iss Aquae q. s. ad B ii j Misce. Sig. : Teaspoonful every two, three, or four hours as needed. If the cough is not troublesome, omit the codein. Sleeplessness is usually controlled by sponging or bath and fresh air. If the patient is still unable to sleep, some hypnotic should be given. If the circu- lation is good, trional or sulphonal gr. x in hot milk or whisky may be given. Veronal gr. v is safer and very efficacious. Morphin in small doses should be given where the heart is weak. When the heart begins to fail, strychnin should be used, but it should not be pushed except in emergency. Given hypodermatically, gr. Yso every six hours, is best. 188 DISEASES OF THE LUNGS A^s^D PLEUE^. If there is profuse cold sweating, with cardiac failure, atropin sulphate gr. M.20, repeated every six hours, is indicated. Whisky or brandy should be given to alcoholics, and may be used when cardiac stimulants are indi- cated. Half an ounce every three hours until effect. Aromatic spirits of ammonia and spirits of min- dererus are excellent where mild stimulants are needed. Digitalis is highly recommended by many in se- vere cases. The infusion is probably the best, but the tincture, in large doses (nx v-ttl xv) every three hours, is used. I^ Potassii acetatis 3 j Jnfusi digitalis (leaves) 5 iij Misce. Sig. : Tablespoonful every two or three hours, depending upon the severity of the case. Or: E Spiritus ammonii aromatici ^ ss Fluidextracti digitalis 3 iiss Glycerini q. s. ad § iv Llisce et fiat misturse. Sig.: Teaspoonful every three or four hours, or oftener if needed. Quinin is very generally given in pneumonia. Yeo makes very decided claims for it given in an effervescent form — in gr. j-gr. iij every three hours. His method of prescribing it is as follows: IJ Quininse sulphatis gr. j-gr. iij Acidi citrici gr. x-gr. xv Sacchari lactis gr. x Misce et fiat pulvere No. I. LOBAE PNEUMONIA. 189 This powder is dissolved in a little water and added to the following draught : IJ. Potassii bicarbonatis gr. x-gr. xv Ammonii carbonatis gr. iij-gr. v Syrupi aurantii 3 j Aquae q. s. ad § j Misee et fiat haustus. This dose to be given every two or three hours. The fact that quinin in small doses has been shown to increase leucocytosis probably explains its beneficial action. Never give large doses, and best not given in consolidation. Aconite and veratrum are often used in the early stage or that of engorgement with the idea of jugu- lating the disease. They are best given in small and oft-repeated doses, and the alkaloid can be used to better advantage. Neither drug should be used after the congestion is succeeded by consolidation. Creosote, or, better, creosotal (the carbonate), is highly extolled. It is taken into the blood and ex- creted through the lungs, and thus its germicidal action is obtained. It is given in 10-minim doses in capsules or in an emulsion. At the crisis the collapse following is best over- come by hypodermic of atropin. Nitroglycerin is especially indicated when the urine is scanty and contains more than a trace of albumin. Notwithstanding its high recommendations, hypo- dermoclysis is rarely indicated in pneumonia, and the very excellent contraindication exists of too much fluid for a tiring heart. 190 DISEASES OF THE LUNGS AND PLEURA, In convalescence great care should be exercised to protect a heart that has been overworked, that dilatation may not occur. A return to a full diet should be slow, and the patient kept at rest for two months after his apparent recovery. Broncho-Pneumonia (Lobular Pneumonia). Remember that this occurs most frequently at the extremes of life, and that it is a terminal event in many chronic conditions. Remember the frequency with which it follows the contagious diseases of childhood. Remember that chronic Bright 's disease in the aged is often complicated by broncho-pneumonia. Remember that the tubercle bacilli often produce a fatal broncho-pneumonia. Remember that the disease is almost always bilateral, while lobar pneumonia is almost always unilateral and occurs in adults. Remember that if in convalescence from measles or in pertussis a child has an accession of fever, with cough, rapid pulse, and rapid breathing, and on aus- cultation fine rales be heard, a diagnosis of broncho- pneumonia should be made. Remember that dyspnea is a prominent symptom, and the deficiency of air is shown by the rapid respir- atory rate. Remember that cyanosis develops later, due to ac- cumulation of carbon dioxid. Remember that the fine, subcrepitant rales are BEONCHO-PNEUMONIA. 191 heard at first, and later lubular breathing over the affected areas. Remember that percussion usually shows a circum- scribed relative dullness, which is usually bilateral, radiating along the spinal column. Remember that miliary tuberculosis is usually lo- calized in the apices of the lungs, and the presence of choroidal tubercles in the eye facilitates the diag- nosis. Treatment. The proper care of a child convalescing from measles, diphtheria, and whooping-cough will pre- vent such a serious complication as broncho-pneu- monia. Keep the room at an even temperature and the air moist with vapor. Calomel gr. Vio-gr. Yq should be given hourly until a good movement from the bowels is obtained. The bowels must be kept open during the illness with salines. Fever, if high, use water, either as cool sponging, pack, and, in severe cases, the bath. Keep ice cap to the head. Aconite or veratrum, as the tincture, may be used cautiously to lower temperature. It is best given alone in drop doses every half to one hour in water until effect, then every one or two hours. A good combination is the following, and it possesses the advantage of having a stimulant in combination : 192 DISEASES OF THE LUNGS AISTD PLEIIRiE. IJ Aconitin amorphous, Veratrini aa gr. i,^q Digitalini • . • ., gr. i^ Aquae q. s. ad 5 ij Misce et fiat solutio. Sig. : Teaspoonful every half hour for 5 doses, then hourly. A good saline fever mixture : IJ Potassii citratis gr. xxx-gr. 1 Liquoris ammonii acetatis B