CHAPTER X. DISEASES OF THE LUNGS AND PLEURA. (Part 3)

j Spiritus ammonii aromatici 3 iv Syrupi aurantii 3 vj Aquse q. s. ad § ij Misce et fiat solutio. Sig.: Teaspoonful every two hours. To this may be added sodium bromid if the child is nervous. Cough is best relieved with codein. IJ Codeinse phosphatis gr. ij-gr. iv Ammonii carbonatis gr. xxx Tincturse hyoscyaminse 5 iv Syrupi pruni virginianse 3 vj Aquae camphorae q. s. ad § i j Misce. Sig.: Teaspoonful every two hours. Or: IJ Ammonii carbonatis 3 ij Ammonii iodidi 3 iij Syrupi glyeyrrhizse ^ ij Syrupi tolutani § ij Misce. Sig.: Teaspoonful every two or three hours. Or: IJ Vini antimonii 3 j Spiritus aetheris nitrosi 3 iij Tincturse opii camphoratse 3 iiss Liquoris ammonii acetatis . . q. s. ad § ij Misce. Sig.: Teaspoonful every two hours for child three to five years. BRONCHO-PNEUMONIA. 193 Brandy should be given, best in milk, when stimu- lants are needed. Diet should be light and nutritious, such as milk, broths, and eggs in the form of albumen water. Plenty of cold water should be given. A cup of cold water should be kept by the bed, and the child en- couraged to drink freely. If the pulse shows any signs of weakening, brandy should be given either in milk or in albumen water. Strychnin is indicated in rapid cardiac failure. For a child of six months gr. ^oo should be given hypodermatically every three or four hours. Tincture of belladonna ni j-tii ij every two or three hours is an excellent respiratory stimulant, but atropin, combined with strychnin, is much better. Venesection is very seldom indicated in children or the aged. Remember that it is a patient you are treating, not pneumonia, and be governed accordingly. During convalescence tonics containing iron are needed and of these none are better than: IJ Elixiris ferri, quininee et strycli- ninse phosphatis, Essentia pepsini ( FaircMld ) ..aa^iss Misce. Sig.: Teaspoonful three times daily. Or: - IJ Euquinini ( Merck ) gr. xxxv Syrupi pruni virginianse 3 iv Misce et fiat misturse et adde Liquoris potassii arsenitis TTL xxx-TTL xl Aquae menthse piperitse .... q. s. ad § i j Misce, Sig.: Teaspoonful three times daily after meals. 194 DISEASES OF THE LUNGS AND PLEUEiE. Chronic Interstitial Pneumonia. Remember that the history is very important, as it frequently occurs as a sequence of inhalations of iron, coal, or stone dust, and in the course of syphilis. Remember that the characteristic feature of this affection is atrophy of the lung. Remember that inspection shows retraction of the thorax on the affected side, with approximation of the ribs, and the spine curved toward the affected side. Remember that in severe cases there will be drop- ping of the shoulder and projection of the scapula, together with reduction or absence of respiratory movements. Remember that in atrophy of the left lung the apex beat of the heart is displaced to the left and to a higher intercostal space, and the pulsation more dif- fuse, because of greater cardiac surface exposure. Remember that in the second left interspace over the pulmonary artery a systolic bulging and a dias- tolic thrill becomes visible and palpable. The thrill is due to the closure of the pulmonic valves, and auscultation reveals an accentuation of the valve sound. Remember that if the atrophy is at the apices of the lungs, they will be shrunken; and if at the base, the abdominal organs adjacent to the diaphragm are displaced upward. CHKOJSriC INTERSTITIAL PNEUMONIA. 195 Remember that examination of the sputum for the tubercle bacilli is the only definite way to exclude tuberculosis. Remember that there will be no shortness of breath in the ordinary exercise, but exertion, such as climb- ing stairs, may cause dyspnea. Remember that chronic cough is always found, but there may or may not be abundant sputum. Remember that death from hemorrhage or cardiac failure may occur. Remember that fever, when present, means tuber- culosis if not due to other acute associated process. Treatment. The patient should be protected from changes of temperature. It is better to send him to a warm, dry climate. The diet must be nutritious and easily di- gested. The bowels should be kept regular. The skin should be active, and flannel should be worn. For the severe cough of the associated bronchitis the treatment would be the same as that outlined under chronic bronchitis. Oil of turpentine gtt. x-gtt. xx three times daily is excellent. There is nothing that will restore the elasticity of the lung. Breathing exercise should be carried out to expand the pulmonary tissue. Violent exercise should be interdicted because of the danger of hemorrhage. 196 DISEASES OF THE LUiS'GS AXD PLEUE^. Emphysema. Remember that heredity plays an important role in emphysema. Remember that bronchitis is a very common as- sociate. Remember that dyspnea, with harsh, wheezy res- piration and prolonged expiration, is characteristic of emphysema. The ratio between inspiration and expiration, which is normally 1 to 4, may be changed to 4 to 1. Remember that cyanosis of extreme grade is more common in this than in other affections. Remember that the inspiratory effort is short, but expiratory is greatly prolonged. Remember that the large, barrel-shaped chest and rounded shoulders, with prominent clavicles and deej) sternal fossa, are signs of emphysema. Remember that the drum-like note on percussion is due to the distended air vesicles. The cardiac area of dullness is greatly reduced or obliterated, and the liver dullness lowered even to the costal arch. Remember that the breath sounds are feeble and soft in character. Remember that the obstruction to the lesser cir- culation causes hypertrophy of the right heart and accentuation of second pulmonic sound. Remember that cough and expectoration so often found in emphysema are due to the accompanying bronchitis. emphysema pulmonary gaxgrexe. 197 Treatment. The obstruction in the lesser circulation will cause digestive disturbances ; hence the diet should be nu- tritious, easily digested, and taken in small amounts, but frequently. The bowels should be kept open. Iron and codliver oil are both indicated, and strychnin may be advantageously added. Strychnin is admirable, and should be given in full doses, beginning with gr. %o three times daily and increased gradually until gr. %2 are given. Arsenic is good — Fowler 's solution — 5 drops three times daily, or arsenic trioxid gr. %o naay be used. The chronic bronchitis should be treated as al- ready outlined. The patient must be carefully pro- tected from exposure. For asthmatic attacks that so frequently occur a hypodermic of morphin sulphate gr. %, with atropin sulphate gr. %2o, repeated every four to six hours if needed, is excellent. The main reliance should be placed upon plenty of good food, protection from exposure, and the free use of strychnin for a long period of time. Pulmonary Gangrene. Remember that this is a sequence of a variety of conditions in the lungs — as lobar pneumonia in the debilitated or diabetic patient, aspiration pneu- monia, embolism of the pulmonary artery, and it is in this manner that gangrene occurs in typhoid. 198 DISEASES OF THE LUNGS AND PLEURA. Remember that the symptoms of the preliminary conditions precede those of gangrene. Remember that the sputum is very characteristic, usually profuse and fetid. The odor is cadaverous or mawkishly sweet and penetrating. Remember that pieces of lung tissue can be sepa- rated from the sputa. Remember that the peculiar plugs seen in the sputum in bronchiectasis are absent. Remember that elastic fibers are seen with the microscope. Remember that the color of the sputum is ' ' dirty- green, ' ' gray, or brown, depending upon the amount of blood it contains. Remember that the fever is not high, but the pulse is rapid, with great general prostration. Treatment. The patient should be kept on his back, to avoid leakage into sound bronchi. The diet should be nutritious, and the strength of the patient must be su^Dported. Alcoholic stimulation should be used freely. Turpentine is excellent, gtt. xv-gtt. xxx, espe- cially when there is a complicating hemorrhage. Carbolic spray may be used, or better plan is to use an inhaler, covering the mouth and nose, and charged with a carbolic solution, or with guaiacol (or creosote), alcohol, and chloroform, equal parts. PULMONARY TUBERCULOSIS. 199 Creosote may be given both as an antiseptic and deodorant. IJ Creosoti (Beech-wood) Vfl xxx Alcoholis B j Glycerini 3 vj Aquae q. s. ad B viij Misee. Sig. : Tablespoonful three times daily. When the gangrenous area can be located and the general condition of the patient is good, surgical in- tervention is indicated. Pulmonary Tuberculosis. Remember that catarrh localized at the apices is very suggestive of tubercular infection. Remember that dullness on percussion over the apex, with the patient in the sitting posture, is sig- nificant of early stage of tuberculosis. Remember that a deviation from the normal sounds on auscultation — as jerky respiration, pro- longed expiration, intensified or coarse vesicular breathing, or distinct respiratory murmur — is con- firmatory of percussion findings. Remember that evening elevation of temperature is present early in tubercular infection, but the tem- perature must be taken at least four times a day. The fever may be of the remittent or intermittent type. Remember that the gradual loss of weight and strength in young adults is exceedingly significant of phthisis pulmonalis. 200 DISEASES OF THE LUNGS AND PLEURA. Remember tliat ''night sweats" occur more often in phthisis than in any other condition. Remember that the examination of the sputum will show, in time, the tubercle bacilli and is pathog- nomonic of tuberculosis of the lung, but they may not be found early in the disease, as they depend upon the stage of softening and breaking down of infected lung tissue, with expectoration of the pus- like material. Remember that it is necessary to differentiate the formation of a cavity and pneumothorax, especially the sacculated form. The intercostal spaces over the cavities are re- tracted as a rule, while in pneumothorax the inter- spaces are bulging, and pectoral fremitus is intensi- fied over a cavity, but diminished over pneumo- thorax. Remember that the cracked-pot sou.nd on percus- sion is found over cavities, while distention of the thorax, displacement of viscera, especially heart and liver, and the change of dullness in the lower por- tions upon change of position point to pneumo- thorax. Remember that cough is present in the majority of cases — a dry, hacking cough — but there are no characteristic features about it. Remember that the ''stomach cough" of the dys- peptic is probably of tuberculous origin. Remember that the rosy cheeks and bright, spark- ling eyes accompany the hectic fever of phthisis. PULMONARY TUBERCULOSIS. 201 Remember that Koch 's tuberculin may be used in case of doubt to determine the presence of a tuber- cular infection. The following method may be fol- lowed : for three days the temperature is to be taken every three hours and recorded. On the fourth day 1 milligram of pure tuberculin is injected hypoder- matically, and, if no febrile reaction occurs in ten or twelve hours, the test is negative. In three days twice this amount is injected and the temperature watched for twelve hours. This is again repeated in three days, using larger dose until finally 5 milli- grams are injected at a dose, when, if there be no fever, headache, and lassitude, the patient may be said to be free of tubercular infection. In positive reaction there will be a rise of 2° to 4° F. in the tem- perature. Do not use tuberculin if a diagnosis is possible without it. Remember that a rapid pulse and hurried breath- ing should arouse suspicion. Remember that hemorrhage occurs in the course of the disease, and may be the first intimation that the patient is tubercular. Remember that the muscles overlying an acute, active tubercular infection are rigid, similar to the condition of the right rectus over an acute inflamed appendix. This rigidity is easily detected by light palpation of the intercostal spaces. Remember that the presence of pain in the chest depends upon a coexisting pleurisy. 202 DISEASES OF THE LUNGS AND PLEURA. Always auscultate the lungs posteriorly in the interscapular space, as frequently the earliest changes of the respiratory murmurs are heard in this region. Always obtain the family history, because hered- ity is of some importance, but continued exposure to infection is of great importance in making a diag- nosis early. Treatment. Pulmonary tuberculosis is curable, and, to effect a cure, two things are primarily necessary — viz., nutrition and ventilation. Diet. The food should be highly nutritious, and prepared so that it will appeal to the palate. It must of necessity be a mixed diet to comply best with the above requirements. Proteids are of first importance — all kinds of meats, and preferably with some fat. Eggs are very nutritious, and taken in the form of egg-nog are very efficacious, but the patient easily tires of eggs, and they must be used liberally in pre- paring other foods, as salads, soups, dressings, cus- tards, omelets, etc. Vegetables — as peas, beans, lentils, and rice — that contain large amount of proteid should be given. Fats — as butter, cream, oil, bacon, cream cheese, fatty cheese — where the fat is easily assimilated, should be used. Milk in as large a quantity as possible should be used — three pints daily at regular intervals. pulmojstary tuberculosis. 203 Carbohydrates may and should form a good part of the dietary. Ventilation, or fresh air treatment, is very essen- tial. The best fresh air is obtained by being in the open air day and night. Sunlight and open air is excellent, and the patient should be kept out in the sunlight. The bed-room must be so situated as to receive as much sunlight as possible. The patient must sleep in the open air. This may be done by sleeping on a porch, or with the bed at an open window so that the head will be in the window. There are a number of devices that may be attached to the window frame and protect the patient's body from exposure in bad weather. Exercise must be carefully graded to preserve strength and ward off hemorrhage. At most, it should be light, and, where there has been great loss of strength, resisting exercise and massage is better. Care of the Mouth. The patient must be careful to cleanse the mouth thoroughly several times a day with some antiseptic solution. He should also be frequently cautioned against swallowing the sputum, but should spit it into a cuspidor containing some antiseptic solution or into a piece of cotton and burned. The dishes and drinking cups of the pa- tient should be scalded after use. In brief, every- thing must be done to prevent the patient reinfecting himself, so that he may escape fresh lesions. Medicinal Therapy. Creosote and codliver oil probably lead in therapy of tuberculosis. Creosote may be used both internally and by inhalations. 204 DISEASES OF THE LUIN^GS AXD PLEURA. B Creosoti ( Beecli-\vood ) gtt. vj Gljcerini 3 j Spiritus f rumenti 3 i j Misce. Sig. : Dessertspoonful diluted with water every two, three, or four hours. The dose of creosote may be increased, but large doses should never be given, nor should the drug be pushed to the point of toleration because of the re- action from the drug. If the patient receives any benefit from creosote, it is manifested by increased appetite, improved nutrition, weight added, expec- toration diminished, pus in the sputum lessened, the disappearance of bad odor from the sputum, and associated nontuberculous laryngitis, tracheitis, and bronchitis of the larger tubes cured. When too much creosote is taken, there will be loss of appetite, coated tongue, nausea, vomiting, yellow tinge of the sclera, due to sluggish liver, and sugar or albumin may appear in the urine. The pa- tient must be studied while taking the drug to de- termine whether it should be continued. Inhalations of creosote may be administered either alone or in combination with other well-- known medicaments. I^ Creosoti ( Beechwood ) , Aleoholis, Spiritus chlorof ormi aa 3 j Misce. Sig.: 10 drops on a sponge or inhaler; inhale at first fre- quently for fifteen minutes at a time and gradually lengthen the time to one hour. PULMOXAEY TrBEECULOSIS. 205 Or: IJ Creosoti (Beectwood) TTl, sv Tincturae benzoini compositse § iij Misce. Sig. : Teaspoonful floated on cup of boiling water and steam inhaled three or four times daily. Shake. Or: IJ Creosoti (Beech-wood) TU vij Olei pini sylvestris 3 iiss Tincturse benzoini compositae q. s. ad § iij IMisce. Sig.: Teaspoonful on boiling water and inhaled three or four times daily. Shake. Or: I^ Creosoti (Beechwood) Tll^ s Olei pini sylvestris, Olei terebinthinse aa 5 iiss Tincturse benzoini compositae q. s. ad § iv Misce. Sig. : Teaspoonful on boiling water and inhaled three or four times daily. Shake, Creosote for internal use may be combined as fol- lows: IJ. Creosoti (Beechwood) TTL j-TTj. ij Olei olivae vel olei morrhuae TTL ij-TTL v Misce et fiat capsula Xo. I. Dentur tales capsulse mollis No. L. Sig.: 3 to 7 capsules three times daily after food. Or: I^ Creosoti ( Beechwood ) 3 iv Tincturse gentianse compositse § j Aleoholis § viij Vini xerici q. s. ad 0 ij Misce et fiat solutio. Sig.: 2, 4:, or 6 tablespoonfuls three times daily after meals in glass of milk. 206 DISEASES OF THE LUNGS AND PLEURA. Or: IJ Creosoti (Beech wood) 3ss-3j Olei morrhuae 5 vj Acaciae, Aquse menthse piperitse aa q. s. Misce et fiat emulsio. Sig. : Tablespoonful three to five times daily. Guaiacol, a creosote derivative, may be used. Some of the salts, usually the carbonate or salicy- late, are most frequently given. R Guaiaeolis carbonatis or salicylatis gr. vij Fiat capsula No. I. Dentur tales capsulse