CHAPTER X. DISEASES OF THE LUNGS AND PLEURA. (Part 5)

6 ounces of milk, diluted with 2 ounces of lime water, every four hours, and 4 ounces of albumen water, made from the white of one or two eggs, every four hours. They claim that even that amount is probably too much. On the other hand, a number of excellent physicians are using a more liberal diet — treating the patient rather than the disease. Dr. F. C. Shattuck's menu may be quoted as representing this view: 1. Milk — hot, cold, diluted with lime water, soda water; peptonized milk; cream and water; milk with white of egg; buttermilk; matzoon; milk whey; milk with tea, coffee, or cocoa. 2. Soups — beef, veal, chicken, tomato, potato, oys- ter, mutton, pea, bean, squash; carefully strained and thickened with arrow-root, flour, milk or cream, egg, barley. 3. Malted milk— Horlick 's, Mellin's. 4. Beef juice. TYPHOID. 221 5. Gruels — strained cornmeal, crackers, flour, bar- ley water, toast water, albumen water with lemon juice. 6. Ice cream. 7. Egg — soft boiled or raw; egg-nog. 8. Finally, minced lean meat, scraped beef, the soft part of raw oysters, soft toast, jelly, apple sauce, and macaroni. It is probably true that we have been feeding too little and the patient enters upon his period of con- valescence handicapped. Liquids. Typhoid patients must be given water freely, unless contraindicated by extreme arterio- sclerosis, myocarditis, or serious valvular lesion. In addition to the liquid in the food, they should be given from a half to two quarts daily. The severer the toxemia, the more water should be given. Lemonade is excellent, because it excites the flow of saliva and prevents the mouth becoming dry. Alcohol should be given in cases of profound toxemia and the heart feeble; 8 to 12 ounces of whisky may be given in the twenty-four hours. One strong indorsement for a liberal diet is the fact that the patient seldom needs whisky. Where the tub bath is used and the patient re- quires whisky, it should be given just before or after the bath, depending upon his reaction to the bath. Hydrotherapy. This is next in importance to the diet. The bath, cold packs, or sponging may be used. Of the various methods of applying water, the bath is best when not contraindicated. 222 INFECTIOUS DISEASES. Baths. Are not only given to reduce the tempera- ture, but they mitigate the nervous symptoms, and thus lessen the delirium, stimulate the kidneys, and thus increase the excretions of toxins, and cleanse the skin — in short, affect favorably the whole course of the disease. It is best to begin with water at 80° or 85° F., and gradually reduce the temperature after placing the patient in the tub. Always apply cold to the head. Gently, but briskly, rub the pa- tient while in the bath. The bath should last from ten to fifteen minutes, and the patient is placed be- tween sheets and covered with a blanket after removal and drying. The temperature should be taken immediately after the bath and again in an hour. These baths may be repeated as often as the temperature reaches 103° F. A cup of hot milk may be given and hot-water bottle placed to the feet. Cold Packs. A sheet is wrung out of cold water and the patient wrapped in it. The head and feet are left free. Cold water may be sprinkled over him occasionally, or he may be rubbed with a piece of ice, especially along the vertebrae. The pack is removed in from twenty to thirty minutes, the body dried and covered with sheet and blanket. This may be repeated as often as the temperature indicates it. Cool sponging may be resorted to in mild cases. Alcohol or vinegar should be added to the water. The skin should be only partially dried, so that by evaporation of the moisture on the skin a continuation of the antipyretic effect may be ob- tained. TYPHOID. 223 Contraindications for cold baths or packs are in- testinal hemorrhage, perforation, the old and very young; patients suffering -with acute or serious chronic cardiac or cardiovascular changes, phlebitis, nephritis, pneumonia, pregnancy; very obese, ane- mic, and alcoholics. Medicinal Antipyretics. These should not be given unless baths can not be used, either because of contraindications or prejudices of the family. There are a number of drugs that are antip^Tetic — quinin, phenacetin, antipyrin, pyramidon. Quinin should not be given to typhoid patients in doses large enough to reduce temperature. From recent laboratory reports quinin in 2-gTain doses every three hours vrill stimulate phagocytosis, and perhaps will thus assist the body in fighting the invaders, but the dose is too small to affect the fever; and the laboratory has also shown that quinin in large doses destroys the ameboid movement of leucocytes, and thus interferes with the resisting forces. Antipyrin and phenacetin are better not used in typhoid, because of the cardiac depressing effect. Pyramidon is given gr. iij-gr. iv every two or three hours, and it is claimed by good observers to have no ill effect, except that in some patients it produces excessive diaphoresis. As a precaution, it may be combined with 3 to 4 grains of sodium ben- zoate of caffein. Calomel should be given at the onset, and repeated 224 IKFECTIOUS DISEASES. throughout the disease when tympany indicates ex- tensive gas formation in the bowel. Gr. v-gr. x may be given in one dose, or it may be administered in broken doses. Nobody claims it cuts short the course of typhoid, but the experience of clinicians is favorable to its use because of its combined powers as an antiseptic, glandular stimulant, and eliminant both through the bowels and kidneys. Intestinal antiseptics are indicated, but not, as some think, to cut short the disease nor to abort it. They reduce the bacterial activity in the intestines and thus favorably influence the disease. Turpen- tine in emulsion is best and the sulphocarbolates follow. The following are excellent combinations: IJ Naphtolis 3 j Salolis gr. xxx Pulveris aromatieee gr. xx Misee et fiant pulveres No. XII. Sig. : Powder every four hours. Or: IJ Bismuthi salicylatis 3 iij Iclithalbini 3 iij Sacchari lactis 3 j Misce et fiant pulveres No. XXIV. Sig.: Powder every four hours. Or: 3 Sodii sulphocarbolatis 3 iij Resorcinolis (Merck) gr. xxx Syrupi simplicis § ij Aquae menthse piperitse ^iv Misce. Sig.: Tablespoonful every fovir hours. TYPHOID. 225 Or: IJ. Zinci sulphocarbolatis gr. ss Calcii sulphocarbolatis gr. j Sodii sulphocarbolatis gr. iiiss Bismuthi salicylatis gr. % Mentholis gr. j Misce et fiat pulvere Xo. I. Sig. : Powder every three to six hours, according to odor of stools. This combination is put up in tablet form by Abbott, and is very convenient and effective. Or : IJ Olei terebinthinse 3 iss Olei caryophylli gtt. vj Glycerini, Mucilaginis acaciae aa § ss Aquae destillatse q. s. ad g iij Misce et fiat mistura^. Sig.: Dessertspoonful every two hours during the day. Thymol is preferred by some, because it possesses antiseptic power four times as great as carbolic acid and is innoxious; it is also insoluble, so that it reaches the intestines. It is given in gr. ij-gr. iij every three hours, made into a pill, and should al- ways be given with food. Mouth, teeth, and tongue should be thoroughly cleansed after each feeding. The mouth and teeth should be washed with weak alkaline solution. Bak- ing soda in warm water is excellent, and, if the pa- tient is able, he should rinse the mouth with some mild antiseptic solution. Bed sores are rare where bathing is used in the treatment. It is well to rub the skin over the but- tocks, thighs, and lower back with a weak bichlorid 226 INFECTIOUS DISEASES. solution, followed with alcohol; rub dry and dust with some simple powder or talcum. Diarrhea demands treatment when the daily evacuations exceed six. Silver nitrate gr. %-gr. ^/4 is called a specific by some. Bismuth subnitrate or salicylate gr. v-gr. x, with paregoric 3 ss, every two or three hours, is useful, or the following: R. Pulveris opii gr. % Pulveris camphorse gr. j Plumbi acetatis gr. iij Bismuthi subnitratis gr. xxx Misce et fiat pulvere No. I. Dentur tales pulveres No. XII. Sig. : Powder every four hours. Or: IJ Bismuthi subnitratis 3 i j Tannalbini 3 iij Dionini gr. ij Misce et fiant pulveres No. XII. Sig.: Powder every three hours. Meteorism. First insert a large rubber catheter. Turpentine stupe to the abdomen. A careful re- vision of the diet — as the omission of gruels and peptonizing of the milk. Eserin gr. %o may be given. Hemorrhage. Apply cold to abdomen — as light ice bag. Stop everything by mouth, except cold albu- men water. If patient is restless, give morphin hy- podermatically. Administer calcium salts in large doses. In large hemorrhage, manifested by weak, rapid pulse and signs of collapse, give saline solu- tion into the subcutaneous tissues or into the vein, according to the urgency of the case. It is best to TYPHOID BACILLARY DYSENTERY. 227 omit the morphin if possible, and in no case should the sensorium be completely obtunded, because per- foration may occur and pain is our principal guide. IJ Stypticini gr. xi j Ergotini gr. xxx Elixiris simplicis § iij Misce. Sig. : Tablespoonful every two to three hours. Perforation requires an immediate operation, un- der general anesthesia if possible or under cocain. There can be no delay, as peritonitis will inevitably follow in five or six hours. Urotropin gr. v-gr. x should be administered three times daily for its antiseptic powers in the bile, urine, and cerebrospinal fluid. Many cases of gall- stones will thus be prevented and the urine will not become a distributor of the germs. This drug should be administered during the period of convalescence as well. Tonics, and good food and fresh air in abundance should be given the convalescent. Children should not be returned to school before six months following typhoid. Bacillary Dysentery. Remember that this affection often appears in epidemics, in which children are attacked as well as adults. Remember that hot weather and improper feed- ing of children is a very frequent cause. Remember that the onset is usually sudden, and 228 INFECTIOUS DISEASES. is characterized by slight fever, pain in the ab- domen, and frequent stools. Remember that the stools at first contain a large amount of mucus, but in twenty-four hours blood is passed with it. Remember that frequently pure blood is passed; hence ''bloody flux." Remember that there is a constant desire to go to stool. The motion of the bowels affords no relief. Remember that straining and tenesmus while at stool is very characteristic. Remember that the temperature gradually rises, and the pulse becomes rapid and small. Remember that the frequent stools cause great thirst and rapid emaciation. Remember that the blood of the patient in dilu- tion will agglutinate the Flexner-Harris or Shiga bacilli, depending upon the bacilli causing the in- fection. Remember that the bacilli dysenterise should be sought for with the microscope in the shreds of mucus found in the stools. Remember that liver abscess is not a complication of bacillary dysentery. Remember that severe and painful joint symp- toms may be associated and lead to an erroneous idea of acute rheumatism. Remember that paralysis frequently follows bacil- lary dysentery. It is usually in the form of para- plegia. bacillary dysentery. 229 Treatment. The patient should be confined to bed, as absolute rest is necessary in acute stage. When the pain is severe, a hypodermic of morphin should be given. Diet must be restricted to milk, whey, and broths. During an acute attack neither ice nor cold liquids should be swallowed, although the mouth may be rinsed with cold water to relieve thirst. In the severe cases peptonized milk should be given. Dur- ing convalescence great care must be exercised in the diet. Nutritious and easily digested food should be selected, and solid food should be with- held until all signs of enteritis have disappeared and the stools are normal. Medicinal. When seen early, a dram of mag- nesium or sodium sulphate every two hours until the stools are watery. The continuous administra- tion of the salines is the best form of treatment. The following give excellent satisfaction: R Solutionis magnesii sulphatis satu- rationis § j Tincturse opii, Acidi sulphuric! aromatici aa 3 iv Essentise pepsini ( Fairchild ) q. s. ad S iij Misce. Sig. : Teaspoonful every three hours. Or: IJ Cupri sulphatis gr. ss Magnesii sulphatis 5 j Acidi sulphurici diluti 3 j Aquae menthse piperitse . . . . q. s. ad 5 iv Misce. Sig. : Teaspoonful every four hours. 230 INFECTIOUS DISEASES. Or: IJ Cupri arsenitis gr. % Tincturae opii camphorse 3 iv Essentiae pepsini (Fairchild) q. s. ad 5 iij Misce. Sig. : Teaspoonf ul every three hours. Bichlorid of mercury in gr. %oo-gr. Vso every two hours often gives excellent results. Bismuth is given frequently, but it is more effica- cious in the chronic form. When used, it should be given in massive doses, 3 ss-o j, best given alone mixed with water. Ipecac in large doses is used extensively. No food is given for three hours, then 15 or 20 drops of the tincture of opium is given, and in half an hour 5 ss-5 j of ipecac is given and the patient kept quiet on his back. Should it be vomited, it is repeated in one or two hours. After the acute symptoms sub- side, rectal irrigation should be begun. There are a number of astringents — such as alum, acetate of lead, sulphate of copper and zinc, and silver nitrate. Silver nitrate is best, and large quantities of the solution should be used, so that all parts of the colon will be thoroughly irrigated; 20 to 30 grains to the pint and 5 to 6 pints should be used at a time. The more chronic the condition, the better will be the result. Local Applications. Hot turpentine stupe or poultice will relieve pain and reduce the number of stools. Serum therapy is not at all satisfactory, and we must await further developments along this line. AMEBIC DYSENTEKY. 231 Amebic Dysentery. Remember that there are two forms — the acute and chronic — both caused by the ameba dysenterise. Remember that the acute form is characterized by a sudden onset, with pain, tenesmus, and diar- rhea, the stools containing blood and mucus. Remember that, though the fever is not intense, there is rapid emaciation, and the patient may die in a week. Remember that hemorrhage of the bowel or per- foration, with peritonitis, may occur. Remember that leucocytosis occurs, and the count varies between 10,000 and 16,000. Remember that in the chronic form the onset is more insidious. Remember that in the chronic cases periods of attacks of pain, tenesmus, diarrhea, with mucus and blood in the stools and with slight fever, alternate with periods of constipation and apparent good health. Remember that these patients suffer from indi- gestion, and errors in diet cause a dysenteric attack. Remember that fatigue or sudden chilling of the body from exposure frequently produces an attack. Remember that the ameba coli is present in the stools, and should be sought for in suspected cases. Remember that it is in amebic dysentery that liver abscess is exceedingly common and should be watched for. Always outline the upper border of the liver daily. 232 INFECTIOUS DISEASES. as the abscess is usually located near the upper sur- face and causes an irregular upward curve of hepatic dullness. Remember that other symptoms of liver abscess are fever, sweat, local pain, and edema. Remember these abscesses may rupture and drain through the lung. When this occurs, the sputum is dark and contains the ameba. Treatment. Rest in bed is very important in both forms of the disease, as it hastens recovery. Diet should be governed by the severity of the intestinal trouble. In the acute form it should be liquid, such as milk, whey, and broth. Intestinal antiseptics are used on the theory that ameba require the presence of other bacteria. Acetozone given by mouth and also in enema has accomplished some good. Bismuth in any form should not be given in amebic dysentery. h That local treatment is best can not be disputed. Of all drugs used locally, quinin is best. The solu- tion of quinin should be 1:5000 at first, then in- creased to 1:2500, and later further increased in strength of 1:1000. If the following method of injection be followed, better results will be obtained: The patient should lie on his back, with the hips elevated, so that gravity will assist. From 1 to 2 AMEBIC DYSENTERY ^MEASLES. 233 quarts of the solution should be used. The injec- tion should be given slowly, and the patient should turn from side to side during the injection, so that all parts of the colon will be bathed by the solution. The enema should be retained for fifteen or twenty minutes if iDossible. When the enema causes much pain, it may be preceded by in- jection of laudanum and starch water. Two injec- tions daily should be given. For the severe pain and tenesmus a hypodermic of morphin should be given. Large doses of ipecac are recommended by many, as are also saline injections and injections of ice water. Patients should not be allowed cold drinks during acute attacks, and hot applications to the abdomen often give great relief. Measles. Remember that the period of incubation varies between seven and fourteen days. Remember that the onset is usually with a coryza. The eyes are red and watery, and there is photo- phobia. Remember that the troublesome croupy cough be- gins early and continues throughout the course. Remember that there is fever on the first day, and that the peculiarity of the fever is its remission on the third.