CHAPTER X. DISEASES OF THE LUNGS AND PLEURA. (Part 4)

No. L. Sig.: 2 to 12 capsules daily. Creosotal is frequently better borne by the stomach, and may be prescribed. IJ Creosotalis § iij Sig. : Half teaspoonful three to five times daily in milk. Or: I^ Creosotalis 3 v Olei morrhuae § iij Acaciae, Aquae menthae piperitse . . aa q. s. ad § vj Misce et flat emulsio. Sig.: Tablespoonful three to six times daily after meals. There are a number of drugs to be used in tuber- - culosis, partly to keep up nutrition and partly to replace certain substances excreted in abnormally large amounts. Arsenic is first. Either in pill form or Fowler's solution. It stimulates nutrition and is an excellent general tonic. Salt. Patient should be instructed to use large PULMONARY TUBERCULOSIS. 207 quantity of table salt to replace the abnormal loss in sputum and urine. The phosphates should also be given. The best are the pharmacopeial preparations : B Syrupi hypophosphitis § vj Or: R Syrupi calcii lactophosphitis 5 vj Sig. : To be given in teaspoonful doses three times daily. Anorexia must be combated. It is important that nutrition be maintained. If high fever is the cause of the anorexia, food should be given at the time the temperature is down and endeavor must be made to reduce the fever. If pain on swallowing or cough interfere with the taking of food, narcotics should be given before meals. Stomachics may be used to combat anorexia, as: ^ Tincturae nucis vomicse 3 ij Tincturge gentianse compositse, Tincturse cinchonse comp. aa q. s. ad § iij Misce. Sig.: Half teaspoonful before meals. Fever. Drugs should not be given to reduce tem- perature until rest in bed and fresh air have failed. Unless fever is high and interferes with nutrition or causes unpleasant symptoms, no attempt should be made to reduce it. When high, the diet should be liquid, but should be plentiful. Pyramidon gr. j-gr. iij every three hours until effect, or one single large dose gr. xv dissolved in hot water. This is the safest and best drug to be used. 208 DISEASES OF THE LUNGS AIs'D PLEUE^. Other coal-tar derivatives may be used, but, when antipyrin or phenacetin are used and appear to in- crease diaphoresis, it is best to change to other methods, or give them in much smaller doses. Hydropathic measures for reducing fever are not used to any great extent in phthisis. Sponging the body under cover may be used. Night Sweats. Sponging with equal parts of water and alcohol on going to bed, and, if necessary, during the night, may prevent them. Brandy, a tea- spoonful in a cup of hot or cold milk, may be given at bedtime. An ounce of whisky may be adminis- tered a short time before the expected sweat. Atropin sulphate gr. Kso in tablets may be given hourly in the evening for 4 or 5 doses. Agaricin may be used, but, owing to its tendency to produce diarrhea, it is better to combine it with Dover's powder. IJi Agaricini gr. iij Pulveris Doveri gr. xxx Althsese, Mueilaginis acacise aa q. s. Misce et fiat massa. Divide pilulse No. XX. Sig. : 1 or 2 pills five hours before the expected sTveat. Camphoric acid has the advantage of producing quick effect, which lasts for six hours. It is given in capsule of 1 or 2 grains in the evening. A dusting powder of either tannoform or zinc peroxid, to be dusted over the skin, is often very beneficial in checking the sweat. PULMONARY TUBERCULOSIS. 209 IJ. Zinci peroxidi Ej Talci purificati S iss Misce et fiat pulveris. Sig. : To be dusted on the skin. Cough. Is often torturous and prevents rest. Patient should be taught how to cough to raise sputum by a deep, slow inspiration, followed by a short, quick expiration. "When the nose, pharynx, or larynx is not the cause, then codein should be used to check it. Some- times local treatment to the upper portion of the respiratory tract is all that is necessary. ■ I^ Codeinse phosphatis gr. viij Acidi hydrocyanici diluti 3 j Spiritus chloroformi 3 iss Syrupi lemonis 3 j AquEe q. s. ad § iv Misce. Sig.: Teaspoonful when cough is troublesome. Or: I^ Dionini gr. iv Acidi hydrocyanici diluti TTl, xxx Syrupi tolutani 3 vi Aquse q. s. ad § ij Misce. Sig. : Teaspoonful every three hours for cough. Hemorrhage is best treated by recumbent posture of the patient, with head propped up, and positive assurance of the physician that all will be right. Place an ice bag over the pericardium to quiet the heart and give hypodermic of morphin gr. ^-gr. Yz. Nitroglycerin to lower blood pressure is recom- mended by some. 210 DISEASES OF THE LUNGS AND PLEURA. Calcium lactate in half-dram doses three times a day for two days may stop repeated small hemor- rhages. Adrenalin hypodermatically and salt solution should be used when large hemorrhage endangers life. Mercurial Treatment of Tuberculosis. Excellent results are reported from the new Fort Lyon Naval Hospital by hypodermatic use of mer- cury succinimide. Two strengths are used — gr. M.o and gr. % to the tablet. One injection of gr. K is given every other day until thirty injections have been given; then one week's rest, when injections are resumed, using gr. % and gr. %o alternately, and later gr. %o was used. A later method has been advised of administering the drug in gradually in- creasing doses until the therapeutic limit is reached. When the maximum dose for the patient is estab- lished, it is divided by two and the injections con- tinued on this basis. The open air and food treat- ment is also carried out in conjunction with the mercury treatment. At present it is better not to attempt the use of tuberculin as a curative measure. As to the advisability of sending tubercular pa- tients away from home, we are strongly opposed. Nothing can be worse than to be seriously sick in a strange land among strangers. There is nothing to be gained away from home that can not be had at PULMONARY TUBERCULOSIS ACUTE PLEURISY. 211 home. There are many devices to apply to a win- dow and to the patient's bed in such a manner that the head and shoulders are in the open air, while the body is protected. Finally, let us urge a careful supervision by the attending physician of the patient's sputum. Let the short, concise statement ring in our ears, "No sputum, no tuberculosis." A piece of paper, rectan- gular in shape, rolled cornerwise so as to form a funnel, and the pointed end doubled back, makes an excellent spit cup, that should be used and thrown into the fire. Acute Pleurisy. Remember that in children or the aged the only symptoms that may be present are dyspnea on exer- tion and increasing pallor. Remember that chill, fever, and pain, or "stitch in the side, ' ' usually announce the onset of pleurisy. Remember that the pain is sharp and lancinating, and the cough makes it worse. Remember that on auscultation a dry, friction rub is heard prior to the exudate, and this friction sound is pathognomonic. Remember that fever does not rise so rapidly nor ' so high as in pneumonia. Remember that the pain may be felt in the abdo- men or low down in the back. " Don't mistake the dry, crepitant rales for the friction sound. The friction sound is not continu- 212 DISEASES OF THE LUNGS AND PLEUE^. ous, and not restricted to inspiration as are crepitant rales, but is divided between inspiration and expira- tion, and is distinguished as being very superficial, or close to the ear. Coughing up the secretions has no effect upon the pleuritic sound. Remember that effusion into the pleural sac causes marked changes. The friction rub heard on auscul- tation, and so characteristic of pleurisy in the early stage, disappears. Remember that bulging of the intercostal spaces signifies effusion. Remember that the patient changes posture, and now lies on the affected side to give more freedom in breathing. Remember that on auscultation the breath sounds are distant and tubular, and vocal resonance on pal- pation is diminished or absent. Remember that the dullness on percussion over an effusion is flat, and there is a sense of resistance to the fingers. Remember Grocco's triangle of dullness in effu- sion. It is found along the spine on the side oppo- site the effusion, and from one-quarter to one inch wide, with apex upward. It is due to the displace- ment of the mediastinum by the fluid. The patient should be in the sitting posture. Remember that Skoda 's resonance is found just above the line of effusion, posteriorly as well as in the subclavicular space. It is a tympanitic note, due to the compression of the lung. ACUTE PLEURISY. 213 Remember that the insertion of the hypodermic needle under aseptic precautions and the withdrawal of fluid determines two points — viz., an effusion and whether serous or purulent. Remember that liquid in pleural sac will cause displacement of organs, and the cardiac displace- ment is the one most easily determined. Remember that in a tumor of the mediastinum the dullness usually extends from below upward, is irregular in outline, and not restricted to one side. Remember that as the tumor grows there will be compression of nerves, vessels, and esophagus. Remember the following points in differentiating pleurisy and pneumonia: 1. Dullness of pleurisy is absolute (woody), offer- ing great resistance on percussion. 2. Pectoral fremitus absent or diminished over an effusion. 3. Crepitant rale is absent in pleurisy. 4. Displacement of organs is marked in effusion. 5. Sputum of pneumonia always present and rusty-colored. 6. Fever of pneumonia is high. Treatment. Patient should be put to bed. Pain in the early stages is the most urgent symp- tom for treatment. A hypodermic of morphin is the best way to re- lieve it. 214 DISEASES OF THE LUNGS AND PLEUE^. The ice bag to the affected side, leeches, hot fomentations, or mustard plaster will give relief where pain is not severe. Immobilizing the side gives prompt relief. Ad- hesive strips are nsed. They are cut long — ^long enough to extend about two inches beyond the me- dian line posteriorly and anteriorly. The three-inch is best, and the strips should overlap one-third. They should be applied with the lungs as near col- lapsed as possible — at complete expiration — begin- ning at the lower margin and strapping upward until the axilla is reached. Calomel, followed by saline, should be given. Diet should be light. When effusion occurs, it should be dry. No liquids be given. 'Concentrated saline purges should be given in the morning before breakfast. Salt should be withheld. Effusion is best relieved by aspiration. An ordi- nary trocar may be used or Potain's aspirating set may be obtained. The site depends upon the loca- tion of the liquid — usually in the midaxillary line, in the seventh intercostal space. The skin is thor- oughly cleansed. The patient places the hand of the affected side on the shoulder of the opposite side, thus widening the intercostal spaces. The needle is thrust in close to the upper margin of the rib, so as to avoid wounding the artery. The amount of fluid to be drawn off depends upon the reaction of the patient. All of a large exudate should not be withdrawn at one time, as a severe paroxysm of ACUTE PLEURISY. 215 coughing is caused by sudden relief of the pressure upon the lung. In early stage, when fever and circulatory excite- ment exist before effusion occurs, the following may be administered: IJ Tincturse aconiti TTI, x Spiritus aetheris nitrosi 3 j Syrupi pruni virginianse 3 iv Liquoris potassii citratis . . q. s. ad § iij Misce. Sig. : Tablespoonful hourly until pulse becomes soft, then every two hours. Or: J^ Potassii citratis 3 v Antipyrini 3 j Liquoris ammonii acetatis § iij Syrupi limonis 5 i j Aquae q. s. ad § viij Misce. Sig.: Tablespoonful hourly for four doses, then every two or three hours. lodid of potash and sodium salicylate are of little benefit, although frequently used. They are very liable to upset the stomach. CHAPTEE XI. INFECTIOUS DISEASES. Typhoid (Enteric Fever). Remember that, while the disease is more common in early adults, the disease is often seen in children. Remember that in children there is frequently ab- sent some of the usually constant symptoms. Remember that the onset in children may be so sudden and the diarrhea so severe that acute en- teritis is diagnosed. Remember that, as a rule, the onset is gradual, and that for ten days or two weeks there are lassi- tude and inaptitude for work. Remember that nose bleed is an early and fairly constant sign in typhoid, especially when the pa- tient is not subject to epistaxis in health. Remember that headache is an early and fairly constant symptom, and occasionally it may be very severe, accompanied by photophobia, retraction of the head, and muscular twitching, suggesting menin- gitis. Remember that severe facial neuralgia may mark the onset of typhoid. Remember that the first intimation may be acute mania, pronounced delirium, or drowsiness and stupor, simulating basilar meningitis. Remember that an initial bronchitis is very com- 216 TYPHOID. 217 mon in typhoid, but occasionally it is of so great a severity as to obscure other features of the disease. Remember that the onset may be by a chill, pain in the side, hurried breathing, and pleurisy, or pneu- monia may be suspected. Remember that severe abdominal pain and tender- ness in the appendiceal region has led to a diag- nosis of appendicitis. Remember that at the beginning of typhoid the cheeks are flushed and the eyes are bright, but at the close of the first week we find the dull, heavy look so familiar. Remember that the fever may not be of the ordi- nary type. There may be a rapid rise to 103° or 104° F. following a chill or convulsion. Usually the "step-ladder" rise of the temperature from day to day during the first week is observed. Remember that after the fastigium is reached the fever continues with but slight daily remissions. As a rule, the fever terminates by lysis, but it may dis- appear rapidly and in twenty-four hours the tem- perature be normal. This may be associated with severe sweating. Remember that a sudden drop in the temperature strongly indicates intestinal hemorrhage. Remember that "rose spots" are not present in all cases of typhoid, but that when present they are pathognomonic of the infection. They are small red spots found on the abdomen, that disappear on pres- sure and come in crops. They make their appear- 218 IKFECTIOUS DISEASES. ance from the seventh to the tenth day. There may be few on the abdomen and the eruption may be general. Remember that while a dry, hot skin is usually found at the height of the fever, there are cases where sweating is characteristic; usually associated with chilly sensations. Remember that paroxysms of chills, fever, and sweats may occur, and thus simulate malaria, but they are lacking in periodicity and may occur sev- eral times in the twenty-four hours. Remember that the dicrotic pulse is more often found in typhoid than in any other condition, and that the increase of the pulse rate is not propor- tionate to the increased temperature. Remember that an enlarged, soft spleen is an al- most constant clinical symptom of typhoid. If the vertical dullness over the splenic area exceeds the depth of two ribs and an interspace, enlargement is present. The best way to determine enlargement is by palpation. Remember that the "pea-soup" stools occur in the second week, as does also status typhosus — stupor, somnolence, difficulty of hearing, indistinct- ness of speech, muttering delirium, and picking at the bed clothes. Remember that the agglutination test of Widal is the most conclusive sign we have of typhoid infec- tion. Remember that the results of the test are just as TYPHOID. 219 good if you use cultures of dead bacilli, and the microscope is not needed to determine a positive or negative reaction. Remember that many tests should be made in case the first proves negative, because the formation of antibodies is often delayed and the reaction not obtained until late in the disease. Remember that a sudden drop in the temperature, feeble and rapid pulse, and pallor are unequivocal signs of hemorrhage, even though it has not yet appeared in the stools. This accident most often occurs in the second or third week of the course of the disease. Remember that the signs of perforation are never the same as those of peritonitis, and it is reprehen- sible for a physician to await the onset of the latter, as the few hours intervening between the occurrence of the one and the onset of the other are the life- saving hours. Remember that the signs of perforation are: 1. A sharp, severe pain, often paroxysmal in character, in the hypogastric region and to the right of the median line. 2. Tenderness on pressure, most marked in the hypogastrium. 3. Muscular rigidity on light palpation. 4. Drop in the temperature, sweating, and increase rate of pulse and respiration. Remember that at this period the patient becomes an urgent case for the surgeon and ceases to be a proper case for the internist. 220 INFECTIOUS DISEASES. Remember that after four to six hours peritonitis follows perforation; the temperature rises; balloon- ing of abdomen; disappearance of liver dullness; muscular rigidity; rapid, feeble pulse; cold sweat — death. Treatment. Diet. There are two views relative to the diet. On the one hand, we have those who restrict the diet to liquid. A representative of this type is the one used by Osier and McCrea, consisting of 4 to