Principles of Medical Treatment: Sixth Edition, Revised and Enlarged [6th ed., rev. a. enl. Reprint 2014] 9780674433472, 9780674431584

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P R I N C I P L E S OF MEDICAL T R E A T M E N T

LONDON : HUMPHREY MILFORD OXFORD UNIVERSITY PRESS

PRINCIPLES OF MEDICAL TREATMENT BY

G E O R G E

C H E E V E R

S H A T T U C K ,

M.D.,

A . M .

Assistant Professor of Tropical Medicine, Harvard Medical School Junior ViHling Physician, Boston City Hospital, in Charge of the Service for Tropical Diseases Formerly Assistanl Visiting Physician, Massachusetts General Hospital, and Assistant in Clinical Medicine, Harvard Medical School

SIXTH REVISED WITH

EDITION

AND

ENLARGED

CONTRIBUTIONS BY THE FOLLOWING

AUTHORS

JOSEPH C . A U B , M . D .

GEORGE R . MINOT,

GERALD BLAKE, M . D .

EDWIN H . PLACE,

M.D. M.D.

JOHN B . H A W E S , 2D, M . D .

FRANCIS M . RACKEMANN,

CHARLES H . LAWRENCE, M . D .

BENJAMN H . RAGLE,

C . M O R T O N SMITH,

M.D.

C A M B R I D G E H A R V A R D

U N I V E R S I T Y

1926

P R E S S

M.D.

M.D.

COPYRIGHT, 1 9 2 6 ВУ T H E P R E S I D E N T A N D F E L L O W S O F HARVARD COLLEGE

PRINTED AT THE HARVARD UNIVERSITY PRESS CAMBRIDGE, MASS., U. 3. A.

то FREDERICK CHEEVER SHATTUCK

PREFACE book represents an attempt to set forth clearly and concisely sound principles of medical practice based, so far as possible, upon scientific medical knowledge. Special effort has been made to emphasize principles and to describe separately the methods recommended for putting them into practice. As an aid in correlating principles of treatment with knowledge of the mode of action of disease, salient facts have been outlined in most of the chapters as a prelude to treatment. Material which appeared in previous editions has been completely rewritten, expanded or thoroughly revised. The chapters on Asthma, Syphilis, Lead Poisoning, Anemia, Endocrine Disorders, Preoperative and Postoperative Medical Treatment, and Vaccine Therapy are entirely new. As editor of the chapters from other pens it is a pleasure to express my deep appreciation to the contributors whose special qualifications to write authoritatively upon their subjects are well known. Special acknowledgment is due to Miss Alice B. Newell for the most painstaking care with the proof and for seeing the book through the press. THIS

G. C. S.

CONTENTS I. II.

DISORDERS OF THE CIRCULATORY SYSTEM . . . .

3

NEPHRITIS

27

III.

A C U T E INFECTIOUS D I S E A S E S

37

IV.

A C U T E INFECTIONS MOST COMMON IN CHILDHOOD

49

V.

A C U T E INFECTIONS OF THE RESPIRATORY T R A C T

75

PULMONARY TUBERCULOSIS

89

VI. VII.

ASTHMA

107

GASTRO-INTESTINAL DISORDERS

113

SYPHILIS

127

L E A D POISONING

141

ANEMIA

I4S

DIABETES MELLITUS

ISS

XIII.

ENDOCRINE DISORDERS

167

XIV.

PREOPERATIVE AND POSTOPERATIVE

VIII. IX. X. XI. XII.

TREATMENT XV. XVI.

MEDICAL 181

VACCINE THERAPY

199

MEDICATION

205

INDEX

253

P R I N C I P L E S OF MEDICAL T R E A T M E N T

CHAPTER I DISORDERS OF THE CIRCULATORY SYSTEM BY GEORGE CHEEVER SHATTUCK, M.D.

PATHOLOGY AND

DIAGNOSIS

IN acute attacks of cardiac insufficiency the treatment must generally be directed toward the relief of urgent symptoms; but thereafter it is important to ascertain the underlying pathology as a basis for further treatment and for prognosis. Diagnosis may be analyzed as follows: 1. 2. 3. 4.

Etiology. Location and degree of damage. Degree of functional impairment at the time. Capacity for improvement.

It is often impossible to obtain all the important facts when decompensation is severe. Functional impairment is believed to depend more on associated myocardial damage than on the extent of valvular lesions. Hypertrophy generally indicates more or less myocardial damage. Dilatation practically always means myocardial damage. Dilatation may precede hypertrophy in acute cases or supervene in chronic cases. When there is hypertrophy with good compensation, dilatation is relatively slight; but when compensation fails, dilatation increases. I. T Y P E S OF C A R D I A C

DISEASE

Any of the lesions enumerated below may be compensated when first seen; but in types i to 4 inclusive, cardiac insufficiency generally develops in time. The chief determining factor is the severity of associated myocardial damage. 1. Congenital: most commonly discovered in early childhood. 2. Infectious: most commonly discovered in youth.

4

PRINCIPLES OF MEDICAI. T R E A T M E N T 3. Syphilitic: most commonly discovered in middle life. 4. Degenerative: most commonly discovered in old age. 5. Myocardial weakness in infectious diseases and sepsis. 1.

CONGENITAL

LESIONS

Pulmonic stenosis is the most common of these. It is seldom mistaken for other types of valve lesion, but may easily be confused with anomalies of structure which have similar signs and which are often combined with it. Hypertrophy is prominent. 2.

INPECTIOUS LESIONS

(a) A cute Stage. Inflammation of valves due to presence of bacteria on the valve. The heart muscle is weakened and there may be dilatation. Lesions are found commonly at the mitral valve or at the aortic and mitral valves, seldom at the aortic valve alone. Occasionally the mitral, aortic, and tricuspid valves are all diseased. Stenosis develops frequently. Stenosis at the aortic and mitral valves suggests tricuspid stenosis as well. Evidence of recent preëxisting rheumatic fever, chorea, or tonsillitis strengthens a diagnosis of active endocarditis. The infection may be acute or subacute. The symptoms are those of general infection with or without failure of compensation. The chief dangers are from toxemia, exhaustion, cardiac dilatation, or embolism. (b) Obsolete Stage. Valves are deformed and scarred as a result of inflammation. There is more or less degeneration of the heart muscle, which may be well or partly compensated for by hypertrophy. Dilatation may be slight or marked. Obsolete lesions, when well compensated, may give no symptoms. They first attract attention by diminished cardiac efficiency or by failure of compensation. (c) Recurrent Stage. Reinfection with inflammation at site of old lesion. Myocardial degeneration and marked

DISORDERS OF CIRCULATORY SYSTEM

5

hypertrophy are common. More or less dilatation is generally present. 3.

SvpmLiTic LESIONS

The first symptoms may be those of cardiac insufficiency or of angina pectoris. The lesion generally begins in the ascending aorta, extends later to the aortic valve, and may involve a coronary artery. It may lead to extensive myocardial damage with fibrosis, aneurism, or rupture of the heart, or more frequently to aortic aneurism. The first demonstrable signs, as a rule, are dilatation of the ascending aorta, and a systolic murmur in the aortic area. The diastolic murmur of aortic regurgitation develops later. 4.

D E G E N E R A T I V E LESIONS

The background is one of senility and general arteriosclerosis, to which sclerosis of the aorta with fusiform dilatation and sclerosis of the aortic valve is incidental. There is generally evidence of myocardial weakness, and angina pectoris may be a feature. 5. MYOCARDIAL W E A K N E S S IN INFECTIOUS AND SEPSIS

DISEASES

This subject will be dealt with under the head of Circulatory Disorders of the Infectious Diseases and Sepsis. II. GENERAL PRINCIPLES OF T R E A T M E N T FOR CARDIAC INSUFFICIENCY 1. 2. 3. 4. 5.

Rest. Depletion. Medication. Suitable Diet. Regulation of Mode of Life.

Principles of treatment are the same for all types and degrees of insufficiency, but methods must be adapted to the individual case, with due regard for the degree of severity of the symptoms, the probable etiology, and other circumstances of the case.

6

PRINCIPLES OF M E D I C A L

TREATMENT

METHODS OF APPLYING PRINCIPLES

I. Rest (a) (δ) (c) much in the

Semirecumbent position in bed or chair. Minimum exertion: good nursing care. Relieve discomfort and secure sleep. When there is discomfort, morphine subcutaneously is indicated early stages of decompensation. 2. Depletion

Purgation. Obtain watery catharsis more or less profuse according to amount of edema. When edema is absent or slight, avoid excessive purgation lest exhaustion result. Plethoric or fat individuals generally benefit from purgation, but it may injure those who are emaciated. Magnesium sulphate is useful as a purgative. Limitation of Liquids. Total liquids, including liquid foods, should not exceed three pints in twenty-four hours. One pint in twenty-four hours is near the minimum. The patient should not be allowed to suffer from thirst. Sucking cracked ice, gargling, or the use of chewing gum, unless dyspnea prevents, may relieve thirst. Diuresis may be expected to follow the use of digitalis when there is cardiac edema. In mild cases of insufficiency, rest, purgation, and limitation of liquids without digitalis may sxiffice. When edema is persistent or extreme, diuretics should be prescribed. Theobromine or its substitutes may be expected to act well, provided the kidneys are not severely damaged. Calomel should not be used as a diuretic if the patient has nephritis, because salivation may result. Theophylline may act better than theobromine in some cases. Venesection is indicated occasionally when there is engorgement of the right ventricle with marked evidence of venous stasis; e.g., dyspnea, cyanosis, pulmonary edema, and engorgement of neck-veins and liver. A pint of blood or even more may be withdrawn. Venesection is contraindicated by emaciation, by marked weakness or by anemia. Blood is generally withdrawn by incis-

DISORDERS OF CIRCULATORY SYSTEM

7

ing a vein on the inner side of the elbow. A tourniquet may be put around the arm to render the veins prominent. The incision should be made in the long axis of the vein with the point of a sharp knife. The bleeding can be stopped with a pad and bandage. Suturing the vein is unnecessary. The blood can be withdrawn from the vein by aspiration if a suitable apparatus is at hand. Leeching is useful as a substitute for venesection when the latter would be undesirable or when symptoms are less severe. Leeching wiU generally relieve pain associated with engorgement of the liver. Apply a dozen leeches over the right hypochondrium and allow them to remain until they drop off. The abdomen should then be covered with a large, moist absorbent dressing to favor oozing from the bites. A drop of milk placed on the skin encourages the leech to bite. Salt causes him to let go. Tapping is necessary when fluid in the chest, pericardial sac, or abdominal cavity seriously embarrasses the heart or respiration. 3. Medication Digitalis is the cardiac "stimulant"/»ar excellence, h\it it may be more accurately spoken of as a heart tonic. An active preparation in sufficient dosage does good in almost any variety of cardiac insufficiency. The most marked benefit is to be expected in severe cases of auricular fibrillation or flutter. Circulatory disturbances in the acute infectious diseases are comparatively little influenced by digitalis. Rarely, failure to get improvement from digitaUs is due to chronic lesions of the myocardium so extensive that the heart is incapable of further response. W i e n , after pushing digitalis in a suitable case, neither benefit nor evidence of excessive effect follows within a few days, the preparation is probably inactive. For fiu-ther information about the dosage and use of preparations of the digitalis group and about their use in emergencies, see Digitalis. Quinidine sulphate has proved of great value in carefully selected cases to restore normal rhythm in auricular flutter

8

PRINCIPLES OF MEDICAL TREATMENT

or auricular fibrillation, and to prevent the occurrence of these abnormal rhythms. When administered in unsuitable cases or by improper methods, the drug may do harm or may even cause death. Those inexperienced in the use of quinidine sulphate are advised to study the subject carefully .before prescribing this drug. Its use has been well described by Dr. Paul D. White,' and by Drs. White and Sprague.'' Recurring exacerbations of dyspnea can often be relieved promptly by the use of the following: aromatic spirits of ammonia, i drach. (4 cc.), in half a glass of water by mouth; whisky or brandy, | to i oz. (15-30 cc.), plain or with a little water by mouth; camphor in oil,® 3 grs. (0.2 Gm.), injected intramuscularly; or cocaine hydrochloride, i to Î gr. (0.008-0.016 Gm.), injected subcutaneously. The latter is said to be dangerous, but may act very well. Insufficiency with much pain requires morphine. This drug seems to act under these circumstances as an efficient cardiac stimulant. It brings also physical comfort and psychic relief which favor recuperation. To insure prompt effect under these circumstances the morphine should be used subcutaneously. 4.

Diet

Spare the patient unnecessary effort, particularly if there is much dyspnea, by ordering food which is easy to swallow and which requires no chewing. Seek to prevent cardiac embarrassment from gastric distention by prescribing frequent small feedings and by avoiding gas-producing foods. Emaciated patients should take as much concentrated nourishment as they can digest, in order to strengthen the heart-muscle by improved nutrition. Fat or plethoric individuals may benefit by fasting. The Karell diet, 800 cc. of milk per day for five to seven days and no other food or liquid, combines the principle of limitation of fluid-intake with that of relative starvation. It is suitable for well-nourished patients with edema. The chief disadvantage for the patient is its monotony. ' Paul D. White, "Quinidine Sulphate in Auricular Fibrillation (Absolute Cardiac Arrhythmia)," Bost. Med. &· Surg. Jour., cxcii, 185 (Jan., «925). ' Paul D. White and Howard B. Sprague, "Cases Illustrating the Indications for the Use of Quinidine Sulphate in Heart Disorders," Ibid., cxciii, 91 (July, 1025). ' Should be specially prepared for subcutaneous use.

DISORDERS OF CIRCULATORY SYSTEM

9

5. Convalesceme When compensation has been established with the patient at rest, increase of activity must be very gradual and must be carefully supervised. Passive exercise may be serviceable in severe cases before voluntary activity is begun. When the patient begins to resume a normal life, activity should still be regulated for weeks or months, in order that the heart be not overtaxed. Graduated exercise may be used to strengthen the heart. Physical fatigue or activities causing dyspnea may do harm. Peace of mind should be aimed at, and unnecessary responsibility should be avoided if it causes fatigue or worry. It is generally necessary to tell the patient something about his condition and to warn him to avoid activities which induce much fatigue and exertions which cause much dyspnea. Judgment and caution must be exercised in dealing with an apprehensive patient lest danger become exaggerated in his mind, and harm result. III. I.

SUPPLEMENTARY PRINCIPLES METHODS

ACTIVE A C U T E OR RECURRENT

AND

ENDOCARDITIS

Treatment for the infection must often be combined with measures to combat cardiac insufficiency. Methods must vary with degree of severity of the symptoms and the chronicity of the lesion. Principles, (i) Favor dilution and elimination of toxins. (2) Maintenance of nutrition is of prime importance. (3) Convalescence requires prolonged supervision. (4) Recurrence of infection is to be prevented. Methods. Liquids should be taken abundantly to dilute toxins and to favor elimination except when cardiac dilatation threatens or when there is edema. Liquids must then be more or less restricted. The intake and output of fluid should be measured and recorded. Feedings should be frequent, the food nutritious, and the amount regulated by digestive power.

IO

PRINCIPLES OF MEDICAL TREATMENT

Digitalis is to be avoided unless clearly necessary, be_cause stronger cardiac action might favor embolism. The effect of digitalis in these cases is variable and uncertain. Tachycardia may sometimes be reduced by an ice bag placed over the precordia. Convalescence. To cure the infection completely, keep the patient in bed and as quiet as possible for months after the pulse and temperature have returned to normal. Permanent damage nearly always remains. The degree of possible improvement depends on the location and extent of the lesions and on the recuperative power of the patient. Activity should be very gradually resumed. Exercise should be systematically regulated, in order to develop the full capacity of the heart without overtaxing it. Prevention. Recurrence of infection seems to be very common in damaged hearts but some apparent recurrences are exacerbations of a latent subacute or chronic cardiac infection. To prevent recurrence: Search for and eliminate aU foci of infection in sinuses, teeth, tonsüs, or genito-urinary tract. Diseased tonsils, as a rule, should be removed at the first suitable opportunity. It is probably unwise to remove them when acutely inflamed. Warn the patient against exposure and insist that he attend promptly to ailments, even if slight, and avoid mental strain and any physical exertion which produces dyspnea or fatigue. 2. SYPfflLIS O F T H E

HEART

Little improvement can be expected unless the diagnosis has been made before extensive and irreparable damage has occurred. Treatment. Antisyphilitic treatment must be added to the methods used for cardiac diseases in general. To begin with full dosage of arsphenamine is dangerous. It is probably wiser to begin with courses of iodide and mercury and to follow these with minimal and gradually increasing doses of arsphenamine. See also Syphilitic Angina.

DISORDERS OF C I R C U L A T O R Y S Y S T E M

II

3. DEGENERATIVE HEART LESIONS

Prognosis. The capacity for improvement in the heart itself varies with the extent of the lesion, the duration of the symptoms, and the vigor of the patient. Treatment. General principles apply, with certain modifications, as follows: Regulation of life is of the utmost importance during and after convalescence, and the patient's cooperation must be secured to this end. Sufficient rest is of the utmost importance. Many of these patients should take digitalis more or less frequently for long periods or for the rest of their lives. The best dosage of digitalis for the individual can be determined only by trial. Several small doses per week, taken at regular intervals, may be sufficient. Warn the patient never to run short of this medicine or to give it up on his own responsibility. The heart muscle may, perhaps, be so changed that it cannot respond to any form of treatment. Ill-nourished patients should rarely be purged except when edema is considerable, but a fat patient will generally benefit by a dose of Epsom salts once or twice a week, particularly if cough or slight edema of the legs persists. When blood pressure is high, nitrites may be of value to lighten the work of the heart by lowering blood pressure temporarily. Coincident angina pectoris may require special attention. ANGINA PECTORIS

Definition. Pain or distress attributable to spasm, or to occlusion of a coronary artery. Spasm is generally associated with syphilitic or degenerative change in the vessel-wall, but lesions may be confined to other parts of the heart or to the aorta, and "neurotic angina," in which there is no known lesion, is rather common. Occlusion may be thrombotic or embolic. Angina may be indicative of beginning cardiac exhaustion. Classification, (i) Syphilitic: common in men of early middle Ше. (2) Degenerative or arteriosclerotic: common

12

PRINCIPLES OF MEDICAL TREATMENT

in old men. (3) Embolic: seen in endocarditis or intracardiac thrombosis. (4) Neurotic: common in young women. Diagnosis. An accurate history of the mode of onset, duration, and radiation of the pain, and the discovery of an adequate background for the disease, are of the greatest importance for diagnosis. Pain on exertion suggests angina. Angina in a young or middle-aged man suggests syphilis. A complete physical examination may show nothing important. Angina in a young woman suggests psychic trauma. "Painless angina," otherwise typical, is seen rarely. Prognosis. The prognosis in severe angina due to organic heart disease must be uncertain and guarded, but, with time, the heart may adapt itself and the patient may live for twenty years or more after onset of this symptom. Optimism is not only justified in many cases, but is generally beneficial to the patient. SYPmLiTic

ANGINA

Pathology. Syphilitic changes in the aorta, aortic valves, or coronary arteries, diminishing their circulation, are generally present. Etiology. A late manifestation of syphilis; commonest in middle life. Prognosis. The prognosis is very uncertain. Treatment of Anginal Attacks. Use nitroglycerin subcutaneously, or amyl nitrite by inhalation, or both, immediately. If the patient is not relieved in a few minutes, repeat the dose. If nitroglycerin gives no effect in repeated doses, amyl nitrite may, perhaps, relieve. If the pain is unusually severe and obstinate, morphine should be injected. Do not attempt to transport the patient and do not aUow him to make the slightest exertion for a time after the symptoms have passed. Rest in bed is advisable after a severe attack.

DISORDERS OF C I R C U L A T O R Y S Y S T E M

13

Subsequent treatment, i . Antisyphilitic measures. See Syphilis of the Heart. 2. Regulation of life to reduce demands on the heart to what it can meet is of the utmost importance. (a) Anything known to bring on angina in the individual, e.g., exercise after meals, must be avoided. (b) Physical and mental strain must be prevented. (c) Avoid distention of the stomach and bowels. {d) Food and liquids should be taken always in moderation. (e) Tobacco and alcohol should be used in great moderation, if at all. (/) Bowels must be kept free. 3. Cardiac insufficiency, if present, requires appropriate treatment on general principles. 4. SmaU doses of digitalis taken regularly often help to reduce the number of attacks, even when the usual signs of cardiac insufficiency are absent. Theobromine sodiosalicylate, 5 grs. (0.324 Gm.) t. i. d., or barium chloride, TV gr. (0.0065 Gm.) t. i. d., may be tried for the same purpose. 5. A t the first sign of an attack the patient should sit still and take nitroglycerin or amyl nitrite, repeat it in a few minutes if not relieved, and remain quiet for a time after the attack has passed. An expected attack can sometimes be prevented by timely use of nitroglycerin. The drug must be always accessible without effort. Nitroglycerin should be chewed and absorbed in the mouth, and amyl nitrite taken by inhaling it from a handkerchief. If amyl nitrite is to be used, it is important to provide pearls which break easily but not spontaneously. DEGENERATIVE ANGINA

Pathology. Coronary sclerosis and chronic myocardial degeneration, with or without fibrous myocarditis, will often be demonstrable as part of a wide-spread arteriosclerosis. Prognosis. Years of life may be possible, but sudden death may occur at any time.

14

PRINCIPLES OF MEDICAL T R E A T M E N T

Treatment. 1. Regulate life to avoid strain. 2. When there is any cardiac insufficiency, the patient should take digitalis regularly and an occasional dose of salts, for long periods. The dose of digitalis most effective for the individual can be determined only by careful trial. 3. Digitalis, theobromine, potassium iodide, or barium chloride in small doses may limit the number of attacks or even prevent them. 4. If an old syphilis be suspected, treat as for syphilitic angina. 5. The treatment for the attack is the same as for syphilitic angina. EMBOLIC ANGINA

Vaso-dilators are not likely to give relief. Morphine is usually required, in large doses. Death may come suddenly at onset of symptoms, but recovery is sometimes possible. NEUROTIC

ANGINA

Pathology. No characteristic changes are recognized. Etiology. Commonly due to excess in tea, coffee, or tobacco, or to féar or emotional shock, and often associated with debility. I t is seen, almost exclusively, in neurotic young women. Prognosis. Death is not to be expected and the chance of complete cure is excellent. Treatment. 1. Remove the cause when possible. 2. General hygienic measures. B y these means recurrence can be prevented. The attack is generally too brief and mild to require treatment but when severe it should be treated like organic angina. NOTE: Spasm of the cardiac end of the esophagus may simulate angina pectoris. H Y P E R T E N S I O N WITH C A R D I A C

INSUFFICIENCY

Etiology and Symptoms. Hypertension is commonest in chronic nephritis and is seen also in arteriosclerosis. Heavy responsibility seems often to be a factor, but sometimes it occurs without apparent cause.

D I S O R D E R S OF C I R C U L A T O R Y S Y S T E M

15

T h e hypertension and left ventricular hypertrophy develop gradually. Symptoms of insufficiency often increase so gradually as to be disregarded b y the patient for months. T h e condition is generally more critical than the signs would seem to indicate. Acute pulmonary edema is common in these cases. M a n y of them show signs of toxemia attributable to deficient renal elimination. A reasonable degree of hypertension in many chronic cases seems to be a compensatory reaction which should not be combated after the acute symptoms of insufficiency have passed. In some such cases convalescence is accompanied b y a rise of arterial pressure. Treatment. General principles and methods are applicable with the following additions: 1. Reduce the work of the heart b y lowering blood pressure a t least temporarily unless the urinary output falls in consequence. {a^ Vaso-dilators, e.g., nitroglycerin, lower blood pressure temporarily and often promote diuresis also. {b) Purgation, diuresis, venesection, and measures tending to relieve toxemia or to improve the circulation, seem to favor if not to cause reduction of pressure in hypertension. (c) Fasting for a day, or marked restriction of food for several days, m a y benefit plethoric individuals. I t is one of the surest means of lowering pressure. Emaciation must be avoided because it increases cardiac weakness. (d) Relief from psychic strain, e.g., business cares, is essential. I t m a y be followed b y a lasting fall in pressure. (e) Removal of foci of infection, e.g., drainage of pus by extraction of teeth, may lower Mood pressure. 2. When toxemia is present reduce it b y : (a) Purgation or diuresis. (b) Restriction of food, and of protein in particular. (c) Hot-air baths or hot soaks, if cardiac symptoms permit.

16

PRINCIPLES OF MEDICAL T R E A T M E N T

3. If toxemic symptoms persist after improvement in the circulation they are probably uremic in origin and should be treated accordingly. PULMONARY EDEMA WITH HYPERTENSION

NOTE: Occurs commonly and characteristically in hypertension. The attack generally follows exertion and may not have been preceded by marked symptoms of cardiac insufficiency. The onset is sudden and alarming. The symptoms in severe cases are marked dyspnea, cyanosis, wheezing, cough, and pinkish, frothy expectoration. There may be precordial pain. Treatment. Mild attacks may pass off after a little rest. Severe attacks require energetic and prompt treatment as follows: 1. Prop the patient up so that he can sit upright without effort. 2. Give morphine sulphate Jgr. (0.016 Gm.), atropine sulphate τέττ to Λ gr. (0.00065-0.001 Gm.),and nitroglycerin τΐ® to sV gr. (0.00065-0.001 Gm.), subcutaneously at once. 3. Unless improvement begins within ten to fifteen minutes the nitroglycerin should be repeated and venesection may be required. 4. The following drugs may be of service: By inhalation:

Amyl nitrite, s mm. (0.3 cc.).

By mouth:

Aromatic spirits of ammonia, i drach. (4 cc.). "Hofímann's Anodyne," ' i drach. (4 cc.).

Whisky or brandy, from 4 drach. to i oz. (iS-30 cc.). Subcutaneously: Cocaine hydrochloride, J gr. (0.016 Gm.) Said to be dangerous. Intravenously: Strophanthin.

5. Do not attempt to transport the patient until immediate danger has passed. 6. Rest in bed is advisable for a few days, to allow the heart to recover. 7. Digitalis, purgation, etc., may be needed. 8. Subsequent regulation of life is essential to avoid recurrence. ) Spiritus Aetlieris Compositus (N. F.).

DISORDERS OF CIRCULATORY

SYSTEM

17

PULMONARY EDEMA WITHOUT HYPERTENSION

Slight pulmonary edema may appear in cardiac insufficiency from any cause. It is common in mitral stenosis, but seldom severe enough to require special treatment. When severe, it should be treated as in hypertension, except that, the blood pressure being normal or low, nitrites are of doubtful value and may perhaps do harm. Pulmonary edema occurs also in severe infectious diseases such as pneumonia and sepsis. It may then be very acute, but is not necessarily of essentially cardiac origin. HEART-BLOCK

Etiology. Heart-block may result from degenerative, syphilitic, or infectious lesions involving the bundle of His, or from excessive dosage of digitaHs, or from a combination of factors which, acting singly, would not suffice to produce it. When the bundle is already damaged, a small dose of digitalis may induce block. Symptoms. It is not usually associated with severe decompensation, but symptoms may be serious, or death may occur during sudden transitions from sinus to ventricular rhythm. The Stokes-Adams syndrome is attributable to sudden onset of heart-block. Treatment. As a rule, drugs of the digitalis group should be omitted at the first sign of block. Other treatment must be based on the probable etiology in each case and upon symptoms, according to the general principle of the treatment of cardiac disease. ^ PERICARDITIS

Serous pericarditis is generally associated with rheumatic arthritis, and generally yields promptly to treatment suitable for rheumatic fever. Aspiration is occasionally required to relieve dangerous symptoms. When there are signs of decompensation, myocardial and perhaps endocardial lesions probably coexist. Treatment as for acute endocarditis is then needed. 1 Cohn has reported relief from a t t a c k s of syncope, which he attributed to ventricular fibrillation in the presence of complete heart-block, b y treatment with barium chloride. (ArcA. of Int. Med., 1925, xxrvi.)

18

PRINCIPLES OF MEDICAL T R E A T M E N T

Purulent pericarditis is generally associated with other suppurative lesions requiring treatment. When suspected, the pericardium should be aspirated at once for diagnosis and to relieve symptoms. Operative drainage should be arranged for promptly. MALNUTRITION OF MYOCASDIUM

Emaciation or severe anemia may cause serious circulatory weakness. Syncope may supervene from low blood pressure. Treatment. Rest and improvement of nutrition are essential. It may be necessary to keep the patient in bed for a time. Alcohol may be of service as an appetizer. A wine glass of sherry, to which may be added bitters or a few minims of tincture of nux vomica, may be prescribed before meals, or whisky with water or soda, or beer, if palatable to the patient, may be taken with meals. Other patients capable only of taking liquids, and who are in a condition of semistarvation, may sometimes take large quantities of alcohol for a time with benefit. In such cases it seems to act as a food. SURGICAL SHOCK

Whether it develops from trauma or after operation, loss of blood may be a factor in the production of this condition. The picture is essentially that of vascular relaxation with accumulation of blood in the splanchnic vessels, deficient return of blood to the heart, consequent low blood pressure, and decreased supply of oxygen to the medulla. The level of the diastolic pressure is the best index of danger or of improvement. Treatment. The essentials of treatment are: 1. Undisturbed rest. Do not move the patient in bed or lift him out of it, if this can possibly be avoided, for several hours, even if the response to treatment has been good. Use morphine freely if there is pain. 2. Warmth is important to maintain body temperature. Heaters should generally be used in the bed. 3. Raise the foot of the bed about twelve inches and permit no more than one thin pillow under the head.

DISORDERS OF CIRCULATORY SYSTEM

19

4. Transfusion often produces the most striking improvement. When transfusion cannot be performed promptly, intravenous injection of glucose solution, or even of normal saline solution, is of transient benefit. 5. Hot tea and other measures recommended for the treatment of vascular relaxation (page 23) may be of service. IV.

C I R C U L A T O R Y D I S O R D E R S OF T H E F E C T I O U S D I S E A S E S A N D SEPSIS

IN-

G E N E R A L INFORMATION

Circulatory variations, moderate in degree, occur in health. Some of them are related to the taking of food, to exercise, to excitement, or to sleep. Analogous changes may occur in disease. In febrile diseases variations, sudden or gradual, in the rate and character of the pulse are of common occurrence, independent entirely of treatment. They may be most difficult of interpretation and may lead to false opinions as to the efiects of treatment. Some of the changes are coincident with, and probably dependent upon, changes of bodily temperature. The physician should watch for the earliest evidences of circulatory weakness and should note the nature and sequence of the phenomena, in order that he may have indications of what is taking place. He should seek by every possible means to forestall severe symptoms, but, if they develop nevertheless, he must generally base treatment either on a guess as to the essential nature of the disturbances or treat the symptoms blindly. Before this subject can be presented satisfactorily, more must be learned of the histopathology and of the pathological physiology of the circulatory phenomena in the various kinds of infections, as well as more about the effects of drugs in the different toxemias. Blood Pressure. The first important modification of blood pressure is generally manifested by a fall in the diastohc pressure. This results in large "bounding pulse" or a dicrotic pulse. When, later, the systolic pressure falls markedly, the pulse becomes small and " soft." Sometimes

20

P R I N C I P L E S OF M E D I C A L

TREATMENT

a compensating constriction of the peripheral vessels takes place and helps to maintain the peripheral circulation for a time. The pulse is then small but not soft, and is called " w i r y . " The wiry pulse is an indication of danger. It may be followed by the " thready pulse," which is rapid, small, and very soft, and which seems to vary slightly in force and rhythm. Such a pulse indicates grave danger. Arrhythmias of various kinds may develop in febrile diseases. Their significance depends upon their type and degree of severity and on the conditions under which they occur. Tachycardia, or acceleration, with httle change in pulsewave, or blood pressure, is to be expected with slight fever in mild or early infections. Nervousness or anxiety may be a factor. D o not overlook hyperthyroidism. A rise of pulse-rate to 120 or over per minute may be followed by more serious symptoms, but danger is not generally imminent at first. Bradycardia, not due to block, may occur during convalescence from the acute febrile diseases, or may be associated with jaundice or increased intracranial pressure. It is constant in some individuals even when healthy. It has no important significance except when caused by increased intracranial pressure or heart-block. PROPHYLAXIS IN GENERAL

To Ward off Serious Circulatory Symptoms : 1. Combat toxemia:

Neutralize toxin with antitoxin practicable. Dilute toxins. Promote their elimination.

when

2. Conserve patient's strength:

Promote comfort and secure sleep, Minimize exertion. Prevent anxiety.

3. Avoid mechanical handicaps to circulation:

Prevent abdominal distention, Recumbent posture with head low is best when comfortable for the patient.

4. Maintain nutrition:

Careful attention to diet, with due regard to the individual and to circumstances. Free use of alcohol is beneficial in some cases. It is harmful in others.

DISORDERS OF CIRCULATORY SYSTEM

21

S- Stimulants:

A n abundance of cool, fresh air at all times in the sicliroom acts as a tonic. Drugs should be used only when specially indicated. Sponge baths are beneficial in suitable cases. See T)φhoid.

6. Prepare for emergency in serious cases:

H a v e saline or glucose solution in readiness for intravenous use. H a v e blood of patient typed, and know where to get donor if needed for transfusion. TREATMENT IN GENERAL

When circulatory weakness of a serious or alarming character has developed, it may be impossible to determine its fundamental nature. Treatment must then be largely symptomatic, but there are a few broad principles to be borne in mind. 1. When the methods advised for prophylaxis have not been adequately applied, further efforts should be made along these lines. 2. When you believe that the heart itself is weak, do not increase its load by copious administration of water. Intravenous infusions or transfusions, if used at aU, must be small in amount and must be administered very slowly. 3. When the blood pressure is very low, let the force of gravity work with you to maintain blood flow to the medulla, and strive to increase the volume of the blood in circulation. 4. Methods of treatment must be selected with due regard for all circumstances and with relation to the urgency of symptoms. 5. Avoid the use of drugs having a depressing effect on the circulatory system. SPECIAL METHODS OF TREATMENT

I. Myocardial damage causing manifestations of cardiac weakness may be the principal feature of a case, but it is more often combined with symptoms attributable to defects of function in other parts of the circulatory system. Sudden death in acute febrile conditions is far more often due to myocardial failure than to pulmonary embolism, even when no gross lesion of the myocardium is present.

22

PRINCIPLES OF MEDICAL TREATMENT

Treatment. Myocardial damage sufficient to produce circulatory weakness requires caution in the administration of fluids by mouth or otherwise. This is particularly true of intravenous infusions and of transfusion. Suitable preparations of the digitalis group may be tried by mouth, subcutaneously, or intravenously, although they are not likely to avaü much against the myocardial damage associated with toxemia. Even in emergency, powerful preparations such as strophanthin should seldom be used in full single dosage intravenously. The response may be prompt and striking, but may soon be followed by a marked fall of blood pressure. Divided doses are preferable. 2. Vascular relaxation, with marked fall of systolic and diastolic pressure, is a sign of danger, and the more so the more quickly it develops and the lower the diastolic pressure. Probably, various causes or a combination of them may produce it; e.g., the action of toxins on the blood vessels themselves or on their nervous controlling mechanism, or, perhaps, physical exhaustion. In the more serious cases dilatation of the splanchnic vessels is believed to play the most important part. Such phenomena resulting in circulatory coUapse may develop rapidly or gradually in sepsis or in the infectious diseases. When the condition develops rapidly, it is called toxemic shock. The sequence of events seems to be: (a) relaxation of the vessels, with fall of blood pressure and accumulation of blood in the vessels, so that the return of blood to the heart becomes scanty and reduced intracardiac pressure results; ib) deficient coronary circulation, resulting in weak heart action and further impairment of the circulation; (c) deficient oxygen supply to the centres of circulation and respiration in the medulla, causing further drop in blood pressure, which may result in failure of function of the meduUary centres and consequent death. It is important to distinguish as clearly as possible between "toxemic shock" and circulatory coUapse due essentially to myocardial weakness, because treatment suitable for toxemic shock is likely to prove fatal to patients suffering from myocardial weakness. Sudden attacks of circulatory collapse, perhaps cardiac, perhaps vascular in origin, may recur in severe cases of typhus fever, sometimes in the

DISORDERS OF CIRCULATORY SYSTEM

23

daytime, more often late at night. They may pass off with or without treatment, or may prove fatal. Severe grades of vascular relaxation are seen in typhus, in typhoid, and in pneumonia. Recovery is possible, but death the rule. Treatment, (a) Do not allow a patient with low blood pressure to be propped up unless dyspnea demands it, because syncope may result and death may follow. One thin pillow is generally enough, but in severe conditions this may be removed and it may be necessary, particularly in emergency, to raise the foot of the bed about twelve inches. Do not lower it again for hours or days. It should then be lowered a little at intervals, lest sudden change of position disturb the circulation. (6) T o increase the volume of the circulating blood and to promote elimination of toxins, copious ingestion of fluid should be insisted upon, except when there is coincident pronounced weakness of the myocardium, or pulmonary edema. When sufficient fluid cannot be taken by mouth, saline or glucose solution, five to ten per cent, should be used by rectal enema several times daily, or by rectal seepage. In more urgent cases saline or glucose solution can be used intravenously. (Injection of normal saline solution, into the peritoneal cavity has been suggested, but I have had no experience with this method.) About a pint should be given at a time. When the intravenous route is used, the fluid must be allowed to run slowly and the pulse must be carefully watched meanwhile. If, after initial improvement, it loses force or becomes at all irregular, stop the transfusion at once, lest cardiac dflatation result. When the intravenous route is impracticable, saline solution can be administered by hypodermoclysis. (c) Transfusion with blood or with preserved corpuscles may be expected to have a more lasting effect than solutions. (d) In emergency, raise the foot of the bed, and administer something producing a prompt reflex response, e.g., a hot drink of tea, a spoonful of brandy undiluted, or an intramuscular injection of a syringe full of brandy, ether, alcohol, or spirits of camphor.

24

PRINCIPLES OF MEDICAL TREATMENT

Blood may be squeezed back to the heart by firm bandaging of the limbs or a tight swathe applied around the abdomen. Intravenous medication with stimulants of the digitalis group or with powerful vaso-constrictors, such as epinephrin or Pituitrin, are required only for emergencies. They should be injected very slowly, and not more than half the full dose should be used at one time. It is better to repeat the dose in a short time or at intervals than to cause a marked and sudden rise of blood pressure, which is generally followed by a disastrous fall of pressure. A preparation of caffeine may be prescribed by mouth or injected subcutaneously for its supposed tonic effect. Caffeine seems at times to improve the pulse but it may cause restlessness and loss of sleep. 3. Pulmonary edema in the infections may result from: (a) Hypostasis. (Ò) Passive congestion. (c) Intrapulmonary obstruction. (d) Toxemia. Treatment. Pulmonary edema due to (a) hypostasis requires that the patient be not allowed to remain constantly on the back. Measures to improve the general circulation and to deepen the respiration, e.g., sponge baths, are beneficial when not contraindicated. (δ) Passive congestion requires treatment directed to improving the action of the heart. (c) Cardiac embarrassment from extensive intrapulmonary obstruction may occur in the early stages of pneumonia when consolidation is widespread, in pulmonary embolism (when not immediately fatal), or as a result of extensive massive collapse. Venesection promptly performed is of great service when the symptoms are acute and severe. Small, repeated doses of strophanthin may be used thereafter intravenously until the symptoms abate. (d) Toxemic edema, also called active edema, may appear in severe infectious diseases, e.g., pneumonia, or in sepsis, and may complicate a preëxisting bronchitis. When it occurs alone, the sputum is frothy and white or pinkish in color and the symptoms suggest asthma. The condition

DISORDERS OF CIRCULATORY SYSTEM

25

may be mild or severe and tends to recur at night at about the same hour. In the severest cases it may develop in the daytime and persist. The prognosis is then grave. When complicated with bronchitis, the frothy expectoration is mixed with the mucoid or mucopurulent sputum of bronchitis. Treatment. Toxemic edema in its mild form yields promptly to subcutaneous injection of atropine r h gr. (0.00054 Gm.) with morphine \ gr. (0.0108 Gm.), or to atropine jV gr. (0.001 Gm.) alone. The dose may have to be repeated after a few hours in the severer forms, and larger dosage of atropine may perhaps be needed in very acute edema with cyanosis, such as sometimes develops in pneumonia. When there is much bronchitis, the effect of atropine is less striking, and morphine should not be used too frequently lest it prevent expectoration. 4. Dehydration may result from prolonged and severe diarrhea, persistent vomiting, or deficient ingestion of fluid. Treatment requires free administration of fluids by mouth and rectum, when practicable, and otherwise by hypodermoclysis or intravenously. The latter method may have dramatic results lasting long enough to carry the patient out of immediate danger. The infusion may have to be repeated several times at intervals of from six to twentyfour hours. Not less than a pint of fluid should be given at a time. Normal saline solution or glucose solution can be used. The latter is to be preferred for ill-nourished patients. 5. General physical exhaustion with incidental weakness of the myocardium may be the chief cause of circulatory disorders in painful or distressing conditions which prevent sleep. Such disorders may occur, for example, in pneumonia. Treatment. Morphine should be used hypodermically for one or more nights in dosage sufficient to secure comfort and sleep. The benefit resulting may be pronounced. 6. Endocarditis, pericarditis, and gross bacterial lesions are dealt with above on pages 9, 17, and 4 and 5, respectively.

C H A P T E R II NEPHRITIS BY GEORGE CHEEVER SHATTUCK, M.D.

CLASSIFICATION 1. 2. 3. 4. 5. 6. 7.

Acute Glomerulo-nephritis. Chronic Glomerulo-nephritis. Syphilitic Nephritis. Toxic Nephritis. Renal Irritation. Renal Arteriosclerosis. Passive Congestion of the Kidney.

This classification aims to distinguish the more important renal disorders the recognition of which is helpful for treatment. GLOMERULO-NEPHRITIS PATHOLOGY AND

DIAGNOSIS

Glomerulo-nephritis, acute, subacute, or chronic, results as a rule from infection with the Streptococcus viridans; and this type of nephritis includes the great majority of all cases of true nephritis. Recovery may take place after the acute stage or the disease may become chronic and incurable. T h e stages and phases are as follows: Stages. . .

Acute Subacute Chronic

Latent Phases... Active

A n y stage may be without symptoms. T h e urine in the early acute stage may be negative. In chronic cases at times there is no albumin and little sediment, but the specific gravity is constantly low. Active phases of the subacute stage are frequently mistaken for acute nephritis, which is rare in adults. L e f t ventricular hypertrophy and hypertension develop grad-

28

PRINCIPLES OF M E D I C A L

TREATMENT

ually and there is a progressive fall in specific gravityassociated with an increase in amount of urine. The last stage shows marked left-ventricular hypertrophy, a blood-pressure generally over 200 mm. of mercury and a urine of very low gravity, containing Httle or no albumin and a scanty sediment. A t this stage many of the glomeruli and much of the parenchyma have been replaced by connective tissue, and shrinkage has followed so that the kidneys are much diminished in size. The chief dangers are from uremia or from cardiac insufñciency, secondary to hypertension. In the absence of arteriosclerosis a provisional diagnosis of chronic nephritis may often be made by the evidence of hypertension and of cardiac hypertrophy. Cases of chronic nephritis complicated with arteriosclerosis are liable to apoplexy. ACUTE GLOMERULO-NEPHRITIS PRINCIPLES

OF

TREATMENT

1. Reduce the demands on the kidney by: (a) Rest in bed; (Ô) Elimination by other channels — sweating or purging; (c) Suitable diet; (d) Limitation of liquids when required. 2. Maintain nutrition. 3. Avoid exposure to cold or to sudden cooling. 4. Drugs should be used only when indicated; never by routine. METHODS OF

TREATMENT

SWEATING

1. 2. 3. 4. 5.

Hot-air bath in bed or chair. Hot tub-bath. Hot wet-pack. Electric-light bath. Turkish or Russian bath.

Hot-air baths are best given in bed. If the baths cause profuse sweating they may be used daily for an hour or more. If sweating does not begin promptly a drink, hot or cold, may start it, or pilocarpine gr. (0.0108 Gm.) may be administered subcutaneously. Pilocarpine may cause pulmonary edema and is, therefore, contraindicated when

NEPHRITIS

29

the heart is weak, the lungs congested, or the patient unconscious. Some patients who sweat little at first respond well to subsequent baths. If sweating cannot be induced, if the pulse becomes weak, or if the patient develops cardiac symptoms during a bath the baths must be given up. The possibility of the development of pulmonary edema or of burning the patient requires careful consideration and close observation during the bath if it is to be used for an unconscious patient. Hospitals provide apparatus for the hot-air bath. In private houses it can be improvised with barrel-hoops or strong wire to arch the bed, an oilcloth from the kitchen table as a rubber sheet, an elbow of stovepipe and a kerosene lamp to provide the heat; or the patient, without clothing, may sit in a cane-bottomed chair under which stands a small lamp. Blankets are then wrapped around the chair and the patient together, leaving no hole for the heat to escape. Care must be taken not to set the blankets on fire. The value of sweating for nephritics has been questioned. I believe, however, that it often promotes diuresis when there is edema, with or without uremia. PLIRGATION

Obtain watery catharsis to reduce edema and to increase elimination of toxic material by the intestinal tract. Magnesium sulphate, or compound jalap powder with additional potassium bitartrate, or elaterium are good for this purpose. In the absence of edema, purgation should not be excessive, lest the patient's nutrition suffer. DIET

Proteids, meat broths, spices, acids and alcohol irritate the kidney and are to be avoided during the acute stage. Milk is an exception to the rule against proteid because experience shows that it is not injurious. A diet exclusively of milk becomes monotonous if long continued, and such large quantities are needed to maintain nutrition that the fluid part may tend to increase edema.^ Salt seems not to be harmful as a rule. When, however, edema persists in spite of other treatment, a "salt-free" diet may be tried; that is, salt is not to be added to food Three quarts of milk furnish about 2,000 calories, which is scant for an adult.

Зо

PRINCIPLES OF MEDICAL T R E A T M E N T

either before or after cooking. This change is followed occasionally by rapid disappearance of the edema. If deemed advisable the phosphate in milk can be precipitated by adding 5 grs. (0.324 Gm.) of calcium carbonate per pint of milk. Diet List (incomplete). Milk, cream, butter, sugar, junket, ice cream, bread, toast, cereals, rice, potato, macaroni, sago, tapioca, spinach, lettuce, sweet raw fruits or stewed fruits. In convalescence enlarge the diet cautiously on account of the danger of relapse. When returning to protein foods, allow eggs first, then fish and lastly meat, red or white. Liquids, including Uquid foods, should be limited strictly when there is anasarca or increasing edema. One pint of fluid in twenty-four hours is minimal. Cracked ice may be sucked for thirst, but, if the patient suffers, more liquid should be allowed. When freely excreted, water is an excellent diuretic. It dilutes irritating substances and favors their elimination. Nutrition. The quantity of food to be prescribed depends on the severity of the nephritis, the physical strength, and the state of nutrition of the patient. Strong, wellnourished patients having severe nephritis may benefit by fasting for a day and by taking thereafter very small quantities of food for several days. A feeble, emaciated and anemic person should receive at least food enough to maintain nutrition without loss. Exposure. T o prevent chill, keep room at equable temperature and let patient wear flannel or lie between blankets. Medication. Irritating diuretics, such as calomel, are dangerous in all forms of nephritis. Theobromine, theophylline and apocynum are useless and may perhaps do harm in acute nephritis. Mild saline diuretics or alkaline mineral waters may be valuable, particularly in convalescence, but it may, perhaps, be wiser to avoid them in severe cases during the early stage. For anemia, iron may be tried; e.g., "Blaud's Pill," or "Basham's M k t u r e " (Liquor ferri et ammonii acetatis U. S.) which contains iron and acts also as a mild diuretic.

NEPHRITIS

31

PROPHYLAXIS

If it appears that the tonsils were the point of entrance or the original seat of disease their removal at a suitable time should be advised. Uremia. For treatment see p. 34. SUBACUTE AND CHRONIC GLOMERULONEPHRITIS P R I N C I P L E S OF

TREATMENT

1. Adequate nourishment is essential because the disease is chronic and a cure not to be expected. 2. Limit demands on the kidney and guard against uremia by (a) diet; (6) elimination. 3. Guard against cardiac insufficiency by avoiding physical and mental strain. 4. Avoid exposure to cold. METHODS Methods are the same, in general, as for acute nephritis, but they must be applied with regard to the condition of the patient, the symptoms and the degree of activity of the disease. Avoid unnecessary restrictions. A too monotonous diet leads to malnutrition. The Active Phase may be treated as acute nephritis for a short time or when there is doubt of the diagnosis, but the diet should soon be increased because adequate nutrition is essential. Latent Phase: subacute, or chronic: 1. Restrict more or less the following: (a) Meats; (é) M e a t broths; (c) Spices; {d) Alcohol; (e) Acids; (/.) Salt. 2. T o favor elimination of toxic material the following may be advised: {a) A saline cathartic every second, third, or fourth day. Bowels must be kept free, {b) H o t tubbaths, Russian, or Turkish baths, once or twice weekly. (c) Alkaline mineral waters with meals. 3. Uremia. For treatment see p. 34. 4. Cardiac Insufficiency demands prompt recognition and treatment. I t results commonly from hypertension, a concomitant of the disease.

32

PRINCIPLES OF M E D I C A L T R E A T M E N T SYPHILITIC NEPHRITIS DIAGNOSIS

Syphilitic nephritis often resembles acute glomerulonephritis but features of the case are apt to be atypical. For example, the amount of albumin may be extremely large, the blood-pressure normal and the usual etiological factors lacking in the history. Syphilitic nephritis, according to Osier, most commonly occurs in the secondary stage of syphilis within six months of the primary lesion and it resembles glomerular nephritis. Gumma of the kidney is rarely recognized but it is probable that some instances of renal arteriosclerosis are of syphilitic origin. Signs of an active syphilis in the presence of a nephritis suggest but do not prove that the two are related. The blood-pressure is not usually much increased. TREATMENT 1. Apply according to the severity and symptoms of the case the principles advised for acute or chronic nephritis. 2. Iodide and mercury or salvarsan should be used in small doses. 3. Watch urine and omit mercury if renal irritation increases under treatment. When the diagnosis is correct the urine generally improves promptly. A s there are no characteristic signs, mistakes of diagnosis easily occur. TOXIC NEPHRITIDES Note. The form of acute nephritis produced by irritant poisons, such as corrosive sublimate, is of the tubular variety. A form of chronic nephritis with hypertension may result from lead poisoning. In chronic suppurative conditions, particularly when related to tuberculosis or syphilis, amyloid degeneration of the kidney may develop. There are other unusual or atypical renal degenerations or nephritides difficult to classify. TREATMENT Symptomatic according to principles enumerated for glomerulo-nephritis.

NEPHRITIS

33

ACUTE RENAL IRRITATION PATHOLOGY AND DIAGNOSIS Acute renal irritation has no important significance but may be mistaken for acute nephritis or vice versa. Albumin, casts and sometimes blood are present in the urine in cases of general infection with fever. The findings are attributable to the excretion of irritating substances. TREATMENT The signs of irritation can be much reduced by the free administration of water. The water dilutes the irritating substance and promotes excretion by stimulating diuresis. No other direct treatment is needed. Caution. Before discharging the patient look for evidence of nephritis. ARTERIOSCLEROTIC RENAL DEGENERATION PATHOLOGY AND DIAGNOSIS Arteriosclerotic degeneration of the kidney is most common in old age. I t may be part of a widespread arteriosclerosis or it may be manifested chiefly in the kidney. There occurs a non-inflammatory destruction of parts of the kidney dependent on sclerosis of the arteries supplying those parts. Local shrinkage and irregularity or roughness of the surface result. Lesions of arteriosclerosis and those of glomerulo-nephritis are often combined in varying degrees in the same case. The urine of the arteriosclerotic kidney at first may show considerable albumin and some blood and casts. Later it resembles that of chronic nephritis. Hypertension and left-ventricular hypertrophy are generally well marked in the later states of renal degeneration. The greatest dangers are from cardiac insufficiency or cerebral hemorrhage. Typical uremia occurs rarely if at all in pure degenerative cases but there is often more or less chronic nephritis combined with the degenerative lesions. Chronic lead poisoning, gout or syphiUs may be important etiologically.

34

PRINCIPLES OF M E D I C A L T R E A T M E N T TREATMENT

1. Search for a cause of arteriosclerosis. If such can be found and if it is believed still to be operative treat it appropriately. Such causes are, for example: {a) Chronic lead poisoning; (δ) Gout; (c) Syphilis; {d) Prolonged tension of responsibility. 2. Nutrition must be maintained. 3. Limit the demands on the kidney by moderate restriction of: {a) Meats; {b) Meat broths; (c) Spices; {d) Alcohol; {e) Acids. 4. Avoid physical and mental strain to guard against (a) Cardiac insufficiency; (ό) Cerebral hemorrhage. S- Cardiac insufficiency, when present, should be treated with reference to its probable cause. 6. Mild toxemia may clear up under cardiac treatment if the heart is at fault. Alkaline diuretics may be of use. Methods advised for uremia may be used when toxemia is marked. PASSIVE CONGESTION OF THE KIDNEY Passive congestion is secondary to congestion in the venous circulation. Therefore, it is commonly symptomatic of cardiac insufficiency. The urine is high colored, scanty and of a high gravity. Albumin and casts are found, varying in amount and number. There are no uremic symptoms, and the urine clears rapidly after removal of the cause of congestion. Passive congestion m a y mask an acute nephritis, especially in the active stage of endocarditis. UREMIA Note. Uremia is an intoxication of unknown nature. I t is common in severe acute nephritis and in chronic nephritis, and particularly so in exacerbations of the subacute stage of chronic glomerulo-nephritis. Symptoms vary much in degree. There m a y be mental sluggishness, drowsiness or coma, loss of appetite, nausea or vomiting, muscular twitchings or convulsions, head-

NEPHRITIS

35

ache, delirium, disturbance of vision, transient ocular paralysis, paresis of the extremities or paroxysmal dyspnea. The urine is usually scanty or suppressed. Retinitis and Cheyne-Stokes respiration are common. The onset may be gradual, and with slight signs, or relatively acute and severe. Edema may be present or absent. METHODS OF

TREATMENT

FOR MILD UREMIA

1. Diet as for mild acute nephritis. 2. Eliminative measures: (a) Purgation; (b) Sweating; (c) Water if there is little or no edema; (d) Saline diuretics. 3. Cardiac stimulation is essential if there is any insufficiency. FOR SEVERE UREMIA

1. Diet should be much restricted in quantity and quality, as for severe acute nephritis. Vomiting or unconsciousness may prevent feeding for a time. 2. Water should be administered freely unless there be much edema. If water cannot be taken by mouth it can be used as saline solution b y : (a) Hypodermoclysis; (b) Intravenously; (c) B y rectum: (i) enema; (2) seepage. 3. Purgation. Magnesium sulphate, or other purgatives may be used. Croton oil is useful especially for unconscious patients. If rubbed up with a little butter, made into a ball and placed on the back of the tongue, it will be swallowed. Repeated doses of purgatives should be employed, if needed, to obtain prompt and profuse watery catharsis, but when there is no edema, excessive purgation may tend to concentrate toxins, and may thus do harm, unless counteracted by free administration of water. 4. Sweating seems in many cases to promote diuresis and to reduce toxemic symptoms. Unless the patient is edematous, fluid withdrawn should be replaced by fluid ingested lest toxic substances become concentrated in the blood. Hot-air baths may be used daily if they cause profuse sweating. T o use the hot-air bath for an unconscious patient is dangerous (see above). Pilocarpine should not be used if there is pulmonary edema, cardiac insufficiency or unconsciousness.

Зб

PRINCIPLES OF MEDICAL T R E A T M E N T

5· Venesection. A pint or more of blood may be withdrawn from a vein at the elbow by incision, or, if a suitable apparatus be at hand, by aspiration. Opinion is divided as to the need or value of injecting saline solution after bleeding. Ordinarily, patients do well without it. 6. Colon irrigations with large quantities of hot water may be tried in the hope of promoting elimination of toxins. 7. Drugs. The use of nitroglycerin or other vasodilators is followed frequently by pronounced diuresis in patients having hypertension. The efíect is transient. Morphine may be given subcutaneously for convulsions. Saline diuretics, for example, "Cream of tartar water," ' Potassium citrate, or "Basham's mixture," may be of use when the severe symptoms have subsided. Heart stimulants are required when there is any cardiac embarrassment. i A saturated solution of potassium bitartrate, the strength of which is 1:200, equal to about 40 grs. in a pint, or to 3 Gm. in 500 cc. of water. Lemon juice or lemon peel can be used for flavoring.

CHAPTER III ACUTE INFECTIOUS DISEASES BY GEORGE CHEEVER SHATTUCK, M.D.

PRINCIPLES OF T R E A T M E N T FOR I N F E C T I O U S DISEASES IN GENERAL 1. Rest in bed: (a) to conserve strength; (6) to reduce metabolic activity. 2. Ingestion of much water; (a) to dilute toxins; (b) T o favor their elimination. 3. Bowels should be kept clear: (a) to favor digestion; (b) to prevent absorption of toxic substances. 4. Good nursing: (a) to secure cleanliness; (b) to conserve strength; (c) to promote comfort; (d) to afford accurate information to physician; (e) to facilitate treatment. 5. Diet should be: (a) easy to swallow; (b) easily digestible; (c) nutritious but not bulky; (d) palatable and varied. 6. Meals should be: (a) frequent and small to favor digestion; (¿>) commensurate in quantity with digestive power. 7. Ventilation of the sickroom should be good. 8. Symptoms should be treated as they arise with regard to the circumstances of the case. 9. Infection of others must be prevented. TYPHOID FEVER Noie. Typhoid is characterized pathologically by peculiar ulceration of the small intestines. Ulceration is less frequent in the colon and is rare in the rectum. Typhoid bacilli enter the blood, the organs, the secretions, and the excretions. The disease is self-limited, lasting from two weeks to three months. Relapses are common and complications frequent. Toxemia is often severe.

38

PRINCIPLES OF MEDICAL T R E A T M E N T PROPHYLAXIS

Inoculation with typhoid vaccine (p. 249) should be required for all hospital nurses or others who may have the care of enteric cases and it should be advised for travelers and others who cannot be certain of the purity of water, milk, and so forth, which they may consume. Because the immunity conferred by inoculation is incomplete, precautions sufficient to guard against heavy infection must still be observed. C O M M O N C A U S E S OF D E A T H 1. Toxemia. 2. Exhaustion. 3. Severe complications: (a) Perforative peritonitis; (b) Repeated hemorrhages. P R I N C I P L E S OF T R E A T M E N T F O R T Y P H O I D 1. Prevent infection of others. 2. Dilute toxins and favor their elimination. 3. Conserve strength of the patient. 4. Diet should be suited to the individual as well as to the disease. 5. Drugs are to be prescribed for definite reasons only and not to reduce fever. 6. Observe the patient's condition closely and modify treatment promptly when indicated. 7. Have the best nursing available and if possible have a day-nurse and a night-nurse. 8. Treat symptoms and complications with due regard to other circumstances of the case. M E T H O D S OF T R E A T M E N T F O R T Y P H O I D I. "Enteric Precautions": (a) isolation of the patient is desirable; (b) flies must be excluded; (c) those who touch the patient should wash their hands promptly; (d) eating utensils should be reserved exclusively for the patient and washed and kept apart; (e) sheets and other linen when removed from the sickroom should be soaked in 5 per cent carbolic acid for at least half an hour, or boiled; (/) the

ACUTE INFECTIOUS DISEASES

39

best method of dealing with feces ^ is that of Kaiser. " I t consists of adding enough hot water to cover the stool in the receptacle and then adding about one-fourth of the entire bulk of quicklime (calcium oxide), covering the receptacle and allowing it to stand for two hours." Urine can be treated similarly by adding enough quicklime to bring it to a boü. (g) Bath-water may be boiled after using when practicable, but this is not worth while where plumbing is good; (h) cleanliness of the attendant is essential. 2. Dilution and elimination of toxins: {a) the urinary output should be kept above 60 oz. (nearly two liters) in twenty-four hours by free administration of water. A much larger quantity of urine can be obtained but it is a question whether water taken in very large quantities may not favor hemorrhage. Liquids, including liquid foods, should total about three quarts daily. (6) The bowels should be kept clear. If they do not move freely suds enemata may be employed as often as necessary. Cathartics are to be avoided as a rule during the ulcerative stage because excessive peristalsis may favor hemorrhage or perforation. 3. Conservation of strength is very important because of the long average duration of typhoid: (a) the nurse should feed the patient, turn him over, allow him to do nothing for himself and should make him comfortable; {b) the maximum of nutrition should be maintained by frequent feedings; (c) visitors should be excluded entirely as a rule. 4. Diet. Prof. F. C. Shattuck's principle in choosing a diet has been stated by him as follows: "Feed with reference to digestive power rather than by name of disease, avoiding such articles of diet as might irritate ulcerated surfaces." Requirements: {a) nonirrita ting to intestine; {b) nutritious but not bulky; (c) easily digestible; {d) palatable and varied; (e) quantity commensurate to digestive power; (J) quality adapted to the patient's condition. Meals should be frequent, at least once m four hours. If the patient can take little at a time he should be fed every two hours or even every hour. 1 H . Linentbal: Monthly Bull. Mass. State Board of Health, Jan., 1914.

40

PRINCIPLES OF MEDICAL T R E A T M E N T

Diet List. An enteric diet may include any foods that conform to the requirements stated above; for example, liquid foods, strained cereals, custard, blanc mange, junket, simple ice cream, soaked toast without the crust, bread or crackers in milk, soft eggs, oysters without the heel, or finely minced chicken. Coleman has shown that, by the free use of milk-sugar and of cream, loss of weight in typhoid may sometimes be prevented. The cream can be added to milk or to other foods. Milk-sugar can be added to liquids, in the proportion of one-half ounce in four ounces (or 15 in 120 cc. of liquid). Coleman's diet, if used indiscriminately, is harmful and may perhaps cause death. Departure from routine diet may be required for various reasons, for example: {a) patient too weak to swallow solid food; (ô) vomiting; (c) persistent diarrhea, often due to excess of milk; {d) severe distention, often due to excess of milk. Advantages of a liberal diet: (a) weight and strength are better maintained; (b) toxemia is less; (c) distention is uncommon; (d) convalescence is shorter; (e) patients suffer less. 5. Medication. Methenamine should be prescribed by routine as a urinary antiseptic. This drug may, rarely, cause hematuria or painful micturition. It should then be omitted for a few days and resumed in smaller dosage. Other drugs may be ordered occasionally for special s)miptoms as required. Antipyretics should not be prescribed to reduce fever, but they may be used for headache in the early stages of typhoid. Being depressants they are dangerous when the circulation is impaired. 6. Observation. Examine the patient once or twice daily during the febrile stage. Look for: (a) signs of circulatory weakness; (δ) pulmonary hypostasis; (c) bed sores; (d) changes in the condition of the abdomen: (i) Distention of the abdomen; (2) Spasm; (3) Tenderness; (4) Distention of bladder from retention. Keep track of: (a) urinary excretion; (¿>) nourishment; (c) account for changes in pulse or temperature. They may be the first

ACUTE INFECTIOUS DISEASES

41

sign of hemorrhage or perforation; (d) keep sterile saline solution ready for use by hypodermoclysis or intravenously in case of need. It is the duty of the physician carefully to supervise treatment during the period when hemorrhage or perforation may occur, and he himself or his assistant should be accessible at times when emergencies may arise. 7. Nursing. The nurse's general duties are to do her utmost to spare the patient exertion, discomfort and mental unrest; to report to the physician at his visit all changes in the condition of the patient; to be prepared to answer questions as to the effect of treatment prescribed; and to notify the physician at once of alarming symptoms or signs suggesting severe hemorrhage or perforation. She should know the possible significance of sudden changes in pulserate and temperature and should look for blood in every fecal dejection. T o prevent accident she should, as far as possible, avoid leaving the patient alone even when he is not apparently delirious. The following complications can generally be prevented by an experienced nurse: (i) Bed sores; (2) Corneal ulceration; (3) Middle-ear infection; (4) Parotitis; (5) Boils; (6) Cracked lips and dry tongue; (7) Tender toes; (8) Hypostatic congestion. (1) T o prevent bed sores: {a) keep sheets smooth, clean and dry; {b) after soihng, clean the skin promptly, dry it, rub in zinc oxide ointment, and powder with starch; (c) change the patient's position occasionally; {d) do not allow prolonged pressure on bony prominences; (e) if a red spot appears where there has been pressure keep pressure off that part by rings or pads and paint the spot with picric acid, one per cent. (2) T o prevent corneal ulceration keep cornea clean by bathing the eyes every four hours with a two per cent watery solution of boric acid. Ulceration may occur in moribund cases in spite of good care. (3-4) Middle-ear infection or parotitis may result from improper care of the mouth. The mouth should be cleaned and the throat sprayed every four hours with a nonirritating antiseptic. Dobell's solution, or "alkaline antiseptic" will serve, diluted, if necessary, with one or two parts of water to avoid irritation of the mucous membranes.

42

PRINCIPLES OF MEDICAL TREATMENT

(5) Boils in crops are generally due to the use of dirty sponges. If a boü appears care must be taken to avoid spreading the infection. (6) Cracked lips can be prevented by the use of cold cream. Excessive dryness of the tongue from mouth breathing can be prevented by the use of vaseline. (7) T o prevent "tender toes" keep weight of bedclothing off the feet. (8) Hypostatic congestion of the bases of the lungs is due in part to protracted lying in one position. It can be combated, if not prevented, by rolling the patient on one side and supporting him in this position for an hour or more by means of a pillow. The patient should then be rolled onto the other side for another period of time, and these maneuvers should be practised at least once daily. ROUTINE ORDERS TO NURSE (a) (b) (c) (d) (e)

Enteric precautions. Prof. F. C. Shattuck's enteric diet. Baths as directed every four hours, p. r. n. Suds enema every other day or p. r. n. Spray throat and wash mouth and eyes every four hours. (J) Methenamine, 5 grs. (0.324 Gm.) t. г. d. (g) Record temperature, pulse and respiration every four hours, the daily excretion of urine, and the amount of food and water ingested. Specific directions for diet and baths should be given with due regard for the circumstances of each case. Frequent modification may be required. 8. Convalescence. In convalescence free evacuation of the bowels is important. Massage may hasten return of strength. S Y M P T O M A T I C T R E A T M E N T FOR T Y P H O I D FEVER AND TOXEMIA Hydrotherapy generally acts well. Benefits expected from it are: (a) fall of temperature of from one to two degrees; (b) fall in rate with increase of force and volume of the pulse; (c) deeper breathing and diminution of pul-

ACUTE INFECTIOUS DISEASES

43

monary hypostasis; (d) better sleep; (e) diminution of symptoms of toxemia. Rules for use of Baths. 1. Baths should be ordered for definite indications only. 2. For children and for thin and feeble patients, baths should be warmer and shorter than for the robust adult. 3. The physician should supervise the first bath and prescribe subsequent baths with regard to the effect of the first one. 4. If the pulse gets weaker the bath should be stopped. 5. Much cyanosis or shivering after the bath indicates that it was too cold, or too long, or that not enough friction was used. 6. Stimulants are seldom required before or after a bath that is suited to the case and well given. 7. Baths must be modified or omitted if they greatly excite the patient, interfere with sleep, or cause a rise of temperature. Routine Bath Order. For temperature ^ of 103.5° F. rectal, give bath every four hours at 85° F. For every half degree of temperature above 103.5° F. lower temperature of bath-water five degrees. Methods of Bathing. " M . G. H. Typhoid Bath." With rubber sheet, supported at edges by roUs of blanket, make tub in bed of patient. Dash water over him, and with the hands, rub vigorously in turn, the chest, limbs, and back, but not the abdomen. The duration of the bath should be twenty minutes or less if so ordered. Sponge baths often act well and are preferred in many cases. A mixture of equal parts of alcohol and two per cent boric acid solution in water at the required temperature can be used for bathing. CIRCULATORY

DISORDERS

For treatment of circulatory disorders see Circulatory Disorders of Fevers and Sepsis. Symptoms generally develop gradually giving time to prescribe. Saline infusions give excellent results in suitable cases. Indications for I Temperatures in acute infections are best taken by rectum because these are more reliable than mouth temperatures. The rectal temperature averages about one degree higher than the mouth temperature.

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PRINCIPLES OF MEDICAL T R E A T M E N T

stimulation are tachycardia of 120 or over, or weakness, inequality, or irregularity of the pulse. DIARRHEA

Severe diarrheas are dangerous and must be checked. 1. Examine stools to determine if they contain undigested food. If so, omit that kind of food or reduce the amount. Curds from milk may be found. 2. Treatment as for Simple Diarrhea. CONSTIPATION

Constipation is a frequent cause of fever in convalescence. Calomel, Castor Oil, Fluid Extract of Cascara Sagrada, or Russian Oil may be given at this stage. Neglect of the bowels may result in fecal impaction. DISTENTION

1. 2. p. r. 3. 4.

If stools show curds reduce or omit milk. Turpentine stupes i may give relief and can be used n. Rectal tube may be tried. Pituitrin may do good. VOMITING

Reduction or modification of diet is advisable for a time at least. Swallowing small pieces of cracked ice, or a teaspoonful of shaved ice with brandy may relieve. HEADACHE

If not relieved by an ice-cap placed on the forehead, phenacetin 5-10 grs. (0.324-0.65 Gm.) with caffeine citrate I gr. (0.065 Gm.), or some other analgesic may be prescribed. COMPLICATIONS

OF

TYPHOID

HEMORRHAGE FROM THE BOWEL

Signs. First sign of small hemorrhage is blood in the stool. First sign of large hemorrhage may be a rapid fall in temperature and a rise in the pulse-rate. 1 See textbook on Nursing,

A C U T E I N F E C T I O U S DISEASES

45

Treatment, (a) Omit nourishment, water, and baths; (δ) give nothing but cracked ice b y mouth for twenty-four hours; (c) give morphine subcutaneously: repeat dose in fifteen minutes or half an hour and repeat again a t halfhour intervals until the respiration becomes slower. D o not let the respiration fall below ten per minute. When it has reached fifteen or less, give morphine in small dosage, if a t all, lest poisoning result. T h e object of using morphine is to stop peristalsis and to keep the patient quiet until the hemorrhage has ceased; (d) if the patient be exsanguinated raise the foot of the bed to prevent death from syncope but do not stimulate unless there is imminent danger, because increase of blood-pressure m a y prolong the hemorrhage. T h e best circulatory stimulants for this condition are a saline infusion or a direct transfusion of blood, (e) For small hemorrhages narcotization with morphine m a y not be required, (f) Patients who are very weak or emaciated should be fed in spite of hemorrhage. PERFORATION

Treatment. Surgical. E a r l y diagnosis and prompt operation are essential to success. W h e n the condition of the abdomen has been watched closely before the appearance of the symptoms of perforation the diagnosis will be easier. Spontaneous recovery is extremely rare.

RHEUMATIC FEVER Note. T h e disease, when typical, is characterized b y a migratory articular and periarticular inflammation with pyrexia and leukocytosis. When untreated the inflammation generally lasts about six weeks. Relapses are common and endocarditis is frequent. Pericarditis or myocarditis develop occasionally. There is reason to believe that rheumatic fever is a form of infectious arthritis. Perhaps most of the cases are due to a specific organism. PRINCIPLES OF

TREATMENT

1. Rest in bed. 2. Relieve pain. 3. Dilute and elimmate toxins.

4б

PRINCIPLES OF MEDICAL T R E A T M E N T

4. Prescribe large quantities of salicylate and of alkali. 5. Prevent recurrence. 6. Watch for cardiac complications. METHODS 1. Relieve pain by protecting the joints with cotton and bandages or by splints. For psychic effect oil of gaultheria may be rubbed on the skin before bandaging. Fomentations may be useful to relieve pain. If the pain be severe and not controlled by other means use morphine hypodermically until the salicylate has had time to act. In subacute cases having little or no fever a hot tubbath may give much relief. 2. Dilution and elimination of toxins can be promoted by the free administration of water. Three quarts or more should be ingested in twenty-four hours unless the heart be weak. Cardiac complications may require limitation of liquids. The bowels should be kept clear. Cathartics may be prescribed as needed. 3. Food should be nutritious and as abundant as can be digested because wasting is often rapid and anemia may develop. 4. Medication. Sodium salicylate or some other salicyl compound should be prescribed in large dosage. The quantity should be proportional to the degree of pain and acuteness of the inflammation. For severe cases 10 grs. (0.65 Gm.) may be ordered every hour until the patient is relieved or toxic. T o avoid irritation of the stomach every dose should be given with a full glass of water. Large doses of sodium bicarbonate seem to diminish the toxic effects of salicylates. Twenty grains or more of soda may be ordered with every dose of salicylate. Enough soda should be taken to render the urine alkaline. Salicin is a good substitute for sodium salicylate and seems to cause less gastric disturbance. Acetylsalicylic acid ("aspirin") (N. N . R.) or oil of gaultheria may be tried. When symptoms have been relieved the dose of the drug can be reduced. I t should be continued for a month or more after the patient is apparently well.

ACUTE INFECTIOUS DISEASES

47

When salicylates act well a fall of temperature occurs in from twenty-four to forty-eight hours and with it there come diminution of joint swelling and marked reHef from pain. The common symptoms of salicylism are nausea or vomiting, tinnitus, headache and occasionally erythema or delirium. When these occur the drug must be omitted until they subside. I t may then be resumed in smaller dosage or in different form. 5. Recurrence of arthritis is common early or late. Early recurrence can generally be avoided by keeping the patient in bed for a week after the inflammation has entirely subsided and by continuing the use of sodium salicylate, 30-40 grs. (2-2.6 Gm.) daily, for one month or more after convalescence. Exercise should be resumed gradually and exposure to cold guarded against. Late recurrence and future cardiac disease can often be prevented by eliminating all foci of suppuration. Inflammation of the tonsils or genital tract, sinus and dental infection and pyorrhea alveolaris should be looked for. Tonsillectomy may reveal deep suppuration not demonstrable externally. Tonsillectomy should be insisted on if the tonsils are a likely source of future infection. T o operate while the tonsils are acutely inflamed is dangerous. Pyorrhea can be benefited by rubbing the gums daily with a one per cent solution of potassium permanganate and by rinsing or sponging the mouth frequently with hydrogen peroxide. Extractions may be required. 6. Cardiac complications may be latent or severe. Circulatory weakness may require limitation of liquids. The patient should remain flat in bed for weeks or months after the disappearance of all signs of active cardiac infection, and should avoid exertion of all kinds for several months thereafter to give the heart ample time to hypertrophy or to adjust itself to the changes. There is reason to believe that saUcylates taken in large quantity tend to ward off endocarditis. For further information on Endocarditis, see Chapter I.

C H A P T E R IV ACUTE INFECTIONS MOST COMMON IN CHILDHOOD BY E D W I N H . P L A C E , M . D . Physician in Chief of South (Contagious) Department, Boston City Hospital Clinical Professor of Pediatrics, Harvard Medical School

SCARLET FEVER I. M A N N E R OF SPREAD Exit of virus: the virus escapes chiefly from throat and nose or infected ear, or from other lesions of the mucous membrane or skin, such as impetigo, boils, or sinuses. Probably the virus does not escape from sound mucous membrane, in urine or feces, or in desquamating skin. Viability of virus: apparently it may survive for many days, and possibly for weeks or months. Under ordinary conditions of light and air, it probably dies in a few days and in sunlight in a few hours. Manner of transfer: transference is effected chiefly by direct contact, but also by indirect contact or droplets. Milk is the only food known to spread scarlet fever. There are no gross changes in infected milk. Point of entry: entrance may be gained almost certainly by the throat, possibly by the nose, and probably by wounds. Persistence of virus: in lesions of skin or mucous membrane, where there is any loss of continuity of the epithelial lining, the virus persists for weeks or months. The more active the inflammation of these lesions and the greater the discharge, the greater their contagiousness. The most contagious period usually is during the early stage of acute inflammation of the throat and nose, but varies directly with the extent of mucous membrane inflammation, so that, in some cases, the highest contagiousness is in late

SO

PRINCIPLES OF MEDICAL

TREATMENT

convalescence. I have never found a contagious period longer than seven months. Incubation Period is one to seven days; rarely perhaps longer; average three to four days. Π. PROPHYLAXIS IMMUNITY

One attack usually gives immunity for life, but there are marked exceptions. Immunity may rarely be lost in one month. In a small percentage of cases immunity seems to develop late. Natural Immunity increases much after eight years of age, and is marked after twenty-one years. It is considerable during the first year, and lowest from two to six years of age. Active Immunity. Gabritschusky claims to have produced it by means of vaccines of streptococci obtained from scarlet fever cases. Three injections, at intervals of four days, of doses of from one to ten millions, may be used. The efiects probably are due to the toxin administered coincidentally. Toxin immunization, the result of the researches of the Dicks, is obtained by weekly injections of toxin, in increasing doses, for three to five injections. The optimum dose cannot yet be decided. The Dicks' procedure is as follows: ist injection soo toxin units 2d " I,soo " 3d " 5,000 « « 4th " IS,ООО " Sth " 20,000 " Reactions usually are local only and consist of redness, swelling, and tenderness three to five inches in diameter, but they may extend over the whole arm. Occasionally malaise and, rarely, a generalized eruption develops. Immunity appears in from three to five weeks in ninety per cent of the cases. The duration is probably for years, but the limits have not yet been determined. This protection has proved of great value for nurses in contagious hospitals, and has practically eliminated scarlet fever among them. It should be used whenever susceptibles are likely to be exposed to scarlet fever.

ACUTE INFECTIONS IN CHILDHOOD

51

Passive Immunity may be secured by injections of scarlatinal antitoxin. This immunity may last from two to eight weeks. Dosage, 2000 units (sufbcient to neutralize 200,000 toxin units or skin-test doses). Dick Test. This test measures the immunity to scarlet fever and is similar to the Schick test for diphtheria. A standard dose for man of scarlatinal streptococcus toxin is injected intradermally. The reaction appears in about eight hours, reaching the maximum usually in twenty to twenty-four hours and rarely in forty-eight hours. The typical reaction is an area of redness and infiltration two to three cm. in diameter. Severe reactions may be 7-ro cm. in diameter. Reactions of less than i cm. are usually considered negative. Subsidence is rapid, usually in twentyfour hours, leaving no trace. Occasionally the reaction may persist for days and there may be slight pigmentation and desquamation. Results are read in twenty-four hours. Control tests are made with toxin heated at ioo°C. for two hours. Those showing no reaction to the Dick text are immune to scarlet fever. ASEPSIS

See Diphtheria, p. 68. ISOLATION

Isolation is of great value and should be begun as early as possible. Finding of missed cases in a family, neighborhood, or school is often possible by investigation when the first case is recognized. Other cases should always be searched for by examination of contacts for evidence of sore throat, sore nose, discharging ears, enlarged glands, nephritis, arthritis, endocarditis, desquamation, or any discharging lesion. The finding of these signs does not necessarily show that the individual has had scarlet fever, but they should be accepted as grounds for suspicion and for isolation. Isolation, as a rule, should be continued for four weeks and until there is no discharging lesion or open sore. Culturing such suspects for scarlet fever streptococci is of great value. If no hemolytic streptococci can be obtained in several cultures from the suspected lesions, the patient may be released. If hemolytic streptococci are

52

PRINCIPLES OF MEDICAL T R E A T M E N T

found, the organism may be tested for toxin production, or the patient held until clinically well or bacteriologically free. Carriers who show no cUnical reactions, such as redness, discharge, or abnormal tonsils, are probably not of great epidemiological importance. The Technic of isolation is that of surgical asepsis reversed. It aims to limit infection to a small zone instead of to keep a small area free from infection. Air currents play no practical part in spreading scarlet fever. (a) Avoid infecting clothing of attendants or utensils by careless touching of patients or by putting infected hand or things into pockets. Wear gloves. (Z>) Wash hands thoroughly on leaving zone of infection. Do not handle face or uninfected objects until hands are thoroughly cleansed. Be careful of door-knobs. (c) Boil dishes and utensils when they leave the patient. Do not put infected dishes or other articles in an uninfected zone. (d) Boil the patient's clothes, or soak then in five per cent phenol or similar germicidal solution. Be careful not to infect surroundings in removing these objects from the infected zone. (e) T o prevent the discharges from the nose, throat, or ear from being spread about the sickroom, use soft piece of paper, towel, or cloth, and at once deposit it in a paper bag or burn it. (J) Do not allow infected objects such as thermometer, pencils, stethoscope, books, or money to be taken from infected zone without proper disinfection. (g) Thorough cleansing of the patient when released from the infected zone, although of questionable importance, must still be practised. The mouth should be thoroughly cleansed, and antiseptic sprays may be used in the nose, although their value is uncertain. Patients should not be released until all signs of inflammation of the mucous membranes have entirely subsided, or the lesion shown to be free from hemolytic streptococci. QUARANTINE

Susceptible exposed persons should not be allowed to go to new places or come in contact with susceptibles until one to two weeks after the last exposure. If immunized by

ACUTE INFECTIONS IN CHILDHOOD

53

antitoxin, or if shown immune by the Dick test, quarantine may be properly omitted, provided that provision is made by proper isolation to prevent indirect spread of the disease. Care should be taken to see that these contacts have not, themselves, had a mild and overlooked infection. Closing of schools is unnecessary provided that the pupils are carefully studied to eliminate promptly those who become ill and those who are active carriers. Culturing has not yet been widely used because of the difficulties, but it is capable in some cases of being made very useful. Closure of the school for a short period, such as two weeks, does little good because carriers are likely still to be present. Adults need not be quarantined as a rule unless dealing in raw foods, especially milk, cream, and ice cream. DISINFECTION

Disinfection is of doubtful value as a general measure of control. Proper cleanliness and asepsis about the patient obviate this necessity. In rooms which are well-lighted and aired, objects that might have been infected have usually ceased to be a source of danger by the time the patient has ceased to harbor the organisms and can be released. Disinfection can be effected by exposure to sun, by thorough cleansing and washing with soap and water, by means of germicidal solutions such as phenol or corrosive sublimate, or through prolonged exposure to formaldehyde gas. All things that can be boiled, such as linen, should be so treated. III. T R E A T M E N T The great dangers of scarlet fever are sepsis, cardiac involvement, nephritis, and toxemia. Of these, sepsis is by far the greatest factor in mortality. Scarlet fever antitoxin is produced by inoculation of horses with scarlatinal streptococci by either the Dochez or Dick methods or modifications. The strength of the antitoxic serum is measured by its power to neutralize scarlet fever toxin as shown by intradermal injections of the mixtures. Park suggests as the antitoxic unit the amount that will neutralize 100 toxin units.

54

PRINCIPLES OF MEDICAL T R E A T M E N T TREATMENT o r

ТОХЕША

Use of Antitoxin. In from eight to twenty-four hours after use of antitoxin there appears a rapid subsidence of the toxic symptoms, fever, malaise, delirium, and rash. The results are more dramatic than those following almost any other therapeutic measure. The serum has no certain action on the septic compHcations. Dosage for moderate cases is 5,000-10,000 units, and for very severe cases 20,000-50,000 units. If effects do not appear in twelve to twenty-four hours, a larger dose should be given. Convalescent patient's blood-serum is of limited application, but has some value. From 50-100 cc. may be used preferably by intravenous injection. The convalescent's blood may be obtained one to three weeks after the temperature has become normal. The serum should be tested for syphiUs and for bacterial contamination before being used. The whole blood of a convalescent either citrated or injected as soon as drawn may be used for intramuscular injections. Eliminatile treatment, (a) Free fluid intake is important. One and a half liters, more or less, should be taken daily, according to age. When fluid is not taken freely, it should be administered by rectum or subcutaneously, or, in very toxic cases, intravenously as saline solution, (b) Mild catharsis and (c) daily warm baths are beneficial. G E N E R A L SEPSIS

Prevention is the essential. T o guard the portals of entry: {a) Cleanse the mouth, gums, and teeth with a cotton swab applicator two or three times daily. Saline, sodium bicarbonate or borax solution, or a combination of these with ten or twenty per cent glycerine, or some other mild cleansing solution such as Dobell's, may be used. (0) Protect the mucous membranes from trauma. Albolene and similar petroleum oils are of value following cleansing of the mouth, especially in mouth breathers, or when there is mucous membrane infection. Carious teeth, old roots, and tartar deposits should be attended to.

ACUTE INFECTIONS IN CHILDHOOD

55

(c) Antiseptics such as phenol, eucalyptus, argyrol, silver nitrate, and iodine, are of doubtful value in the mouth. Their use may cause chemical injury to the mucous membrane. If they are to be used, careful consideration should be given to the amount of harm they do to tissue as well as to bacteria. The least injurious to tissue are usually the best. (d) Nasal infection and nasal vault infection as well as accessory sinus disease may be sources of danger, but are difficult to treat effectually. Mechanical cleansing by swabs is allowable. Syringing is liable to cause injury or to spread infection. Patients, if old enough, may clear the nose by blowing. Application of ointments and medicated oils is of value for protection and for mild antiseptic action. (e) Removal of tonsils and adenoids as early as possible in the acute stage of infection has been suggested and, in practice, seems to be beneficial. I n a limited number of cases in which tonsillectomy has been performed in the early stage of scarlet fever, a very favorable course has followed. During convalescence it frequently becomes necessary to remove the tonsils and especially the adenoids for persisting infection in them or in the ears or glands. There is no ground under suitable conditions for the ancient conservatism about operating in scarlet fever. ( f ) Resistance should be maintained by rest and other supportive measures. Treatment. Methods are the same as for prevention: rest in bed, large fluid intake, baths and alcohol rubs, cocoa-butter rubs, ice-cap or ice-collar, sunshine, fresh air, outdoor treatment. Secure sleep and promote comfort by alleviating causes of discomfort by any means available. Sleep and rest should not be sacrificed to the use of antiseptics. Supply energy by easily assimilated foods. Sugar is of great value. LOCAL SEPSIS

Throat. Chemicals are of questionable value. CleanHness and soothing applications are indicated. In older patients hot irrigations with twenty per cent glucose solution are of value. Coughing or struggling when irrigations are given contraindicates their use. Spraying with ten to twenty per cent argyrol, or with five to ten per cent silver

5б

PRINCIPLES OF MEDICAL T R E A T M E N T

nitrate may be of some value. Mercurochrome, one per cent solution, is sometimes used. Nose. It is better and safer for the patient to cleanse the nose by blowing than to use irrigations. Sprays are of little value, but may be used. Instillations of 15 per cent argyrol, or camphor 2 gr. (0.13 Gm.), menthol 2 gr. (0.13 Gm.), and iodine i gr. (0.065 Gm.), in albolene i oz. (30 cc.), may be tried. Instillation of plain albolene or insufflations of calomel powder twice daily are often of value. Otitis Media — Prevention. Previous abnormalities of nasal vault, such as adenoids or large turbinates, as well as attempts at local asepsis are important factors in causing otitis, (a) Avoid nasal irrigation, palpation of nasal vault for adenoids, coughing, forcible washing of throat, and the Trendelenberg's position; {b) prevent obstruction of nose from acute swelling, by oily instillations or sprays as above. Adrenalin i :8,ooo in oily preparations (adrenalin inhalant) may sometimes help. Ten drops of 15 per cent argyrol may be instilled into the nostril and allowed to run down into the fossa of Rosenmüller by holding the head to that side while in the supine position for twenty minutes. Treatment, {a) For nose and nasal pharynx, as above ; (6) free drainage by cutting drum if bulging ; repeat if necessary, (c) Irrigate every two to four hours with boric acid or saline solution at i o o - i i o ° F . {d) Especially when discharge is thin, the dry treatment may be used instead of irrigations. It consists of frequent sponging out with sterile cotton and keeping in a narrow wick to the drum, but not closely filling the canal. The -wick must be changed as soon as saturated. To this may be added later boric powder insufflations or instillations of 5 per cent boric acid dissolved in 15 per cent alcohol. Silver salts and other antiseptics are of questionable value, (e) Watch for symptoms of mastoiditis. Mastoiditis — Prevention. treat otitis media.

Watch for and

promptly

Treatment, (a) Drain the middle ear promptly by paracentesis, and repeat as often as necessary. Copious irrigations every two hours, hot. Applications of ice to the

ACUTE INFECTIONS IN CHILDHOOD

57

mastoid process, {b) Operation is indicated if tenderness persists, if edema increases, or if temperature remains up for more than three days. Operation may be desirable even in the absence of these signs. Continued discharge alone may be an indication for operation. Cervical Adenitis — Prevention, (a) Throat- and mouthcleanliness, and attention to teeth and gums are important. (Ô) Removal of tonsils and adenoids may be considered. Even in an acute stage of the disease, removal of the tonsils has given highly favorable results, but further experience is desirable, (c) Treatment of diseases of the nose and accessory sinuses may be necessary. Treatment, (a) Ice appUcations are useful in the first few days and poultices afterward. Resolution without pus often occurs with poultices, (b) Treat throat, mouth, and nose as needed, (c) Incision is required if suppuration occurs. The best results are obtained by not incising too early, but allowing pus to become localized and the induration to subside. Burrowing of pus is rare. If it occurs, incise very promptly. Incision should be no longer than is necessary for drainage, and in lines of cleavage of the skin, to avoid scar. Pyemia requires incision and drainage as lesions develop. Arthritis — Simple. Scarlatinal arthritis and periarthritis is self-limited to a few days. Rest, immobilization by cotton-batting bandages or splints, and appHcatiors of methyl salicylate dressings are useful. Septic arthritis requires incision as soon as diagnosis has been made. Thorough and prolonged washing out of the cavity and sewing up tight has given the best results. Incision followed by rubber-dam drains has not proved as satisfactory. Immobilization is needed. Phlebitis (rare). Elevate the affected part to improve its circulation. Apply heat locally by means of poultices. Citric acid may be prescribed internally. Arterial Thrombosis (rare). Elevation, local heat, amputation only after line of demarcation has formed. Empyema. Drainage by operation. Peritonitis (rare). Operation required. Boils may be benefited by autogenous vaccines.

58

PRINCIPLES OF MEDICAL T R E A T M E N T

Nephritis — Prevention. Combat toxemia of acute stage. See Toxemia, p. 54. Reduce demands on the kidney b y : (a) rest in bed for at least three weeks in all cases; (b) avoid excessive loss of heat and continued chilling of skin; (c)free fluid intake in the absence of edema probably benefits the kidney; (d) diet low in protein, and chiefly of carbohydrate and fat. Avoid extractives, nucleo-proteids, and foods rich in purin. Cream and milk (one to two pints), cereals (especially wheat), rice, baked potatoes, tapioca, sugar, sweet fruits, bread, and green vegetables, except asparagus, are suitable. In the acute stage the patient may refuse everything but fluids. Sugar may be used at this time freely, (e) Daily hot bath; (/) salt intake may be reduced but its value is uncertain; (g) alkalis may be administered. Treatment. See Nephritis, p. 27. Uremia. See page 34. CARDIAC COMPLICATIONS

Endocarditis — Prevention, (a) Avoid and promptly treat local infection, such as alveolar abscess, otitis media, septic joints, diseased tonsils, accessory sinus disease, and other focal infections, which may be responsible for the cardiac infection; (b) prevent exertion during the period likely to be attended by cardiac complications; (c) combat toxemia. Treatment, {a) Rest should be as complete as possible and prolonged until the lesion has entirely healed — two to six months. Cardiac stimulants are contraindicated because cardiac insufficiency does not develop early. An ice-bag, aconite, or bryonia may perhaps give the heart relative rest by quieting its action. (6) Salicylates. Danger of kidney injury must be kept in mind. See also, p. 9. Pericarditis. Prevention is the same as for endocarditis. For treatment morphine may be necessary, because of pain. Posture may need to be upright, also for this reason. Fluid in the pericardium may require aspiration. Pus requires operation and drainage. See also p. 17. FEVER

Usually it is self-limited, not prolonged, and promptly reduced by antitoxin. Alcohol rubs, cold sponges, or cold

ACUTE INFECTIONS IN CIHLDHOOD

59

baths, may be used for a stimulant effect. Friction of the skin is usually advisable while using cold treatment. Friction alone, using cocoa butter, may reduce temperature, stimulate vasomotors, and add to comfort. MEASLES

I. M A N N E R OF S P R E A D Exit of virus from nose and throat and possibly from conjunctiva; not by desquamation. Viability of virus (slight): apparently does not survive under any known natural condition more than one day. Usually it dies in a few hours, especially in light or surmy conditions. Manner of transfer, by droplets and direct contact; at times, by indirect contact; not by food. Point of entry, probably respiratory tract, especially nose and throat. Persistence of virus: it dies with the estabhshment of convalescence or earlier; does not persist after subsidence of measles rash, without regard to secondary infections such as otitis media. Most contagious period is the catarrhal stage. Incubation period is nine to twelve days. Average ten days. II. P R O P H Y L A X I S IMMUNITY

Practically none naturally, except during the first year of life and especially in the first six months. Immunity after one attack is very great and ahnost always complete. Passive immunity. This may be secured for exposed cases by injection of serum of convalescent patients, as first suggested by Weisbecker in 1896. The blood should be drawn about one week after convalescence is established, but blood drawn even years later may be of value. The dose is 2-10 cc. (30-150 min.), and should be given as soon as possible after exposure. The later it is used after exposure, the larger the dose must be. After six days the value is much less certain.

6o

PRINCIPLES OF MEDICAL

TREATMENT

Active immunity. I t was hoped that convalescent serum given after a short incubation of the virus would cut off the disease, but allow an active immunity. In some cases at least this has not been shown to happen. If the dose is small, or the serum given late, a mild, markedly modified measles may develop, which apparently confers active immunity. It is not certain how to secure just this effect, as the disease under our present conditions may be completely prevented or not modified at all. ASEPSIS

Asepsis is particularly difficult in general life because of droplet infection. The most casual contact will allow the disease to be contracted. Avoid the region of persons who sneeze. Keep hands clean and avoid touching mouth or nose with infected hands or infected objects. ISOLATION

Isolation is of little general value because of the contagiousness of the disease, and the appearance of contagiousness usually several days before the disease has been recognized. Isolation, to be of any value, should be secured early in the catarrhal stage and continued until the rash has passed its height, that is, from seven to ten days. There are no carriers. Technic. The patient must be isolated so that droplet infection may not be carried to others, otherwise the technic is the same as for scarlet fever but of much less importance. QUARANTINE

This is one of the most effective means of controlling the disease in exposed groups. The susceptibles should be kept in complete isolation, beginning at least by the seventh day from the first exposure and lasting until the fourteenth day from the last exposure. To exclude those ill with the disease in schools, inspection alone is useless as a rule because of the early appearance of contagiousness. DISINPECTION

Disinfection is of practically no general value. Measles contagion dies with extreme rapidity, and probably in-

ACUTE INFECTIONS IN CHILDHOOD

6i

variably -within twenty-four hours after leaving the body under ordinary conditions. The surroundings of patients who have recovered have ceased to be infectious. III.

TREATMENT

The chief cause of death is secondary infection of the mucous membranes. Of such infections pneumonia is of the greatest importance. Treatment, therefore, should be directed against mucous membrane infection, especially of the lungs. Acute toxemia is to be combated by (β) free fluid intake; {b) catharsis, which must be used carefully to avoid causing diarrhea; and (c) stimulation by means of tepid baths, cool sponging, or friction to skin; e. g., by rubs with cocoa butter. Bronchopneumonia — Prevention, {a) Maintain general resistance by means of fresh air, sunshine, rest in bed, and by a diet easy of digestion and absorption. (&) Maintain local resistance. Cleanliness of the mouth and prevention of nasal and laryngeal obstruction are important. Soothing oily sprays may do good; (c) Other infections, such as colds or diphtheria, are to be avoided. Treatment.

See Bronchopneumonia, p. 77.

Acute laryngitis may be treated by means of (a) expectorants, of which water is the most essential, syrup of ipecac, or syrup of hydriodic acid; (b) steam inhalations with compound tincture of benzoin and menthol, followed by oily sprays; (c) intubation if obstruction occurs and requires it; (d) antitoxin in all cases unless diphtheria has been excluded by examination of the larynx and taking cultures from the larynx; (e) cold applications or ice-collar to neck. See also p. 84. Tracheitis. Treat as for Laryngitis. See above, and also p. 84. Otitis Media.

See Scarlet Fever, p. 56.

Rhinitis, (a) Soothing applications, oily sprays; (b) atropine, as in rhinitis tablets, or camphor; (c) argyrol solution, ten to fifteen per cent instillations or spray.

б2

PRINCIPLES OF MEDICAL T R E A T M E N T

Stomatitis, (a) Mouth-cleansing with mild antiseptic solution, using cotton swab applicators; (b) hydrogen peroxide if teeth and gums are foul; use once or twice daily; (c) chromic acid solution, two to four per cent: apply with swab once daily; (d) removal of carious roots or bad teeth; (e) careful avoidance of trauma of any kind; (/) iodine preparations and silver nitrate may have value in certain selected conditions. Noma — Prevention. Careful cleansing of the mucous membranes of the mouth is important. Avoid trauma from teeth or manipulations. Treat all ulcers promptly with peroxide and apply chromic acid solution. Watch for ulceration, especially at edges of gums, and treat with chromic acid solution, iodine, or arsenic. Treatment. B y means of an escharotic, destroy completely the infected area; the actual cautery under chloroform anesthesia is the best. Conjunctivitis, {a) Wash three times daily with boric acid solution; {b) apply white vaseline to the lids; (c) avoid injuring the cornea. Enterocolitis — Prevention. Avoid overfeeding and be sure that milk and other food is free from contamination or is pasteurized or sterilized. Avoid unwise catharsis. Avoid starvation. B. acidophilus milk may be beneficial. Treatment. Force fluid, cereal diet, bismuth in drachm doses every four hours. See also Diarrhea, p. 120. PERTUSSIS I. M A N N E R O F S P R E A D Exit of virus, from nose and throat. Viability of virus; it apparently dies rapidly outside the body, but may survive one or two days. Manner of transfer, chiefly by droplets, also by direct contact; rarely by indirect contact. Point of entry, nose or throat. Persistence of virus: it persists for a few weeks, and possibly as long as the characteristic cough. Most contagious period is the early catarrhal stage. Incubation period, one to three weeks; average seven to ten days.

ACUTE INFECTIONS IN CHILDHOOD II.

63

PROPHYLAXIS IMMUNITY

Natural immunity is extremely low in infancy, becomes greater after five years of age, and is considerable in adult life. Acquired immunity from attacks of the disease is marked in the majority of cases but is not rarely lost after years. Immunity by vaccine inoculation is by no means certain. See Vaccine Treatment, p. 204. ASEPSIS

Careful personal asepsis fails to protect one in community life because of droplet infection. The same methods are employed as for varicella. ISOLATION

Contagion begins and is most marked at the catarrhal stage, usually before the diagnosis has been made. Therefore, isolation of cases as they develop in the community rarely controls the disease. T o be effective, isolation should begin at the earliest symptom of "cold." At the paroxysmal stage, contagion is slight and often considered absent. Restrictions may then be reduced and the patient allowed outdoors. Usually he is designated by a distinctive armband or other insignia. Technic is the same as for Measles, p. 60. QUARANTINE

Quarantine is one of the important means of control. Exposed persons should be kept under suitable restraint until three weeks after the last exposure, and should then be free of catarrhal symptoms. DISINFECTION

Disinfection is not required after recovery. Infected objects are not a source of danger after one or two days.

б4

PRINCIPLES OF MEDICAL T R E A T M E N T III.

TREATMENT

Vaccines are still subjudice. Variable results may be due to (a) rapid deterioration of antigen; (b) insufficient dose; (c) strains having poor antigenic properties, or (d) wrong strain. Vaccines should be fresh, active, and given in dosage sufficient to cause local reaction. Usually double the amount of the preceding dose is given at intervals of two to four days, and generally from three to ten doses are given. A stock vaccine should be polyvalent. Hygiene, (a) Build up the general resistance by fresh air, sunshine, and rest, varying with the amount of prostration or fever, (b) Diet should consist of easily digested foods, such as cereals, milk, bread and butter, rice, simple puddings, chicken, scraped beef, or zwieback. If vomiting occurs, meals should be frequent and small in amount, and given, if possible, after the paroxysm. When a meal is vomited, it should at once be repeated. High protein foods are inadvisable because of the longer stay in the stomach and the danger of loss from vomiting. Free water intake is essential, (c) Bitter tonics or iron may be given. Avoid medicines which might upset the digestion. Local treatment. Avoid irritants such as dust or gases. Oily sprays of albolene with menthol or antiseptics may be applied to the nose, throat, and larynx. Inhalations of steam with benzoin, menthol, or creosote are sometimes useful to stop the paroxysm, but must not be used at the expense of general hygienic treatment. Sedatives should be used only when demanded for severe cough which exhausts the patient or interferes with sleep and nourishment. Antipyrin 1 - 4 gr. (0.065-0.26 Gm.) three times a day, or quinine sulphate 2-5 gr. (0.13-0.324 Gm.) may be tried, or tincture of belladonna, beginning with 1-3 min. (0.06-0.18 cc.) every four hours and increasing until the physiological effect of atropine appears, and then continuing in slightly smaller doses. Chloral may be used in the dose of 2-5 gr. (0.13-0.324 Gm.) once or twice a day. Benzyl benzoate in doses of 2-20 gr. (0.13-1.3 Gm.) may be used every four hours. Paroxysms of cough, (a) Fresh air day and night is, probably, the most efficient means of diminishing cough, (ό)

A C U T E I N F E C T I O N S IN CHILDHOOD

65

Psychic suggestion m a y be used to calm the fear of the patient and psychic upsets and loud noises are to be avoided, (c) A v o i d all respiratory irritants, (d) Pressure on the epigastrium or tight bands around the abdomen m a y be used, (e) T h e use of sprays for the larynx, inhalations, and sedative drugs are described above. X-ray treatment. V e r y favorable results are reported b y Lawrence Smith and others. Although benefit is not alw a y s marked, any hope of it should be seized in this disease. Leonard has used the following dosage: Coolidge tube 60,000 volts, 4 m. amp. 20 inches distance •— i m. m. alum, screen. Under I yr. age 12 m. amp. min. 1-2 " " 24 " " " 2-5 « " 32 " " " Older 40 " " "

This total dosage is divided equally anteriorly and posteriorly. Three treatments are given on alternate days, and another after an interval of a week. IV.

COMPLICATIONS

Bronchopneumonia. Prevent b y means of fresh air and sunshine throughout the disease; rest; keep up nutrition b y wise feeding; avoid fatigue from paroxysms; avoid other infections, such as acute colds; avoid irritants such as dust. For treatment, see p. 77. Stomatitis. See Measles, p. 62. Otitis Media. See Scarlet Fever, p. 56. Cerebral hemorrhages m a y be guarded against b y attempting to control severe paroxysms of cough. VARICELLA I.

M A N N E R OF SPREAD

Exit of virus, probably only through the varicella lesions of skin and mucous membrane. Viability of virus: it apparently survives some hours, days, or weeks. Manner of transfer, direct and indirect contact. Point of entry, probably mucous membrane of throat or nose; possibly gastro-intestinal tract, or wounds.

66

PRINCIPLES OF MEDICAL T R E A T M E N T

Persistence of virus: it may persist in lesions until healed. Most contagious period is the vesicular stage. Incubation period, fourteen to twenty-one days; average three to four days. II.

PROPHYLAXIS

Immunity is considerable under six months, increased distinctly after five years, and rather marked in adult life. Asepsis is difficult to carry on in practice because the disease is extremely contagious. The principles are similar to those for scarlet fever and diphtheria. Isolation should be insisted on as early as possible and continued until complete healing of the lesions. The technic is the same as for Scarlet Fever, p. 52. Quarantine. It is important to keep exposed persons from contact with others from seven days after first exposure to twenty-one days from last exposure. Disinjection.

See Scarlet Fever, p. 53. III.

TREATMENT

The toxemia of varicella is of slight importance. Nephritis rarely follows the disease. The chief danger is from infection of the skin lesions with organisms such as the streptococcus or diphtheria bacillus. Toxemia. During the acute stage of fever cold sponging, ice-caps, rest in bed, and forced fluids are beneficial. Local lesions. Careful asepsis is essential from the beginning. Daily baths with soap and water, preferably by shower, drying the skin with clean towels, and anointing with boric acid, vaseline, or camphorated oil are of value. Underclothes, night-clothes, and sheets should be kept scrupulously clean and changed daily. At times it may be advisable to use weakly chlorinated baths. Chlorinated soda (Liquor Sodae Chlorinatae, U. S.), fifteen per cent, is especially beneficial for treatment of small areas of secondary skin infection. Its use may be followed by application of ammoniated mercurial ointment, or boric acid ointment.

ACUTE INFECTIONS IN CHILDHOOD

67

Mouth lesions. Occasionally many lesions occur in the mouth which may require very careful asepsis and cleansing. Corneal or conjunctival lesions may develop. T o avoid bhndness, treatment of these lesions should be very prompt and active. DIPHTHERIA I.

MANNER

OF

SPREAD

Exit of virus, chiefly from throat, nose or infected ear, but also at times from lesions of skin, as cuts, scratches, or sinuses. Viability of virus: it may survive days, weeks, or some months, but under ordinary conditions of light and air it dies in a few days. In sunlight it dies in a few hours. Manner of transfer, chiefly by direct contact; also by indirect contact and droplets. Milk is the only food known to spread diphtheria. There are no gross changes in infected milk. Points of entry, chiefly the nose and throat, larynx or lungs; rarely the eye sac, skin of genitals, especially in puerperium. Persistence of virus: it persists for days, weeks, months, or even years, in lesions of mucous membranes, such as enlarged or diseased tonsils. Mostly, contagious period varies with extent of mucous membrane lesions and quantity of discharge. Incubation period, one to seven days; average, three to four days. II.

PROPHYLAXIS IMMUNITY

An attack produces lasting immunity in about fifty per cent of the cases. Natural immunity is marked in infancy, especially in the first six months of life. It is lower in bottle-fed babies. The lowest immunity period is from one to five years of age. Adults show immunity in large proportion. Persons in better social conditions show lower immunity than those in poorer conditions.

68

PRINCIPLES OF M E D I C A L

TREATMENT

Active immunity is produced by injections of diphtheria toxin-antitoxin mixtures, or toxoid. The dosage is i / i o L. + toxin dose partially neutralized by antitoxin as determined by standard guinea-pig tests. The reactions are slight and almost wholly local. Three injections are given at weekly intervals. Retests for immunity are made six months later, and the immunization repeated if necessary. About ninety per cent become immune from one injection. Passive immunity. Antitoxin in doses of 1,000-2,000 units produces immunity lasting two to three weeks or more. Local immunity. Local conditions play a part in immunity, as shown by the localization of the disease or the influence of wounds. Good local conditions of the mucous membrane should be secured by removal of bad teeth or roots, diseased tonsils, and adenoids. Diseased gums or mucous membranes require treatment and mechanical or chemical injuries to the mucous membranes are to be avoided. Schick test. Diphtheria toxin, 1/50 M.L.D., is injected intradermally. The reaction in susceptibles appears as a reddened infiltrated area 2-3 cm. in diameter in fortyeight hours, and reaches its height in three to five days. Vesiculation may occur with severe reactions. The subsidence is slow, lasting five to ten days and leaving an area of pigmentation which may last for months. Desquamation usually follows the reaction. Control tests are done with toxin heated at 7o°C. for one half-hour. False reactions occur in twenty-four hours and usually subside -within forty-eight hours. Results are read in forty-eight hours. Immunes show no reaction to this test. ASEPSIS

Avoid putting fingers, pencils or pins into the mouth or nose. Wash the hands carefully before eating. D o not use common drinking cup or common towel. Avoid kissing on lips. Avoid region of people who cough, sneeze or spit. Avoid milk handled or produced under unsanitary conditions, or by ill persons. Avoid dirty public eating-places.

ACUTE INFECTIONS IN CHILDHOOD

69

ISOLATION

Isolation is of great value. Prompt recognition is required to make this effective. Missed cases also must be found by epidemiological studies and culturing suspects. Isolation should be continued until virulent diphtheria bacilli have been absent, as shown by cultures, for at least three days. Technic.

Same as for Scarlet Fever, p. 51. QUARANTINE

Quarantine is of little practical value, because cultures can be taken from exposed persons, and if found to be negative, quarantine need not be continued. Closing of schools or other places of assembly is unnecessary, but measures should be taken to discover carriers as well as clinical cases among those who thus come together. Schick's test is of great value in finding those who are susceptible to the disease. III.

TREATMENT

The chief causes of death in diphtheria are toxic action on brain centres in the early deaths, toxic degeneration of the neuromuscular tissues of the heart and of the nerve-axis cylinders in the deaths after one week. In the laryngeal cases, strangulation from mechanical obstruction and, more commonly, bronchopneumonia are the chief causes of death. The essentials of treatment are, therefore, early neutralization of toxin with antitoxin and sufficiently prompt relief of laryngeal stenosis by intubation. For toxemia antitoxin should be used as early as possible, and preferably on the first day. The dose should depend upon the severity of the symptoms, and the mode of administration varying between 2,000 units for a very mild case and 100,000 units or more for a very severe case. See Diphtheria Antitoxin, p. 216. General eliminative measures are required, p. 54. For obstruction to breathing, antitoxin should be used as early as possible. Intubation is called for when there is stridor, use of ac-

ηο

PRINCIPLES OF MEDICAL TREATMENT

cessory muscles of respiration, restlessness, or dyspnea. Relief should be secured before cyanosis and exhaustion develop. Tracheotomy is required if intubation fails, or when there is obstruction above or below the larynx. Bronchoscopy is useful when there is membranous obstruction low down in the trachea or bronchi. Removal of membrane from the larynx with forceps, swabbing, or suction apparatus is successful in about twenty-five per cent of the cases. It may have to be repeated once or twice at about twelve-hour intervals. Local Treatment. When antitoxin is used, no routine local applications need be made. In selected suitable cases some local application may be desired but they are of little value. As cleansing irrigations for the throat, saline solution, boric acid solution, or Dobell's solution may be used copiously. They should be applied as warm as the patient can tolerate them. Do not exhaust the patient by excessive attention. Bactericidal therapy has failed. Soothing applications, such as albolene and oily sprays, may be used for mechanical protection of the mucous membranes. The nose may be treated in this way or by instillations. Irrigations should not be used in the nose. Rest. In all cases in which toxemia is marked, the patient should be kept in bed for three to six weeks, because cardiac or nerve complications may develop as late as this. Hygiene. Sunshine, fresh air, and freedom from dust are important. Diet. Large amounts of fluid should be taken. The diet should be balanced, easily digestible, and sufficient for energy requirements. IV. TREATMENT OF COMPLICATIONS Cardiac compUcations develop generally in the first three weeks of the disease, and can be prevented only by early use of antitoxin in sufficient amount. Essentials. For the acute cardiac insufficiency which develops early, it is necessary to secure the highest degree of

ACUTE INFECTIONS IN CHILDHOOD

71

rest and to avoid any strain on the heart. The disturbance rarely lasts more than one week, and when strain has been avoided during this period, recovery may be expected. The myocardial weakness may develop later, but is then less dangerous. Methods, (a) Horizontal position. Do not allow the head or body to be raised, {b) When there is nausea or vomiting, nothing should be taken by mouth. Nutrient enemata and saline solution, or glucose solution, five to ten per cent, should be administered by rectum as required for thirst, (c) Morphine may be used subcutaneously in small doses as a sedative, {d) Stimulation is of doubtful value. Caffeine sodium benzoate, 1-5 gr. (0.065-0.324 Gm.), can be administered subcutaneously once in four hours. See also p. 243. Diphtheretic paralysis can be prevented only by early use of antitoxin in sufficient amount. Treatment, (a) Improve the circulation locally by massage, electricity, and passive motion, (b) Improve the general condition by fresh air, sunshine, nutritious food, and iron or other tonics, (c) Antitoxin is of no value after the paralysis has appeared. Otitis Media. Pneumonia.

See Scarlet Fever, p. 56. See Pneumonia, p. 75.

"Chronic tubes") i.e., after intubation.

chronic obstruction of larynx

Prevention: (a) Avoid trauma in performing the operation, (b) B y using a tube of the right size, avoid undue pressure, (c) The tube should be worn for shortest reasonable time. Treatment, (a) If obstruction persists four weeks without improvement, tracheotomy should be performed to avoid laryngeal irritation or injury, (b) After healing of larynx, mechanical dilatation by means of tubes or dilators may be required. Cervical Adenitis.

See Scarlet Fever, p. 57.

Serum Disease, (a) Urticaria. Apply local anodynes and cooling lotions, "white wash," soda bicarbonate baths, demulcent lotions, or methol, three per cent, in alcohol.

72

PRINCIPLES OF MEDICAL TREATMENT

Adrenalin, 5 - 1 4 min., injected subcutaneously causes disappearance of lesions and itching for one to two hours and may be repeated s. 0. s. If no effect follows in ten minutes, increase the dose until effect is secured. (6) Angineurotic edema may be relieved at times by injections of adrenalin, 1:1,000, 1 0 - 1 5 Edema of the glottis due to this cause has never been seen in the South Department (for infectious diseases) of the Boston City Hospital. (c) Erythema multiforme. No treatment is satisfactory. (d) Lymphadenitis is self-limited and requires no treatment. (e) Arthralgia. Immobilization, gaultheria dressings, salicylates, and narcotics may be of service. (/) Arthus's phenomenon, a localized sterile cellulitis at point of injection. Evaporating lotions, cool compresses, and, later, poultices are recommended. (g) Vomiting. Give nothing by mouth and glucose solution by rectum. Anaphylactic Shock — Prevention, (a) Perform a skin test for susceptibility, as follows: scratch the skin and apply a little serum. A local reaction of urticarial type appearing in two to fifteen minutes shows susceptibility. When the patient is susceptible (i. е., sensitized), antitoxin cannot be given safely in ordinary dosage until the patient has been desensitized, (b) To desensitize, inject small doses of serum, beginning with o.oi cc. (0.0016 min.), and increasing continuously to o.i cc. (1.6 min.), 0.5 cc. (8 min.), and i.o cc. (16 min.), at about half-hour intervals, (c) To paralyze the mechanism of shock (i. е., to prevent bronchiole spasm), inject atropine in full dosage subcutaneously half an hour before the serum and adrenalin in full dosage coincidentally with the serum. Treatment. Death usually occurs before treatment can be applied. Methods, {a) Atropine, full doses, (δ) Adrenalin, full doses, (c) Oxygen, {d) Heat.

ACUTE INFECTIONS IN CHILDHOOD

73

V. C A R R I E R S 1. Remove mucous membrane abnormalities when possible. Enlarged tonsils, adenoids, foreign bodies, accessory sinus disease, or carious teeth should have attention. 2. Chemical applications have proved of very doubtful value. Silver nitrate, argyrol, acetic acid, chromic acid, iodine, and dichloramin Τ have been used. Mercurochrome has had no influence on carriers. Gentian violet is one of the best applications. A saturated solution in water should be used once or twice daily.

CHAPTER A C U T E INFECTIONS OF

V RESPIRATORY

TRACT BY G E O R G E C H E E V E R

SHATTUCK,

M.D.

AND

G E R A L D B L A K E , M.D. Associate Physician, Massachusetts General Hospital Instructor in Medicine, Harvard Medical School

LOBAR

PNEUMONIA

Note. An acute infectious disease of multiple etiology, most commonly caused by the pneumococcus. The rate of the pulse and respiration are indices of toxemia. Mortality: is commonly due to : i . Toxemia: (a) Circulatory disturbance ; (δ) Asphyxia. 2. Less often due to complications: (a) Empyema; {b) Pericarditis; (c) Endocarditis. P R I N C I P L E S OF

TREATMENT

1. Secure good nursing and fresh air. 2. Eliminate and dilute toxins. 3. Watch circulation and prescribe digitalis promptly when required. 4. Prescribe other drugs only for special reasons. 5. T a k e precaution to prevent accident. 6. Diet suitable to case. 7. Recognize complications promptly. 8. Serum may be prescribed for cases of T y p e I.

METHODS (1) Eliminate toxins by requiring copious ingestion of water, unless the heart be weak, and by keeping the bowels clear. Watch urinary output to see that the water is being excreted. (2) Out-of-door treatment m a y benefit robust patients, but the old and feeble are likely to do better indoors. Fresh

7б

PRINCIPLES OF MEDICAL TREATMENT

air is, perhaps, the best stiimüant in pneumonia. Sometimes it diminishes dyspnea and promotes comfort. (3) Note the outlines of cardiac dulness, the sounds of the heart and the quality of the pulse at every visit in order promptly to detect any change in them. (4) Digitalis is indicated (a) if the quality of the pulse be poor; (b) if it becomes irregular or (c) if the rate goes above 120. Irregularity early in the illness is less apt to herald danger than that developing late. (See Circulatory Disorders of Infectious Fevers and Sepsis.) (5) Dyspnea with cyanosis can be relieved to some extent by inhalation of oxygen. It can be administered through a catheter passed into the nose. (6) Venesection may be very beneficial, particularly when cyanosis and cardiac embarrassment develop early. (7) Morphine is indicated to relieve pleuritic pain when a tight swathe fails to do so. Sleep is very important to conserve the strength of the patient and morphine may be required to obtain it, especially in the early stages of pneumonia. Morphine is contraindicated whenever bronchial secretion is profuse, because it checks expectoration, and if morphine is to be used in the later stages caution is necessary. (8) When there is much dyspnea diet should consist of food that requires no chewing and that is easily swallowed ; for example, liquids, or Uquids and soft solids. Chewing favors digestion, however, and is beneficial when not contraindicated. The amount should be gauged by the digestive power of the individual, but the usual course of the disease is so short that nutrition is seldom important. Avoid renal irritants and gas-producing foods. (9) Besides the complications above mentioned, be on the watch for a true nephritis. (10) When temperature is very high and the heart doing well, sponge baths may be used to reduce the fever. (11). Tympanites may require treatment. An enema of 1 oz. (30 cc.) of glycerine undiluted generally acts well. (12) Delirium: (a) Push eliminative measures to reduce toxemia, (b) If the patient is emaciated, try to improve his nutrition. Alcohol by mouth may be beneficial for

THE RESPIRATORY TRACT

77

delirium with exhaustion, (c) As a palliative for active delirium, which taxes the patient's strength, morphine gr. (0.0108 Gm.) or, if this fails, morphine ^ gr. (0.008 Gm.) and scopolamine Vioo gr· (0.00065 Gm.) may be used subcutaneously. Hypnotics may be tried cautiously, but circulatory depressants must be avoided. Caution. Delirium, even when slight, may be dangerous. When the nurse leaves the room even for a moment, someone should take her place lest the patient jump from the window. No razor or weapon of any kind should be left within reach of the patient. BRONCHOPNEUMONIA TREATMENT

Treatment is essentially the same as for lobar pneumonia except that the disease generally runs a milder, but longer course. Nutrition, therefore, is more important. Bronchitis is often associated with bronchopneumonia, and when this is the case, expectorants may be of service during convalescence. T h e y are contraindicated in the acute stage. The bronchopneumonia of influenza may be very severe in character (see Influenza). BRONCHITIS ETIOLOGY Acute bronchitis commonly follows infections of the upper respiratory tract and especially infections by the pneumococcus or influenza bacillus. I t occurs symptomatically in some infectious diseases; for example, typhoid and measles. Chronic bronchitis is often associated, in old or middleaged persons, with slight cardiac insufficiency or with emphysema. Rarely, gout is a factor. Excessive inhalation of tobacco smoke may be a factor in the production or continuance of bronchitis. DIAGNOSIS Acute or chronic bronchitis may be simulated by tuberculosis and, therefore, sputum examination is imperative.

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PRINCIPLES OF MEDICAL TREATMENT

Many cases of bronchiectasis following influenza are wrongly diagnosed as bronchitis or as phthisis. T R E A T M E N T OF A C U T E

BRONCHITIS

1. When there are constitutional symptoms the patient should keep warm and avoid change of temperature by staying indoors. 2. If there is fever, bed may be advisable or necessary. 3. Bronchial secretion must be expectorated, but unproductive cough should not be allowed to fatigue the patient or to prevent sleep. If the cough comes from pharyngeal irritation, lozenges may suffice to check it; if from the larynx or trachea, steam inhalations may be serviceable. If necessary for relief of cough codeine sulphate gr. (0.016 Gm.) or diacetylmorphine hydrochloride ^/12 gr. (0.0054 Gm.) maybe prescribed for use in the afternoon or at night. Morning cough is generally needed to clear the lungs. It can be promoted by a hot drink. 4. Substernal distress or pain, see Tracheitis. 5· Expectorants are contraindicated during the acute stage of bronchitis because they irritate the inflamed mucous membrane. They may be used during convalescence, at which time the expectoration is often tenacious and difficult to raise. 6. Several weeks are generally required for complete recovery, but when the patient feels well he may be allowed to resume his occupation. Smoking and cold bathing should be resumed cautiously and unnecessary exposure should be avoided as long as expectoration persists. T R E A T M E N T OF C H R O N I C B R O N C H I T I S 1. Expectorants are generally beneficial, particularly potassium iodide in the dose of 5-10 grs. (0.324-0.65 Gm.), t.i.d., or in the form of syrup of hydriodic acid, i drachm (4 cc.) in water three to five times a day. 2. When there is any sign of cardiac insufficiency, appropriate stimulants are indicated. For slight insufficiency the compound squill pül may act well both as a heart stimulant and as an expectorant. The usual dose is from six to nine pills daily. They should be freshly prepared. Systematic cardiac treatment may be required.

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3. A n equable and warm climate m a y promote comfort, especially for elderly persons. 4. If the presence of bronchiectasis be suspected treat the case as one of bronchiectasis. 5. Acute exacerbations of chronic bronchitis m a y be treated much as is acute bronchitis, but severe symptoms generally indicate that some form of pneumonia has developed, and treatment should be regulated accordingly. 6. Codeine sulphate or diacetylmorphine hydrochloride should not be used consecutively over long periods on account of the danger of forming a habit. 7. T h e bronchitis of overfed patients is often benefited b y depletion. Exclude gout as a factor. 8. Excessive cigarette smoking m a y aggravate the condition or be an important factor in its causation. BRONCHIECTASIS Note. T h e disease is chronic, lasting for thirty years, more or less. T h e patient may be subjected to recurring attacks of bronchopneumonia, or of hemoptysis. M a n y patients have emphysema or asthma.^ T h e condition is often diagnosed wrongly as bronchitis or tuberculosis. M a n y cases are traceable to influenza. T h e sputum, typically, is abundant, purulent, greenish, nummular, can be raised at will b y coughing, and often contains abundant influenza bacilli as well as various other organisms. Repeated examinations m a y be necessary to demonstrate the influenza bacilli. T h e cavities m a y be localized in one lobe or disseminated throughout both lungs. Nutrition is generally good. A s the physical examination may show only a few râles, the diagnosis must rest on the history, the character, and the amount of the sputum. TREATMENT N o method yet devised offers hope of cure. Efforts must be directed to reUeving the patient as far as possible from unpleasant symptoms. I. T e a c h the patient to drain his cavities on rising in the morning, and, if necessary, once or twice later in the day. This can be facilitated by taking a drink of hot water, tea ' E m p y e m a , a b s c e s s , a r t h r a l g i a , or p n e u m o t h o r a x o c c u r in rare instaDces.

8o

PRINCIPLES OF MEDICAL T R E A T M E N T

or coffee at such times. Potassium iodide, 5-10 gr. (0.3240.65 Gm.) or other expectorants may be used if the secretion be too viscid to come up readily. Gomenol jujubes are sometimes of value. ^ 2. Avoid sedatives because they check free expectoration. The material then decomposes in the cavities and gives a foul odor to the breath and to the sputum. 3. In extreme instances of retained secretion the condition with its dyspnea and cyanosis may simulate bronchial asthma. A differential diagnosis can be made from history and sputum. An emetic will give immediate relief by clearing the lungs. 4. Most of these patients are better in warm weather. A uniformly mild climate may relieve but cannot cure. 5. Sputum must not be swallowed because diarrhea may result. 6. Foul-smelling sputum means ineíñcient drainage of cavities. The odor can be ameliorated by the use of 3 min. (0.2 cc.) of eucalyptol on a lump of sugar several times daily. 7. When the disease is localized in one lobe of the lung the chance of relief by surgical means may be considered. ACUTE INFLAMMATION OF THE UPPER RESPIRATORY TRACT REVISED BY G E R A L D B L A K E , M . D .

ETIOLOGY Infectious in most instances. The pneumococcus, streptococcus, staphylococcus, influenza bacillus, diphtheria bacillus, micrococcus catarrhalis or other bacteria may be causative. Among predisposing factors lowered physical resistance and exposure to cold are important. C O U R S E OF D I S E A S E Inflammation generally begins in the nasopharynx (pharyngitis). It usually extends within a few days to the nasal mucous membrane (coryza) and often to the tonsils (tonsillitis) or larynx (laryngitis). The severity and extent of the inflammation depends chiefly on the kind and virulence of the infecting organism and on the resistance of the patient. 1 A preparation of Oleum C a j u p u t i (Ü. S.)

THE RESPIRATORY TRACT

I. 2.

3· 4· 5·

6. 7·

8i

COMPLICATIONS AND SEQUELAE Bronchitis. 8. Bronchiectasis. Otitis media. 9· Septicemia. Peritonsillar abscess. 10. Meningitis. Ix)bar or bronchoII. Peritonitis. pneumonia. 12. Inflammation of the anArthritis. trum, frontal, ethmoiEndocarditis. dal or sphenodial sinuses. Glomerulo-nephritis.

DIAGNOSIS Exclude whooping-cough, scarlet fever, measles and diphtheria. The diagnosis of diphtheria, in some cases, can be made by culture only. Therefore the safest plan is to take a culture in every case of inflammation of the throat, and, if the report be negative but the signs suggestive of diphtheria, to take another culture. PROPHYLAXIS 1. If there is a reasonable probability that the symptoms are due to diphtheria or to one of the exanthemata isolate the patient provisionally. 2. If the clinical evidence points to diphtheria administer antitoxin to the patient without waiting for the report on the culture; or even if the first culture be negative. Prophylactic inoculation of all persons exposed to diphtheria should be insisted on. 3. Patients having infections of the respiratory tract should cover the mouth on coughing or sneezing. 4. Good ventilation of rooms occupied by the patient reduces risk of contagion. TREATMENT APPLICABLE IN GENERAL 1. Keep the patient in a warm but well-ventilated room at a uniform temperature. 2. Promote rest and sleep, using sedatives or hypnotics when needed. 3. Move bowels, at outset, by enema or cathartic unless they have been acting freely. 4. Allay unproductive or irritating cough by lozenge or sedative.

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5. Avoid local irritation by tobacco or concentrated liquor. 6. Cleanse mucous membrane frequently, and soothe inflammation by means of a nonirritating gargle. Warm water, with or without salt or sodium bicarbonate in it, or Liquor Antisepticus Alkalinus (N. F.) may be used diluted with three parts of warm water. 7. Antipyretics; for example, phenacetin 5-10 grs. (0.324-0.65 Gm.) with caffeine citrate i gr. (0.065 Gm.), or salicyl preparations, may alleviate discomfort, especially if there be fever, malaise or pain. 8. Food should be readüy digestible and easy to swallow. ABORTIVE

TREATMENT

This can be effective in the early stages only, and seldom even then. The following measures may be tried. 1. Cleansing, nonirritating gargle. 2. Hot bath before retiring, or 3. Hot drink on retiring to produce sweating. 4. Early to bed, and hypnotic unless sleep comes quickly. 5. Catharsis by calomel or saline. 6. The patient should dress in a warm room and avoid cold bathing on the following morning. M E T H O D S ACUTE

O F

T R E A T M E N T

PHARYNGITIS

1. Cleansing gargle every four hours. 2. Oil spray ' after gargle to protect and soothe mucous membrane. 3. Check cough with lozenges when possible. Otherwise use codeine or diacetylmorphine hydrochloride. 4. Cases with constitutional symptoms of considerable severity may occur. "Lateral Pharyngitis" is t}φical of this group. It is characterized by marked general toxic reaction associated with redness and swelling of the folds of lymphoid tissue at the sides of the pharynx. The severity of the general reaction is out of aU proportion to the mildness of the local inflammation which is due to the pneumococcus. • Petrolatum liquidum will serve. Menthol s grs. (0.324 Gm.) or Eucalyptol S min. (0.3 cc.) or both can be added per oz. (30 cc.) of liquid petrolatum. The D e Vilbiss atomizer is good.

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83

Treatment consists in general measures, of rest, catharsis, use of salicylates for relief of pain and reduction of temperature. Local treatment. Touching the pharynx with 50 per cent solution of silver nitrate is effective in relieving local inflammation. CORÏZA

Keep the nose as free as possible from secretion. Irrigation of the nose with an alkaline solution often gives much relief, but some physicians believe that this practice may lead to inflammation of the frontal sinus or middle ear. An oil spray may be used to free the nasal passages. If the secretion be profuse and watery, its quantity can be diminished by taking V200 gr· (0.00032 Gm.) of atropine sulphate and repeating it in from four to six hours s.o.s. Atropine is contraindicated when secretion is viscid or tenacious. Excessive dosage causes dryness of the throat, increases discomfort, and may cause severe poisoning. Atropine can be used in the form of tincture of belladonna leaves; dose from 10 to 30 min. (0.6 to 2 cc.). ACUTE

TONSILLITIS

1. Take a culture. 2. Whereas the constitutional symptoms are apt to be severe it is generally advisable to keep the patient in bed. 3. Prescribe cleansing gargle to be used every four hours. The tonsils may be painted daily with argyrol from 10 to 20 per cent in watery solution (or a spray of 20 per cent argyrol in water may be used after gargling). 4. An oil spray (page 82), used after gargling, may give some relief by allaying irritation. 5. An ice-bag collar may help much to relieve pain in the throat. 6. The diet must be easy to swallow. Cold drinks or ice-cream may be grateful. 7. Occasional doses of phenacetin or of a salicyl preparation may be beneficial for fever, malaise or pain. 8. Opiates or hypnotics are indicated sometimes. 9. Salicylate in large doses acts weU in some cases of tonsillitis having slight articular symptoms due probably to streptococcus infection.

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PRINCIPLES OF M E D I C A L T R E A T M E N T

10. Note at first visit the size, position and sounds of the heart, and the presence or absence of murmurs. Watch for any change and, before discharging the patient, determine whether the heart or the kidneys have suffered. ACUTE

LARYNGITIS

1. Scarification, intubation or even tracheotomy may be required for edema. 2. Steam, plain or medicated, ordinarily gives relief. It should be used every few hours or as desired. The steam can be inhaled from the mouth or from a pitcher containing boiling water. T o the water may be added i drach. (4 cc.) of compound tincture of benzoin. A steam atomizer which can be used to spray oil and steam together is still better. For very sensitive throats the steam and oil may act better without other ingredients, but menthol 5 grs. (0.324 Gm.), or eucalyptol 5 min. (0.3 cc.), or both can be added per oz. (30 cc.) of liquid petrolatum. Excessive dryness of the air of the room is harmful. I t can be mitigated by allowing steam to escape constantly from kettle or chafing dish. 3. Cough must be checked and talking minimized. 4. Smoking is especially harmful as a rule. ACUTE

TRACHEITIS

Treatment as for larjmgitis may suffice. A flaxseed or mustard poultice ' for the upper chest or steam inhalation may help to relieve substernal distress. Mustard should be avoided if resulting pigmentation would contraindícate its use. Gomenol jujubes ^ taken every three to six hours may relieve. INFLUENZA B Y GERALD B L A K E , M . D .

Note. The etiology is in dispute, but it seems probable that pulmonary and some other complications are attributable to secondary infections in which a variety of organisms may play a part. Among these may be mentioned streptococcus hemolyticus, influenza bacillus, staphylococcus aureus, pneumococcus and micrococcus catarrhalis. > See textbook on nursmg.

2 A preparation of Oleum Cajuputi CU-S.).

THE RESPIRATORY T R A C T

8$

T Y P E S OF I N F L U E N Z A I.

RESPIRATORY

1. Mild like severe coryza. 2. Broncliitic. 3. Bronchopneumonie. II.

G A S T R O INTESTINAL

4. Gastric. 5. Intestinal. Certain symptoms are common to both types; namely, sudden onset, prostration, fever, headache, pain in back and extremities. PROPHYLAXIS 1. Isolation to prevent spreading of the contagion should be carried out in all cases. 2. The use of masks and gowns is advisable for doctors and nurses. Care should be taken that the mask is changed at each visit, or that some mark should be made on the inner surface of the mask so as to prevent the mask being put on inside out at subsequent visits. The appHcation of boric acid ointment inside the nostrils is probably of value in preventing the contagion reaching the mucous membranes. TREATMENT It is of the utmost importance that the patient go to bed immediately at the onset of infection, and remain in bed until recovery is complete in order to prevent complications and to conserve strength. General principles of treatment as of Acute Infectious Diseases. I.

M I L D RESPIRATORY T Y P E

Characterized by the symptoms of acute infection of the upper respiratory tract; coryza, pharyngitis, tonsillitis. Epistaxis is common and may be repeated and severe. General principles of treatment as of Acute Infections of Respiratory Tract. (a) Salicylates may be given for the control of pain and reduction of temperature, but should be used cautiously because of depressant action on heart.

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PRINCIPLES OF MEDICAL

TREATMENT

(b) Local treatment as of Acute Pharyngitis. (c) Epistaxis is best controlled by an anterior plug of gauze wrapped in Cargile membrane. Care should be taken to dip the plug and forceps in hot water just before insertion in order to prevent the plug from adhering to the forceps. Posterior plugging of nares is seldom necessary. 2.

BRONCMTIC

TYPE

Characterized by a persistent cough, substernal pain and signs of bronchitis. Treatment as of Acute Bronchitis. (a) Expectorants are probably harmful in the early stages, and of little value in the later stages of the bronchitis. (b) A change from a damp to a dry climate is sometimes the only measure which seems effective in clearing up the persistent cough. 3.

BRONCHOPNEUMONIC

TYPE

Characterized by symptoms of bronchopneumonia. (a) The foci may be numerous and tend to spread; there is a relatively low rate of pulse and respiration, and evidences of severe toxemia. (b) The sputum may contain much blood. (c) Involvement of the pleura is comparatively rare. The physical signs are confusing. (d) Cyanosis and dyspnea are indications of the severity of the toxemia. It is particularly fatal in pregnant women. In cases showing marked cyanosis, which may be due to profound toxemia, or to early insufficiency of the heart, or to both these causes, beneficial results have been observed from the use of repeated small doses of Epsom salts. The object being to produce purgation. Doses of 1-2 drachms (4-8 cc.) of salts may be given two to four times in the twenty-four hours, depending on the requirements of the individual case, and continued while cyanosis persists. General treatment is that of Lobar Pneumonia. 4.

GASTRIC T Y P E

Characterized by severe epigastric pain and vomiting. There may be spasm of the abdominal muscles. An in-

THE RESPIRATORY TRACT

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flammatory process is excluded by the presence of general symptoms of influenza and the low leukocyte count. General treatment is that of Acute Infectious Disease. Symptomatic treatment as of Acute Indigestion. Alcohol by mouth may be of distinct value when other food is not retained. 5.

INTESTINAL

TYPE

Note. Exclude dysentery and typhoid by laboratory tests. Characterized by diarrhea, general abdominal discomfort, loss of appetite, and so forth. General treatment as of Acute Infectious Diseases. Symptomatic treatment as of Simple Diarrhea. C O M P L I C A T I O N S A N D SEQUELAE 1. Empyema is rare, and when present is usually encapsulated or interlobar. When suspected, thoracentesis should be done, and if without result should be repeated at another point. 2. Bronchiectasis is a common sequel. General treatment is that of Bronchiectasis, 3. Mental symptoms of depression, or true psychosis, together with profound physical weakness, are common. The treatment depends on their severity, rest being sufficient in the less severe cases. Sanatorium treatment is necessary in the more severe cases. 4. The possibility of meningitis and encephalitis should not be forgotten.

C H A P T E R VI PULMONARY TUBERCULOSIS BY J O H N B . HAVVES, 2D, M . D . President, Boston Tuberculosis Association

Synonyms. — Consumption, Phthisis, Tuberculosis of the Lungs. Etiology. The tubercle bacillus, discovered by Robert Koch in 1882. Tuberculosis is not inherited. It is of the utmost importance that this should be clearly and definitely understood by everyone. It should be likewise borne in mind, however, that a predisposition toward the disease or a weakened resistance against it may be and often is inherited. Among the factors predisposmg a patient toward tuberculosis are overwork or bad conditions of work, such as the dangerous trades, etc. A trade may be dangerous because of its inherent quahties, such as the granite and iron industries, which are dangerous on account of the dust; jewelry industries, whereby the worker is exposed to acid fumes, etc. ; and many other such occupations. Or an occupation may be dangerous because of the bad conditions under which the work is carried on. Among such bad conditions may be mentioned poor ventilation, exposure to extreme heat or cold, absence of sunlight, etc. Poverty and poor living conditions are perhaps the most important etiological factors in tuberculosis. The whole housing problem is intimately mixed up with that of tuberculosis. Bad habits, alcoholism, etc., are factors. Certain acute diseases, such as measles and whooping cough, may leave the lungs in a condition to contract tuberculosis or bring into activity an old process. The late epidemic of influenza undoubtedly brought into activity numerous heretofore quiescent cases of tuberculosis, while, in occasional cases during the late war, exposure to poisonous gases has brought about the same result. In general, anything which lowers bodily resistance is a predisposing factor toward tuberculosis.

go

PRINCIPLES OF MEDICAL TREATMENT C O U R S E OF T H E D I S E A S E

Pulmonary tuberculosis is one of our most chronic diseases. It usually lasts from two to seven years. In certain acute cases, however, where the patient has received an overwhelming infection, or where the patient's resistance is greatly lowered, it may run a more rapid course, ending fatally within a few months, or even weeks. In such cases — toward the end, at least — the disease is not confined to the lungs, but becomes a general septicemia, or it may develop into a tuberculous meningitis. Likewise, although two to seven years is the average course, a person may have tuberculosis for a very much longer time, and with it live to a great age. In fact, it is undoubtedly true that many cases of chronic bronchitis, winter cough, etc., are really cases of this chronic form of tuberculosis. The disease is characterized by intermissions — periods varying from a few months to many years, during which it is inactive, with few or no symptoms, perhaps only a slight morning cough and raising of sputum. During this time it is spoken of as being "apparently arrested," or "arrested," or even " a p parently cured." The physician is rash, however, who speaks of any case of pulmonary tuberculosis as being actually cured. The object of treatment is to bring about as permanent arrest as possible. COMPLICATIONS AND

SEQUELAE

1. Tuberculosis elsewhere in the body, especially the throat, the intestines, genito-urinary tract, and fistula in ano. 2. Hemorrhage. It should be borne in mind that hemorrhage, though always an alarming symptom, is rarely a serious one, except when the disease is in the active and progressive stage. 3. Cardiac weakness, due to the toxins generated by the tubercle bacillus. DIAGNOSIS In the diagnosis of any case of tuberculosis, bear in mind the following: I. Absence of proof is not proof of absence. Because you cannot find definite proof that tuberculous disease is present, do not assure a patient that he is not tuberculous.

PULMONARY TUBERCULOSIS

91

2. Differentiate between tuberculous infection and tuberculous disease. Practically every one of us, by the time the fourteenth year is passed, has a tuberculous infection, while only comparatively few of us are doomed to have tuberculous disease. The distinction is of immense importance, and is one that is frequently lost sight of. 3. Errors in diagnosis are more often due to a lack of thoroughness and because the physician is in a hurry than to any great inherent difficulty in the diagnosis itself. 4. If you are in doubt about the diagnosis, do not be afraid to explain this frankly and openly to the patient, and, if necessary, to send him to some one else for a decision. Remember that the patient's whole future depends upon the correctness of your diagnosis. History. A carefully taken history is of immense importance in diagnosis. Do not be in a hurry, but be prepared to take the time to sit down and talk this quietly over with the patient, and if possible with some member of the patient's family. Family History. Inquire in every case if any member of the patient's family has had or has died of tuberculosis. Do not draw too many conclusions from this, however, either one way or the other. Remember that it is the intimacy of exposure in childhood, rather than exposure in adult life, that is of importance. Past History. Inquire into the diseases of childhood, with special reference to measles and whooping cough, and ascertain whether or not there was any period of invalidism or cough following such disease. Find out whether the patient was looked upon as strong and robust during youth, or delicate. Find out if the patient was susceptible to coughs and colds, and inquire into such indefinite conditions as "run down," "slow fever," "debility," "anemia," etc. Such terms are often used to cover the physician's inability to make a proper diagnosis. Present Illness. Inquire when the patient last felt perfectly well, as well as when he first felt sick. Ascertain definitely what was the first symptom or group of symptoms of which he complained. Do not be surprised if in many cases no mention of cough or sputum is made. Remember that the onset of tuberculosis is more often characterized

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PRINCIPLES OF MEDICAL TREATMENT

by general constitutional symptoms, such as loss of weight, strength, energy, etc., than by symptoms relating to the lungs. In inquiring in regard to loss of weight, bear in mind the following definition: " B y loss of weight should be understood an unexplainable loss of at least five per cent below normal limits for that particular individual within four months' time." Likewise, in regard to loss of strength: " B y loss of strength in its pathological sense, is meant undue fatigue and a lack of staying power which are unusual for that individual patient and which cannot be satisfactorily explained." Inquire in every case as to whether the patient has ever spat up any blood or has had a hemorrhage of the lungs. Go into the details of this, and remember that hemorrhage may be defined as follows: " A n y amount of expectorated blood, with or without sputum, may mean that tuberculosis is present and requires careful and thorough investigation as to its source. Blood streaks, blood spots, etc., may or may not mean tuberculosis. On the other hand, a hemorrhage of one or two teaspoonsful is presumptive evidence of the disease." Cough. Inquire as to cough, but bear in mind that there is no cough characteristic of tuberculosis. There may or may not be a frequent hacking cough; likewise, there may be any other kind of a cough. Sputum may or may not be present. The absence of sputum does not in any way militate against the patient's having tuberculosis. PHYSICAL EXAMINATION Fever. Take careful observations of fever over a period of at least four days, four times daily, and remember the following definition: " A n occasional temperature of 99 should not be considered 'fever.' A temperature which persistently runs over 99.4°?. when taken at least four times a day for a period of one week (by mouth five minutes) should be considered of significance and to constitute 'fever.'" While a fever, as defined above, is not absolute proof that the patient is suffering from tuberculosis, it is presumptive evidence that the patient is suffering from a toxemia of some kind. In the absence of other causes for such a fever, tuberculosis should be very seriously considered.

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93

Elevation of Pulse. Where the average normal pulse is already known, an elevation of 15 beats per minute when the pulse is taken quietly at home, during various periods of the day, should be considered abnormal. In cases where the average pulse is not known, an average pulse of 85 or over in men, and 90 or over in women, may be considered to be abnormal. A combination of a subnormal temperature and an elevated pulse as here defined is of great importance. Hyperthyroidism and certain cardiac disorders are the commonest causes of a rapid pulse, aside from tuberculosis. A persistently rapid pulse, however, combined with fever, as defined above, in the absence of hyperthyroidism, is evidence in favor of tuberculosis. Anemia.

This may or may not be present.

General Appearance of the Patient. Put down definitely whether or not the patient looks sick, but bear in mind that extensive tuberculous disease of the lungs may be, and often is, present when the patient presents an appearance of robust health. Tuberculosis Elsewhere in the Body. Tuberculosis elsewhere, except in the throat or intestines, does not necessarily indicate that the lungs are involved, but in every case means that they should be carefully examined. Hoarseness. Any hoarseness or persistent huskiness requires investigation. A tuberculosis lesion in the throat or vocal cords is presumptive evidence that there is or has been disease in the lungs. Sputum. The presence of tubercle bacilli in the sputum is not necessary for a positive diagnosis. Likewise, absence of bacilli in the sputum after one or several examinations is not necessarily proof that there is no tuberculosis present. The diagnosis must be made in the majority of cases before the sputum is positive. When constitutional signs and symptoms are absent or nearly so, and when in the patient's present or past history there is nothing that points to tuberculosis, definite signs in the lungs including persistent râles at one or both apices should be demanded before a definite diagnosis is made, in the absence of a positive sputum. B y "persistent" is meant that the râles must be present after cough at two or

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more examinations, the patient having been under observation for at least a month. When there are definite constitutional signs and symptoms, such as loss of energy and strength, fever, rapid pulse, etc., it is not necessary to have very marked signs in the lungs in order to make a positive diagnosis. In the majority of instances, however, careful examination will reveal some pulmonary abnormality, but not necessarily râles. Usually a process at the apices should be considered tuberculous, and a process at the base to be nontuberculous, until the contrary is proved, unless there is a clear history of pleurisy with effusion. One should consider a typical pleurisy with effusion as presumptive evidence of tuberculosis; a dry pleurisy, or a thickening of the pleura, requires careful questioning and investigation, but is not necessarily evidence of tuberculosis. When in doubt, keep the patient under observation for at least one month, with repeated sputum examinations, before a definite diagnosis is made one way or the other. Depend more on the thermometer and common sense than on the stethoscope, and remember that "absence of proof is not proof of absence." X-Ray. An X-ray examination is a valuable adjunct and often gives important additional information. A definite diagnosis, positive or negative, however, should never be based on the X-ray evidence alone. The final diagnosis rests in the hands of the clinician and not with the roentgenologist. PROPHYLAXIS Remember at all times that tuberculous infection takes place in childhood. Likewise remember that adult infection is rare, and that the average healthy man or woman living under normal hygienic conditions need not fear contracting tuberculosis. The prevention of tuberculosis, therefore, is largely the protection of infants and children from sources of infection. This means: 1. Destroying all sputum, whether or not tubercle bacilli have been found in it. See that the patient uses a sputum cup, flask, or cloth, or paper napkins which can be burned. 2. See that the patient is trained to place his hand or handkerchief in front of his mouth when coughing or sneez-

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ing. Bear in mind, likewise, that this applies not only to the patient with tuberculosis but to every individual, man, woman or child. 3. M a k e it an absolute rule not to allow a consumptive to live intimately with children. If the patient cannot, or will not, take proper precautions or go to a proper institution for treatment, the children should be removed from such a source of infection. E v e n in cases where the danger of infection is apparently very slight, every tuberculous patient should be carefully instructed to avoid close and intimate contact with children. 4. Careful cleansing of the room or premises in which a consumptive has lived. Chemical fumigation is now rarely used. Mechanical cleanliness — soap, water, scrubbing, repainting and repapering — is the best means of treating such rooms or premises in order to make them safe. Remember that sunlight will kill germs of tuberculosis in a comparatively short while, and that under ordinary circumstances blankets, mattresses, etc., that have been used by a consumptive m a y be rendered safe by exposure to sunlight for twelve hours or more. 5. Observance of the ordinary rules of hygiene and right living as to work, sleep, play, food and drink, is the best way for the average person to avoid contracting tuberculosis. TREATMENT IN G E N E R A L

Treatment of the Individual. Treatment should be active and aggressive. I t should begin as soon as the physician has made the diagnosis in his own mind. In certain cases this m a y be before he has seen fit to tell the patient definitely that he has consumption. In the vast majority of cases, however, it is far better, except in the case of children, to talk the matter over plainly and frankly with the patient, and in every instance the physician should make the exact situation clearly understood to some relative or friend. Plain medical terms should be used as much as possible. D o not tell the patient that he has weak lungs, a spot on the lungs, or that his lungs are affected. L e t him know plainly that he has pulmonary tuberculosis, and explain exactly what this is, and w h a t it means. In many cases, it is wiser not to use the word " p h t h i s i s " or " c o n -

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PRINCIPLES OF MEDICAL TREATMENT

sumption," as both of these terms are apt to alarm the patient and his friends unnecessarily. If you yourself are in doubt about the diagnosis, and merely suspect that tuberculosis is the cause of the symptoms but are not sure of it, explain this situation clearly and frankly to the patient and to his relatives and friends. In such instances, it is a good rule to put the patient on trial for one month, and to let him know that, if at the end of that time he is not distinctly better and the symptoms still persist, more radical treatment will have to be instituted. In certain cases, however, owing to a lack of intelligence on the patient's part, or owing to improper home conditions, it is wiser to institute sanatorium treatment at once, even if the diagnosis is not clear. Methods of treatment include the following: 1. 2. 3. 4. 5. 6.

Sanatorium treatment. Home treatment. Climatic treatment. Tuberculin. Heliotherapy, or sunlight treatment. Drugs. SANATORIUM TREATMENT

Despite statements that home treatment is the best method, it is the general consensus of opinion, demonstrated clearly for the past quarter-century, that sanatorium treatment, in the broadest sense of the term, is the best method that is at present available for handling the individual consumptive. The patient's length of stay in a sanatorium may be short or long, according to circumstances. The patient's standard of intelligence, home conditions, finances, mental attitude toward treatment, are all factors in determining the length of stay in an institution, but it may be safely stated that, at some time or other, the vast majority of tuberculous patients should have the training and instruction that only a sanatorium can afford. It should be borne in mind, however, by every physician, and by him imparted to his patients, that sanatorium treatment, even of long duration, rarely if ever cures a tuberculous process, and that the best it can do is to bring about an arrest of the disease, which may continue for a long or short time, as the case may be. The patient's

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stay in a sanatorium, important and vital as it is to his welfare, should be looked upon as only a part of his treatment, the more important part of it being that period which follows his discharge from the sanatorium. Sanatorium treatment, therefore, in its broadest sense, should mean not only that the patient is under care and supervision while he is in the institution, but that the details which he has learned and the methods of treatment which he has found to be essential to his welfare while in the institution should continue for months or even years after he has left its doors. In many states of this country, where there is only one public sanatorium for the entire population, providing a number of beds utterly inadequate for the needs of the community, sanatorium treatment in such instances may necessarily be reserved for the lucky few who, either because their physical condition warrants it, or because their finances make it possible, are able to secure admittance. In such cases, proper home treatment is the only other resource. In Massachusetts and in other Eastern states, there are enough bed facilities for practically every consumptive seeking admission, and in Massachusetts at least, a consumptive, no matter how poor his circumstances and no matter how far advanced his disease, can readily secure adequate sanatorium or hospital treatment. It is the duty of every physician who attempts to handle this disease adequately, to make himself acquainted with the facilities open for consumptives in his community. He should be prepared to give the patient accurate details as to what steps he must take for admission to a state, county, or local sanatorium or hospital, and he should not, as is too often the case, deal only in vague generalities, leaving the practical details to the patient or his family, whose burden is usually already sufficiently great. In selecting a sanatorium for his patient, the physician should consider the following points: {a) Cost per week. (Ô) Accessibility, (c) Climate and altitude. {d) Temperament and disposition of the patient, (e) Length of time patient expects to remain at the sanatorium.

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Cost per Week. Many patients are apt to be utterly stampeded, when they are first told that they have consumption, into spending at once the hard-earned savings of years. They are apt to scorn a state institution, and to demand at once that they be sent to a private sanatorium, utterly regardless of its high cost. The physician should carefully inquire into the patient's financial circumstances. He should remind him that he is dealing with a chronic disease, which, unlike typhoid or pneumonia, is apt to last many months or even years. The patient should be prepared to put aside all pride, and to look at the matter from a sound, economic viewpoint. There are many patients who refuse to go to a state or local institution because they believe that by so doing they become objects of charity. This, in Massachusetts at least, has been done away with, and the worthy and needy patient who receives free treatment in a sanatorium is no more an object of charity than are all other citizens of the Commonwealth who are given police and fire protection, and free education for their children. Accessibility. One of the most important factors in the treatment of tuberculosis is to keep the patient happy and contented. In selecting a sanatorium, therefore, it is important to consider its distance from the patient's home, and to consider the expense and time necessary for friends and relatives to visit the patient. In many instances, it is advisable to send the patient to an institution which is perhaps not so well located in other respects as compared with a more distant one, but which is in easy reach by train or trolley for friends and relatives. Climate and Altitude. No definite law can be laid down for either climate or altitude as to its effect on the individual patient. Although there is absolutely no doubt that a suitable climate, high and dry, is an important factor in the treatment of tuberculosis, to the vast majority of patients such a climate is impossible. It should also be remembered that a patient who is sent away, and who gets well in such a favorable climate, may never be able to return to his home, or to stand the climate in the locality in which he expects to live and spend the rest of his life. In New England, therefore, and in the majority of the Eastern

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states, for all save the wealthy consumptives, it is better for the patient to take the cure in the climate in which he expects or hopes to live. Much the same applies to altitude as to climate. In the Eastern states there is not enough altitude to be an important factor in treatment, while Colorado and the West is full of patients who can maintain their health under Western conditions, but who are prisoners as far as returning to their homes in the East is concerned. These are important factors which should be carefully considered by the physician. Temperament and Disposition of the Patient. Happiness and contentment are more important than fresh air and altitude to the majority of patients. Here, again, individualization is necessary. In some instances, it is distinctly better for the patient to be separated from home influences and surroundings. Such patients are apt to take their treatment more seriously and to realize that they are at work on a very grave and important task. On the other hand, there are patients for whom it is essential that they be in constant and near communication with friends and relatives. The best of food, care and attention, and the most beautiful surroundings will avail but little in such cases, unless there is mental peace and contentment. Length of Time Patient Expects to Remain at the Sanatorium. If the patient's home conditions are such that treatment may be carried on very well after he has learned what to do, he may be advised to go to a private sanatorium for a few weeks or months at a cost which it would be utterly impossible for him to continue for six months or a year. If, however, the physician believes that it is wiser for the patient to spend a long period at the institution, this and the cost per week must be given careful consideration. HOME

TREATMENT

Patients may be divided into three groups as far as home treatment is concerned: 1. Suspicious cases, cases under observation, and those in whom the diagnosis is not absolutely definite. 2. Arrested and apparently arrested cases, whether or not discharged from a sanatorium, and those in whom the disease is inactive.

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3. Patients with active tuberculosis who should go to a sanatorium or hospital but who by force of circumstances must be treated at home. 1. Suspicious Cases, etc. It should be made clear to all patients in this group that home treatment may be only a temporary measure, and that more active treatment in a sanatorium may be and probably will be necessary. 2. ArrestedandApparentlyArrestedCases,etc. Thisgroup is a large one, comprising all those patients who have spent some time in a sanatorium. Whether or not subsequent home treatment will be successful depends largely upon how well the patient has learned his lesson while in an institution. Close medical and nursing supervision is essential in these cases, if the good done at the sanatorium is to be made permanent. There is no class of patients in whom hard work on the part of the physician and nurse will bring about better returns. Home treatment is naturally the best for the majority of these patients. How strict this should be in regard to outdoor sleeping, rest, etc., depends on the individual case. Frequent visits to the home by the nurse and monthly examinations at the dispensary or doctor's office should be required. The amount of work done and the choice of employment are to be decided by the physician. 3. Patients who should go to a Sanatorium but who either cannot or will not do so. In Massachusetts and in many of the Eastern states this group should be a small one; elsewhere, because of lack of beds, it is bound to be a large group. The essentials of successful home treatment are: 1. Adequate and detailed supervision of the patient by physician and nurse. 2. Close cooperation between patient and physician. 3. Provision for outdoor sleeping. 4. Prolonged rest. 5. Finances sufficient to insure proper food and nursing. Home treatment may be substituted for sanatorium treatment: {a) When there are no children in the family who might be exposed to the disease in the open form.

PULMONARY TUBERCULOSIS

loi

(b) When the intelligence of the patient or the patient's family is such that adequate carrying out of details is possible. (c) When adequate nursing and medical supervision is available over a sufficiently long period of time. (d) When there are facilities at home for proper outdoor treatment under favorable hygienic surroundings. It should be explained to the patient that it may become necessary at any time for him to return to the sanatorium or hospital on signs of an impending breakdown. Common sense, optimism, patience and tact are essential factors in treatment. CLIMATIC TREATMENT

Before advising a patient to undertake a journey of any considerable distance in order to obtain the advantages of any special climate, the physician should consider the following points: 1. The cost of transportation, and the cost of board after arrival. No patient should be sent to Colorado, for instance, unless he has at least $1000 or more with which to pay the necessary expenses. 2. Will the patient be happy so far away from his relatives and friends? 3. Has the patient funds sufficient to maintain him comfortably for at least one year? 4. The physician should see that the patient is placed immediately under high-grade medical advice as soon as he arrives at his destination. This should never be left to chance, nor should it be left to the patient to select his own physician. 5. In case the patient has shown a tendency to pulmonary hemorrhages, or in case there has been any sign of cardiac weakness, if the place to which you are considering sending him is at a considerable altitude, will it be safe for the patient in question? 6. If the patient is in the far advanced or progressive stages of the disease, in the majority of instances it is unwise to send him far away.

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TREATMENT

7. Remember in every case that even if the patient gets an apparent arrest of his disease in a certain favorable climate, it may be impossible for him to live in any other climate, or to return home to live with his relatives and friends. On the other hand, the physician should remember that it is undoubtedly true that there are many cases where the points above mentioned do not apply; where the patients will be distinctly benefited by seeking the advantages which a different climate and perhaps a greater altitude can provide. TUBERCULIN

TREATMENT

The general practitioner should not undertake the treatment of his patients with tuberculin. Indeed tuberculin is used little or not at all in the treatment of pulmonary tuberculosis at the present time. H E L I O T H E R A P Y OR SUNLIGHT

TREATMENT

Under careful supervision this may be applied in certain cases of pulmonary tuberculosis. This method of treatment should only rarely be used in adult pulmonary tuberculosis and certainly not unless the physician has made a careful study of the subject and familiarized himself with all its details. It is of particular value in the case of children with tuberculosis of the bronchial glands or elsewhere. It should be borne in mind, however, that sunlight is a powerful agent and may do harm as well as good. The general principle of sunlight treatment is to expose the body gradually, one part at a time, to increasing amounts of sunlight so that eventually the skin of the entire body becomes deeply pigmented. It is a curious, but well-known, fact that those patients whose skin shows a tendency to burn rather than to tan do not react well to sunlight treatment. In the treatment of all cases the head should be kept covered, and there should be a wet cloth over the cardiac area when the chest is being exposed. TREATMENT BY

DRUGS

Drugs, in the treatment of pulmonary tuberculosis, are used merely to treat symptoms, never the disease itself. The intestinal tract must be kept clear, hence, sahne or

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vegetable laxatives are often needed. Diarrhea must be checked. Excessive, unproductive and irritating cough should be allayed. In certain instances, a mild tonic to stimulate appetite is indicated. Aside from these, no drugs are needed in the treatment of pulmonary tuberculosis. TUBERCULOSIS

IN

CHILDREN

DIAGNOSIS

The physician should bear in mind always that the younger the child the more nearly does tuberculous infection approach tuberculous eisease. A positive tuberculin test, whether subcutaneous, cutaneous, or intracutaneous, in a child five years or under, carefully performed and found positive after one or more applications, in the majority of cases means tuberculous disease as well as tuberculous infection. Remember at all times that in childhood the infection takes place first in the glandular system, and that by the time the lungs are definitely involved the disease is in the advanced stages. The X-ray may give important and valuable evidence, but as in the case of adults X-ray evidence alone is not sufficient on which to base a diagnosis. If, however. X-ray examination shows evidence of enlarged bronchial glands and the chüd shows constitutional signs and symptoms, such as loss of weight and strength and especially ease of tire, a positive diagnosis should be made even if according to clinical examination localizing signs in the lungs are conspicuous by their absence. TREATMENT

There is no better method of preventing tuberculosis in adults than by the early and active treatment of tuberculous infection among children. For those children who show signs of active disease as described above, the tuberculosis hospital, sanatorium or the so-called "preventori u m " is the best and most efficient means of treatment. The source of infection in every case should be diligently sought for and eradicated if possible, whether this be bovine or human. For those children in whom the evidence of disease is not sufficient grounds for breaking up the home or sending

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them away, the out-door school, the fresh-air room, and the advice and supervision of the tuberculosis nurse, and adequate medical care, are the best means available for building up the child's strength so that the tuberculous infection will not become tuberculous disease. NON-PULMONARY TUBERCULOSIS Although not properly included in the scope of this chapter, it is not out of place to call attention to certain points concerning this form of tuberculous disease. The physician should bear in mind at all times that tuberculosis, whether it occurs in the lungs or in the bones, joints, glands or other organs, is due to the same organism no matter where the disease is located, and that, while in many instances surgical methods are needed in the nonpulmonary form of the disease, in every case sunlight, fresh air, rest, proper food and hygiene are indicated. The physician treating this form of tuberculous disease should remember at all times that it is not a tuberculous gland or joint which is under consideration, but a man, woman or child who has the disease. It is in this form of tuberculosis that treatment by means of tuberculia and heliotherapy brings about the most striking results. TREATMENT OF THE TUBERCULOSIS PROBLEM Every physician has a duty to perform not only toward his individual patients, but concerning the tuberculosis problem as a whole. Community health although less tangible than the health of the individual is nevertheless of essential importance. Any disease which kills over 200,000 persons in this country every year constitutes a menace, in the elimination of which the medical profession should be the leaders. As far as tuberculosis is concerned the general practitioner can and should help in the following ways: 1. He should be a member of his local tuberculosis organization, or if none such exists should be active in forming one. 2. He should join his state association and the National Tuberculosis Association.

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3. He should make himself thoroughly familiar with the local needs of his community and should help to establish (a) a tuberculosis dispensary; (6) a visiting tuberculosis nurse; (c) proper school hygiene and inspection; (d) proper industrial and factory hygiene and inspection. 4. He should find out what facilities his state already provides for consumptives, what it does to prevent the spread of this disease, and what further facilities and provision are needed for the future. 5. He should use his own personal influence with city and state legislatures, along with that of his state medical society, to bring about proper health legislation. 6. He should report all active cases of pulmonary tuberculosis, especially those with a positive sputum, promptly and accurately, and should cooperate with and not oppose the efforts of local and state health authorities. The following are the most important measures and provisions that every community, state or municipal, aims to establish. It is the duty of the medical profession to help in this work. (a) Beds in hospitals and sanatoria for consumptives in proportion of one bed for every death from this disease. (b) Sanatorium provision for early and favorable cases; hospital provision for advanced, progressive, and emergency cases. (c) A tuberculosis dispensary, which should include a tuberculosis nurse, for every city or town of 10,000 inhabitants or over. (d) School inspection with a school nurse, and open-air schools and fresh-air rooms for children. (e) A proper system of factory inspection with a nurse to assist. (/) Adequate ways and means to educate the medical profession in the early diagnosis of tuberculosis, and the general public concerning its frequency, methods of avoiding contracting tuberculosis, and especially its prevention. (1) To persuade all general hospitals to admit into their wards cases of tuberculosis, suspected tuberculosis or pulmonary disease for study, teaching purposes, diagnosis, and disposal. Only in this way can the younger members of the medical profession become acquainted with the clinical aspects of this problem.

CHAPTER VII THE TREATMENT OF ASTHMA BY F R A N C I S M . R A C K E M A N N ,

M.D.

Instructor in Medicine, Harvard Medical School Chief of Medical Out-Patient Department, Massachusetts General Hospital

FOREWORD

ASTHMA is a symptom, but so characteristic that common usage has made it imply a disease entity. Treatment directed toward the symptom itself often gives marked and striking relief but this first result is usually only temporary unless the cause of the symptom is discovered and removed. The treatment of asthma is not definite nor can it be standardized. Its one important object should be to discover the cause of trouble in the individual patient and then to remove or treat it. The following brief discussion of the pathologic physiology of the asthmatic spasm and of the clinical disorders functional and organic which appear to be responsible for it will indicate the general character of the problem. PATHOLOGY

The symptom asthma depends upon a spasm of the bronchoconstrictor muscles together with an edema of the bronchial mucous membrane. The mechanism by which this spasm is produced is not understood. The acute symptoms which follow the injection of some particular food or the inhalation of a particular dust suggest in the hypersensitive cases a mechanism similar to that of anaphylactic shock, but in other cases the close association of intranasal disorders with asthma indicates a true nerve reflex. CAUSES

I. Foreign protein sensitiveness {extrinsic causes) is responsible in about half the cases. It is important in children where the sensitiveness is commonly to foods such as

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PRINCIPLES OF MEDICAL T R E A T M E N T

eggs, wheat and cow's milk. In adults the sensitiveness is usually to substances occurring in the form of dust such as plant pollens, animal danders, orris root powder, wheat flour and other substances which in many cases are associated with the patient's occupation. 2. Intrinsic causes in nonsensitive individuals include: {a) Acute or chronic low-grade coccus infections of the trachea and bronchi. (Asthma often follo\Cs "colds.") (δ) Foci of infection in teeth, paranasal sinuses, tonsüs, gall bladder, appendix and pelvis. (c) Purely nervous causes as seen in tired-out, exhausted individuals who have had a "hard life." (Care should be taken not to confuse cause and effect of asthma.) (d) Improper habits of living, exercise, eating, diet and discipline, which at times are important in children. (The correction of such habits often provides the cure.) 3. Mixed causes. It is important to recognize that the early functional spasm with the resulting thin mucoid expectoration is prone to lead to secondary infections of the bronchial mucosa with increasing cough and sputum which is at first thick white and later yellow. The process may develop and extend until the picture is typical of bronchiectasis with its accompanying emphysema. B y a careful history the sequence of events may often be traced and the original cause identified. This is important because even in the late stage, treatment directed toward the original primary cause may be undertaken often with considerable profit. DIAGNOSIS A good history is essential. Sharply defined attacks, usually but not always, indicate some foreign protein cause, particularly if they occur in some special place. Freedom from symptoms which occurs with any change in the usual residence or occupation may imply an extrinsic cause at home. Seasonal attacks are almost invariably due to plant pollens. Poorly defined aggravations of asthma indicate its infectious nature, as in the common "winter asthma." Asthma which follows " c o l d s " is usually dependent upon irritation due to the infectious process. Continuous asthma, which persists from month to

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109

month without regard to changes in environment, may be due to some focus of infection, to pulmonary tuberculosis or to a neurosis. Such cases are usually severe but luckily are uncommon. Physical examination will determine the degree of associated emphysema and its chronicity. Moist râles indicate infection and their distribution will probably rule out tuberculosis or abscess. It is essential to discover all possible foci of infection. Myocardial damage, hypertension, chronic nephritis and anemia should be recognized: they may account for the symptoms. Diabetes, uterine retroversion, ovarian cysts have in a few cases been found to be closely related to the asthma, which cleared when they were properly treated. Skin tests are an important diagnostic aid in children but less important in adults. They wiU often identify the particular food, dust, pollen or animal dander which is causing the trouble. They will confirm or eliminate factors suggested by the history. They must check with the history and provide with it a common-sense, reasonable explanation of the cause of the disease. Because of the difficulty in reading the tests, their use should be restricted to those who apply them frequently. T R E A T M E N T OF T H E A S T H M A T I C A T T A C K 1. In general. Every breath is an effort for the patient. Disturb him as little as possible. He should not be made to talk and should be allowed to assume his own position. A table projecting over or across the bed will support his elbows and head, or he may be more comfortable in a chair. Warmth is essential. The room air should be warm and fresh. Asthma powder can be burned under a blanket or in a cone and need not permeate the whole room. Counterirritation to the front chest by means of hot-water bags, plasters or rubbing with liniment may be tried, but the doctor can help most by giving epinephrine} 2. Drugs, {a) Epinephrine is the drug of choice. It stops the spasm probably by stimulating the bronchodilator muscles to overcome the bronchoconstrictors. It is ' "Adrenalin " (N. N . R.) is the name of a proprietary preparation of epinephrine.

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P R I N C I P L E S OF M E D I C A L T R E A T M E N T

effective only when given subcutaneously and the effect is usually miraculous. Large doses (i cc. of the i : i , o o o solution adrenalin chloride) are not often necessary and m a y produce tremor, restlessness and pallor which are distressing. A dose of 0.5 cc. or even as little as 0.3 cc. will usually suffice. T h e effect of adrenalin should last for several hours. If necessary, additional doses can be given a t half-hour intervals. T h e presence of hypertension or of arteriosclerosis should make the use of adrenalin guarded but does not contraindícate it. (b) Asthma powders composed of stramonium leaves and potassium nitrite, in various proportions but usually in equal parts, are on the market under various labels and in various forms. (Stramonium (U. S.) is the basis: Potassii Nitras (U. S.) makes the powder burn.) T h e y are convenient, readily procurable and in many cases entirely efficacious. Whether they aggravate existing bronchial infections is doubtful. (c) Nasal sprays containing cocaine 0.5 to 2 per cent, adrenalin 10 per cent, or both, are a " G o d - s e n d " to some patients, who carry the atomizer with them always, to use when an attack occurs. (d) Atropine sulphate, b y mouth, theoretically relaxes the bronchial spasm, but it is less efficient than adrenalin in most cases. (e) Benzyl benzoate in its various proprietary forms will in a few cases stop the attack or, better, will prevent the attack if given early enough. I t s general use, however, is unsatisfactory. (/) Morphine is a poor drug in asthma. Its action is not direct, and relief comes only as part of a general dulling of the senses. Furthermore, the disease is so chronic that the morphine habit is acquired with greatest ease. TREATMENT OF THE UNDERLYING

CAUSE

Enough has been said under " Causes " and " Diagnosis " to indicate that the general management must be different for each individual case. T h e selection a t the outset of some definite plan of treatment encourages the patient and enables the doctor to regulate a t first-hand these more general measures which follow :

ASTHMA

III

1. A definite routine for each day should be planned and followed whenever possible. 2. The diet is important. T h e patient needs food, but too much food a t one time will do more harm than good. Six small meals should be prescribed. Supper should be light but can be supplemented b y milk and crackers at bedtime, and in addition food should be available during the night. T h e kind of food will v a r y in each case. Some patients do better with less protein; others with less carbohydrate. B o t h diets should be tried. Rich puddings, pies, pastry, cakes and candy should be forbidden. Fruits and green vegetables are useful for constipation. Plenty of water is essential. 3. Rest in the daytime is always advisable where the patient's night sleep is interrupted b y asthma. 4. Exercise should be encouraged between attacks: asthma is a chronic disease and the patient's general tone and vigor must be maintained. SPECIAL FORMS OF TREATMENT

Special forms of treatment are often all-important. 1. When the patient is hypersensitive the scrupulous avoidance of the particular substance, be it food or dust, which is causing the trouble should be insisted upon since, where this is possible, entire relief m a y follow this simple procedure. If, however, complete avoidance cannot be attained, as in the case of plant pollens in summer, or of occupational dusts, recourse must be had to specific treatment. Such treatment requires solutions which contain the active principle of the particular animal or vegetable substance to which the patient is sensitive. These solutions must give no local reactions in the skin of normal control individuals. T h e y must be standardized and they must be sterile. Doses and intervals between doses should always be determined for the individual case. T h e proper dose should be large enough to produce a definite local reaction, but great care should be taken to avoid a general reaction with its urticaria and severe asthmatic paroxysm. Such treatment is not without danger. 2. When the patient is not hypersensitive and there is no apparent cause of asthma except a bronchial infection, other special forms of treatment include:

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(a) Vaccines, which are sometimes of real value. Little is known as to the mechanism of vaccine action, but from the fact that stock vaccines produce results as good as those from autogenous vaccines the effect is ргоЬаЫу nonspecific. The choice of vaccine and the determination of dosage must be made for each case. Good results occur only in those cases where definite local reactions are produced by the treatments. (b) Nonspecific protein injections of such foreign substances as milk, peptone, tuberculin and autogenous defibrinated blood all have their advocates and may be tried in desperate cases. (c) Potassium iodide and other expectorants are of proved value in cases with definite bronchial infections where the sputum is very thick and tenacious and where the bronchial spasm is persistent and chronic. If given for too long a time, however, it will become irritating in itself and will prolong a cough which would disappear without it. (á) X-ray treatment is a more recent suggestion. It has been tried out in only a few cases, but gives some promise of success. How substantial or permanent this success will be, remains to be seen. CONCLUSION

No treatment will be successful unless it is based upon an appreciation of the underlying cause of the asthma as gained from an intelHgent study of the patient.

CHAPTER V i l i GASTRO-INTESTINAL DISORDERS BY GEORGE CHEEVER SHATTUCK, M.D.

GASTRIC AND DUODENAL

ULCER

I N D I C A T I O N S FOR M E D I C A L T R E A T M E N T 1. Recent ulcers. 2. Chronic ulcers with mild symptoms. 3. Chronic ulcers which have not had satisfactory medical treatment. 4. Ulcers for which surgical treatment is too dangerous or has been refused. 5. As a preparation for operation. The prognosis under medical treatment is better, the more recent the ulcer. P R I N C I P L E S OF T R E A T M E N T The principles and methods are essentially the same whether the ulcer is in the stomach or in the duodenum. 1. Prolonged rest for the patient and for the digestive tract. 2. Avoidance of food mechanically or chemically irritating. 3. Reduction of gastric secretion to the minimum. 4. Good care of teeth. METHODS 1. Rest in bed for a month or more is essential. 2. Diet should consist chiefly of soft carbohydrates, fats, milk and eggs. Feeding should be frequent. Treatment may be begun by starvation for several days, if the stomach be very irritable. Nutritive enemata are seldom, if ever, of much value because they are not well absorbed. During the period of starvation three pints of

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PRINCIPLES OF MEDICAL TREATMENT

saline solution should be given daily by rectum. Cracked ice may be sucked to allay thirst. Begin feeding with small quantities of milk (see Vomiting, page 119). Later, bread, or crackers and milk, milktoast, strained cereals with cream and sugar, rice, custard, blanc mange, junket, simple ice cream, mashed or baked potato with cream or butter, eggnog, raw, soft boiled or dropped egg, purée, soft fruits, and so forth can be added to the dietary until the patient is taking ample nourishment. The nutritive value of liquids can be much increased by adding to them sugar of milk, from J^ to i oz. in 4 oz. (or from 15-30 Gm. in 120 cc.) of liquid. Cream may be added to milk, and butter should be used freely. Irritating foods, for example, coarse vegetables, condiments, acids, and particularly alcohol must be avoided. Hot drinks and meat broths, as a rule, should not be taken. Protein foods, in the opinion of the writer, are to be avoided, as a rule, except in the form of milk or eggs. 3. Modification of diet is required for patients that are emaciated, or feeble and anemic. For them starvation may be harmful, and it is wise to begin feeding by mouth soon after the hemorrhage has stopped, and quickly to increase the amount of food ingested in order to accelerate healing by improved nutrition. The experience of the patient with the peculiarities of his digestion requires consideration. In marked contrast to the views expressed above are those held by some physicians who advocate a diet consisting chiefly of protein. Their aim is to neutralize by means of protein the acid secretion as fast as formed. Frequent feedings are recommended with the same object. Lenhartz is one of these. His method may be preferred for some cases. His diet schedule follows, page 1 1 7 . 4. Reduction of gastric secretion ^ may be favored by starvation, by a diet low in protein, by the avoidance of salt and by the administration of one-half to one tablespoonful of olive oil several times daily. 5. Medication, (a) Sodium bicarbonate ^ should be 1 Small doses of atropine are recommended b y some physicians. 2 Magnesium oxide is preferred b y some physicians.

GASTRO-INTESTINAL DISORDERS

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prescribed freely for relief of pain or distress in the dose of one-half to one teaspoonful, or more if required, in a glass of water. A hot-water b a g m a y relieve, (è) A f t e r feeding has been begun bismuth subnitrate well mixed with water should be given three times daily in teaspoonful doses half an hour before meals with the hope of benefit b y coating the ulcer mechanically. Bismuth is not constipating in this dose. I t is important that the bismuth used should be free from arsenic, (c) T h e bowels should be kept free b y enema or b y mild cathartics. Milk of magnesia acts well as a mild cathartic and also as an antacid. 6. Convalescence, (a) General hygienic measures, including attention to the bowels, are important, (b) Work should be resumed gradually and much fatigue, psychical even more than physical, should be avoided, (c) Rest, lying down for from one-half to one hour after meals, is of great benefit. (d) Food should be taken in the middle of the morning, the middle of the afternoon and at bedtime in addition to the three usual meals, (e) T h e more strictly the diet and regimen can be followed, the greater the chance of success, but it is better to enlarge the dietary than to undernourish the patient, because good nutrition favors healing of the ulcer. T h e treatment should be followed as strictly as practicable for from six months to a year. T R E A T M E N T OF

COMPLICATIONS

I. Hemorrhages, when small, require no special treatment. When a severe hemorrhage occurs the patient should lie as still as possible and morphine should be given subcutaneously in dosage sufficient to bring the patient well under its influence and to inhibit peristalsis (page 45). Further medication is not likely to do good. A n ice-bag m a y be placed over the stomach. Stimulation of the circulation b y saline solution, b y transfusion of blood, or b y drugs should be withheld unless demanded b y immediate danger, because anything which raises the blood pressure may prolong the hemorrhage. If syncope be feared after severe hemorrhage it is advisable to raise the foot of the bed. Operation is seldom indicated to stop a hemorrhage be-

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PRINCIPLES OF MEDICAL T R E A T M E N T

cause most hemorrhages stop spontaneously, and because, when the patient has become exsanguinated, operation is dangerous. Repeated hemorrhage is an indication for operation after the patient has recovered sufficiently from the resulting anemia. Transfusion may be beneficial to hasten recovery or to prepare for subsequent operation. 2. Perforation may be acute or subacute. It may lead to general peritonitis, to abscess, or to adhesions causing persistent, severe s)miptoms. The acute perforations with spreading peritonitis should receive surgical treatment with the least possible delay. Subacute perforation, when recognized, is an indication for operation but may not constitute an emergency. 3. Pyloric obstruction, when severe, requires operation. Incomplete obstruction with gastric dilatation can often be relieved temporarily and sometimes for long periods by rest in bed, lavage daily before breakfast, and a soft diet with limited liquids. Under such treatment the dilated stomach may contract and acute inflammation at the pylorus may subside. This is an excellent preparation for operation. Operation should be urged early for pyloric obstruction because after symptoms have made it imperative the weakened condition of the patient adds greatly to the risk. 4. Persistent severe symptoms which do not yield to medical treatment demand that operation be seriously considered.

ACUTE GASTRIC INDIGESTION Pathology. Probably irritation, with hyperemia, and possibly with inflammation of the mucous membrane of the stomach, of the intestines or of both. Etiology, (a) Ingestion of food unwholesome either in itself or for the individual; (b) excess of food; (c) excess of alcohol or other beverage. Diagnosis of indigestion is made by history and by exclusion. D o not overlook the following diseases which may cause vomiting: (a) acute infectious diseases including malaria; (δ) nephritis; (c) pregnancy; (á) migraine;

LENHARTZ D a y s after hemorrhage N u m b e r of e g g s . . . .

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20

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ii8

PRINCIPLES OF MEDICAL T R E A T M E N T

(e) lead colic; (/) hysteria; (g) acute drug poisoning; (h) brain tumor; (i) tabes dorsalis; (_;) angina pectoris; chronic gastric or intestinal diseases; (J) acute surgical conditions, for example, appendicitis, cholecystitis, renal colic, and so forth. P R I N C I P L E S OF 1. 2. 3. 4.

TREATMENT

Rest and warmth for patient. Removal of cause of symptoms. Rest for digestive tract. Symptomatic treatment. METHODS

Methods must be chosen with regard to the cause, severity and nature of symptoms. 1. Rest and warmth. The patient should lie down and should be warmly covered or should remain in bed. Hotwater bags may be useful for cold extremities or for abdominal distress or pain. Rest and warmth diminish metabolic waste and promote recuperation. 2. Removal of cause. If there is epigastric pain without spasm and if the stomach has not been freely emptied, emesis should be induced by administering quantities of warm water or b y means of a teaspoonful of mustardpowder mixed in a cup of warm water. If the stomach has been emptied and pain persists it may be due to hyperacidity and can then be relieved by administering a teaspoonful or more of sodium bicarbonate in a glass of water. If there is colic and gurgling in the intestine the bowel should be evacuated unless profuse diarrhea has cleared it thoroughly. A saline cathartic, or calomel followed by a saline cathartic, may be of service if the stomach can retain it. An enema may be given at any time for prompt effect or if cathartics cannot be retained. Both emesis and catharsis are necessary for some severe cases. 3. Rest for digestive tract. Well-nourished patients generally do best when food is entirely withheld for from twelve to twenty-four hours. Plain water or mineral water may be allowed in smail quantities at short intervals.

GASTRO-INTESTINAL DISORDERS

119

When beginning to feed it is wise to use liquids, such as beef tea, chicken broth, hot milk or orange juice, a few ounces, every two hours. T h e nourishment should be increased in amount and in kind more or less rapidly according to the physician's estimate of the patient's digestive capacity. Hunger and a clean tongue generally indicate that considerable quantities of food can be assimilated but a coated tongue and lack of appetite mean the reverse. 4. Symptomatic treatment, (a) Nausea generally yields to rest and abstinence from food; emesis is advisable for some cases. (6) Vomiting usually stops spontaneously when the stomach has been emptied. If it does not yield to rest and abstinence from food it m a y be checked sometimes b y a teaspoonful of shaved ice with brandy, b y a drop of tincture of iodine in a teaspoonful of water, by gr· (0.016 Gm.) of cocaine hydrochloride dissolved in a teaspoonful of water, b y gr. (0.008 Gm.) of morphine sulphate absorbed from the mouth, or b y gastric lavage. Food should be withheld entirely for from about three to twelve hours after vomiting has ceased. Water should be allowed during this period in very small amounts if a t all. Cracked ice may be sucked for thirst. When vomiting persists over a period of days, saline solution must be administered in the form of enemata, by rectal seepage or b y hypodermoclysis. Three pints in twenty-four hours is enough. These measures and rectal feeding are very rarely needed in acute indigestion. Feeding should be resumed cautiously, beginning with milk diluted with mineral-water, lime-water, or carbonated water; or with orange juice or broth in teaspoonfuls every half-hour. T h e quantity of nourishment should be increased and the intervals between feedings lengthened gradually. (c) Diarrhea should not be checked until undigested food and old fecal matter has been discharged. If watery diarrhea persists in a mild form a few doses of about 15 grs. (i Gm.) of bismuth subnitrate m a y sufSce to stop it. When diarrhea is severe opiates are often required. A teaspoonful of paregoric m a y be prescribed for this purpose after each loose movement, or a dose of morphine may be administered. For other medicaments see below.

I20

PRINCIPLES OF M E D I C A L T R E A T M E N T

(d) Colic can be checked, when slight, by the application of heat to the abdomen and b y rest and abstinence from food. Paregoric, other preparations of opium, or morphine m a y be used for severe pain but they are contraindicated in full dosage until the intestinal tract has been cleared, or when conditions which m a y require surgical interference cannot confidently be ruled out. SIMPLE DIARRHEA DIAGNOSIS Note. T h e cause of "simple diarrhea" is an effort of the body to rid itself of imperfectly digested food. D o not overlook the following conditions which may cause diarrhea: (a) dysentery, bacillary or amebic; (b) other infectious diseases, e.g., typhoid; (c) nephritis with coUtis; {d) carcinoma of lower bowel; (e) fecal impaction with intermittent diarrhea; (/) rectal diseases with tenesmus; (g) mucous colitis; (h) reflex or nervous diarrhea, for example, due to chill, exophthahnic goiter, or perhaps to anxiety; (г) habitual excess in eating and insufficient exercise. P R I N C I P L E S OF

TREATMENT

1. Clear the digestive tract. 2. Rest the digestive tract. 3. Limit peristalsis when excessive and painful. METHODS 1. To remove irritant. Unless bowel has been thoroughly evacuated, prescribe a purge which will act quickly, and ascertain that this result has been obtained before proceeding to other kinds of medication. Castor oil is generally the most satisfactory purge for these conditions but sometimes a mild saline or calomel, followed by a saline cathartic, may be preferred. 2. To rest the digestive tract the patient should, as a rule, abstain from food until hungry. Food should be administered later in small and gradually increasing amounts, and a diet should be prescribed which will not irritate the in-

GASTRO-INTESTINAL DISORDERS

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testine and which will leave little residue. Eggs, broths and lean meats are suitable as a rule. Starches containing little cellulose may be preferred occasionally. Fats, fruits and coarse vegetables in general are to be avoided. Liquids should be bland and not cold. 3. To limit peristalsis: (a) Rest, preferably in bed. (δ) Restriction of ingesta. Meals should be small and frequent. In severe conditions of short duration food and liquids may be forbidden entirely for a time, The length of time depends on the state of nutrition and tolerance of the patient. (c) Warmth, externally and internally; that is, a warm room, avoidance of changes of temperature, a hotwater bag on abdomen, and hot drinks. MEDICATION 1. Astringents. Bismuth subnitrate, 10-20 grs. (0.651.3 Gm.) every two to eight hours. Acidum tannicum (U. S.), some other preparation of tannin, boiled green tea, or red wine may be prescribed. 2. Sedatives. Opiates are best; for example, Tinctura Opii Camphorata (U. S.), "Paregoric," or Tinctura Opii (U. S.), or Misturae Contra Diarrhoeam (N. F. 3d ed.), "Cholera Mixture," or "Squibb's Diarrhoea Mixture," or " C . O. T . " p i l P containing camphor i gr. (0.065 Gm.), opium gr. (0.016 Gm.) and tannic acid 2 grs. (0.13 Gm.). CONSTIPATION Note. Constipation is a symptom seen in many diseases, some functional, some organic. The treatment should combat the cause or causes in the individual case. Hence, a clear understanding of each case is of prime importance. Classification of Constipation 1. Spasmodic form — ninety per cent of all cases: (a) mucous colitis; (b) neurasthenia; (c) lead poisoning; (d) intra-abdominal or pelvic inflammation; (e) fissure of anus. 2. Atonic form. Muscular weakness or general debility due to: (a) fevers; (fi) anemia; (c) cachexia; (d) senile debiUty. 1 Not official.

122

PRINCIPLES OF MEDICAL T R E A T M E N T

3. Obstructive form: (a) stricture; (b) adhesions; (c) pressure from tumor or pregnancy; (d) ptosis with kink; (e) acute obstruction. 4. Less common varieties of constipation are excluded for lack of space. Diagnosis of stricture, adhesions and ptosis or kink can seldom be made satisfactorily without bismuth X-rays, but X-ray evidence is often misleading. P R I N C I P L E S OF T R E A T M E N T 1. The essential causes of chronic constipation without gross lesion are bad hygiene, neurasthenia, or a combination of both. Therefore, it is often imperative to encourage the patient as well as to correct his habits. 2. Clear the intestinal tract thoroughly and keep it clear, including the rectum and the cecum. 3. Soothe or stimulate the bowel by suitable diet as required. 4. Use cathartics sparingly or not at all, in order to avoid irritation of the bowel by them. 5. Prescribe sufñcient liquid in definite quantity. 6. Enjoin proper mastication of food and prescribe false teeth if needed. 7. Instruct patient about regularity in defecation. 8. Exercise or abdominal massage, unless contraindicated, are likely to be useful for sedentary persons. METHODS FOR SPASMODIC

CONSTIPATION

Note. Spasm of the colon, particularly marked in the region of the hepatic flexure, is very commonly shown by the X-ray in cases of constipation. The cause of this spasm is not obvious, but personal observation has led me to believe that it represents, in many cases, a response to irritation. Tjhe source of the irritation may perhaps be improperly digested food or retained scyballae. Whatever the cause, many of these cases show abnormal sensitiveness to deep pressure in the region of the cecum, the sigmoid, or the transverse colon, and many are operated upon for "chronic appendicitis." The relief following the operation is generally transient and much harm may result. Mucous colitis seems to be a more advanced stage of the condition outlined above. Neurasthenic symptoms are

GASTRO-INTESTINAL DISORDERS

123

prominent in this stage but are often in evidence much earlier, if not from the beginning. Proceeding on the basis of the theory above outlined, the following method was evolved and has proved its value: 1. Clear the bowel thoroughly by using oil enema ta and irrigations in more severe cases of long standing, and castor oil or calomel in milder cases. 2. Restrict diet markedly both in quantity and quality for the first week in order to rest the bowel, and avoid anything which might act as an irritant to it; for example, foods rich in cellulose, acids, spices, tea, coffee and alcoholic beverages. The list of suitable foods which follows is not complete, and should not be followed too closely in all cases. The experience of the patient may be valuable. Diet list. Fresh milk, cream, butter, sugar, rice, macaroni, sago, tapioca, strained oatmeal, cream of wheat, white bread or toast, potato, baked, boiled or mashed, junket, custard, blanc mange, eggs, boiled, poached, scrambled or shirred, finely minced chicken or lamb, boiled tongue, or tender steak if it can be well chewed. 3. After the first week and until abdominal sensitiveness has disappeared the nonirritating diet should be continued in quantity sufficient to maintain weight. Variety should be secured by adding to the list from time to time. 4. Action of the bowels during this period may require the daily use of an enema, but agar or Russian oil should be tried and may suffice. Cathartics which act by virtue of their irritating qualities are to be scrupulously avoided. 5. Gradual return to a normal diet rich in cellulose and fruit should follow the disappearance of abdominal sensitiveness. 6. General hygienic measures are very important. Exercises designed to improve posture and to strengthen the abdominal muscles may be required, and massage of the cecum and colon may be helpful. Lead poisoning with constipation. Antispasmodic medication with morphine or atropine is required. Intra-abdominal or pelvic inflammation or fissure of the anus may cause constipation by reflex spasm. Treatment demands removal of the cause by appropriate means.

124

PRINCIPLES OF MEDICAL TREATMENT

METHODS FOR ATONIC CONSTIPATION Postfebrile constipation, being transient, may be treated with mild laxatives for convenience. Constipation in anemia, cachexia, or senile debility. The patient's convenience should be considered, especially in ambulatory cases, or when the chance of ultimate cure is small. Nux vomica may be of service, and laxatives, glycerine suppositories, or enemata may be advised according to circumstances. Fecal impaction should be guarded against and watery catharsis must be avoided. Massage may do good and mechanical support by means of a corset-belt may aid defecation when the abdominal waU is weak.. A diet rich in cellulose, fruits, and sugar may help to stimulate peristalsis. Graham bread, oatmeal, cracked wheat, green vegetables, beets, carrots, turnips, tomatoes, raw or stewed fruits and jams are particularly to be recommended for those who can digest them. METHODS FOR OBSTRUCTIVE CONSTIPATION Stricture. Operation will generally be required. Palliation by means of Russian oil by mouth, or by rectal injections of oil followed by cleansing enemata may be beneficial. Adhesions. The palliative measures just mentioned may suffice. Exercise or massage may do good. Operation should not be advised without mature consideration. Pressure. Palliate or operate according to circumstances. Ptosis. A suitable abdominal supporter may relieve. Other palliative measures and exercise or massage may help. Operation offers little hope of rehef, as a rule. Acute obstruction. Prompt operation is imperative. METHODS USEFUL IN VARIOUS KINDS OF CONSTIPATION I. Massage daily may be very beneficial. "Cannon-ball Massage." A heavy ball is necessary — twelve or sixteen-pound " s h o t " (made for athletics), covered with leather or strong cloth, will serve. Once or twice daily the patient, lying on his back, should roll the

GASTRO-INTESTINAL DISORDERS

125

shot repeatedly around the abdomen ^ from the cecum along the course of the colon for fifteen minutes before going to the toilet. 2. Enemata. (a) I n long-continued constipation the rectum may never empty itself completely ( " d y s c h e s i a " ) · A s a result, the reflex to defecation m a y be lost. This reflex can sometimes be regained after the rectum has been kept clear for a time b y means of a course of oil injections at night, followed by cleansing enemata in the morning. Olive or linseed oil is suitable for the purpose. From 4 6 oz. (120-180 cc.) should be used a t each injection and the oil should be retained through the night, (b) Cleansing enemata of warm water with the addition of sodium bicarbonate or of common salt, i drach. (4 Gm.) to the pint (500 cc.) can be used when the mucous membrane has become irritable, (c) Cold water, hot water, or soapsuds and water are more potent for evacuating the bowel than saline solution or warm water, (d) Strong enemata consisting of glycerine alone, from i drach. to i oz. (4-30 cc.), or of saturated solution of magnesium sulphate, glycerine and water, 2 oz. of each (60 cc.), can be used if required. 3. Laxatives should be used only in conjunction with suitable diet, abundant liquid (six to eight glasses of water daily), and hygienic habits. N o one laxative suits all persons. (a) Fluid extract of cascara sagrada can be used in doses of 10-15 min. (0.6-1 cc.), after meals, or in a single dose of 10-30 min. (0.6-2 cc.) at bedtime. When regularity of the bowels has thus been established, the dose of cascara can be diminished drop by drop until medicine is no longer required. {b) Prunes and senna. Instruct patient to stew three dozen prunes with two tablespoonsful of senna leaves (enclose leaves in a cheese-cloth bag), and to eat ten prunes once or twice daily. When the bowels have been regular for a time the amount of senna can be reduced until prunes only are taken. Later, the number of prunes can be reduced. (c) Russian oil or agar-agar, either or both, may be tried. T h e y act mechanically and do not irritate the intestines. T h e result is often very satisfactory. 1 T h e abdominal muscles should be relaxed while the ball is being rolled.

CHAPTER IX SYPHILIS BY C. M O R T O N S M I T H , M . D . Physician in Chief, Department of Syphilis, Massachusetts General Hospital Clinical Professor of Syphilology, Harvard Medical School

ETIOLOGY may be acquired or congenital. Infection in acquired syphilis probably does not take place through sound skin, but the Treponema pallidum, also called Spirochaeta pallida, may gain access through small breaks in the skin or mucous membrane. The organism is present in the discharge from moist lesions and, during the early stages of the disease, is found in the blood. SYPHILIS

TRANSMISSION

Although syphilis is generally acquired during sexual relations with a syphilitic person in an infectious stage of the disease, the possibility of accidental transmission of syphilis in other ways should be borne in mind. Extragenital infections, innocently acquired, are not infrequent. The fact that the organism may live outside the body for about five or six hours on a dry surface, or for about twenty-four hours if kept warm and moist, indicates the possibility of indirect transmission of the disease in some instances. Syphilis is contagious particularly in the primary and secondary stages when contact with moist lesions can occur. Latent syphihs may be transmissible only to the offspring. When the internal organs alone are affected in the late stages of the disease, transmission to others is not to be feared. INCUBATION P E R I O D

Generally eighteen to thirty-five days. The so-called "second period of incubation," from appearance of the chancre until the outbreak of secondary lesion, is from six to eight weeks.

128

PRINCIPLES OF MEDICAL TREATMENT PATHOLOGY

The primary lesion always develops at the site of inoculation. Such lesions may be multiple, but they are not autoinoculable. Primary syphilis is never a local disease. The Treponema has been recovered from regional lymph nodes of animals within forty-eight hours after inoculation and from the blood-stream within a week. It is now believed that the foundation for aortitis, aneurism, tabes, and paresis is laid in the early months of infection. DIAGNOSIS Regional lymph nodes become enlarged early. The whole chain is involved, and suppuration occurs only as a result of coincident infection with some other organism. Fever up to 100° F. in the afternoon is not infrequent during the late primary and early secondary stages of syphilis. The disease may invade any of the organs or tissues of the body, and its manifestations may simulate most of the skin and many of the visceral diseases. Remember the possibility of extragenital infection innocently acquired. Congenital syphilis, early or late, may present the same type of lesions as occur at a corresponding stage in acquired syphilis. Cardiac disease is not uncommon in these children, and tabes or paresis may develop at puberty. Congenitally luetic babies usually appear healthy at birth. The disease manifests itself most frequently in the second, third, fourth, or fifth week, but may appear later. Interstitial keratitis and symmetrical synovitis of the knee-joints, which generally appear between the ages of five and fifteen, should be borne in mind. The latter may be mistaken for tuberculosis, from which it is readily distinguishable by the absence of bony change as seen by the X-ray. The X-ray is also very valuable for demonstrating periostitis. It should be possible to demonstrate the Treponema either with the dark-field microscope or in stained smears of "deep serum" from an early primary lesion. Wright's blood stain is satisfactory for the purpose. Previous use of mercurials on the primary lesion usually destroys the or-

SYPHILIS

129

ganism in the serum and renders a dark-field examination negative. The Wassermann reaction with serum from the primary lesion may be positive within three weeks, but the blood Wassermann generally remains negative for four or five weeks. It should be strongly positive before the beginning of the second stage of the (Ûsease. Iodides, mercury, and arsphenamine are the drugs employed in the so-called therapeutic test for syphilis. PROGNOSIS

Prognosis of acquired syphilis should be good when treatment is begun in the primary or early secondary stages. SOCIAL

ASPECTS

The modern conception of the treatment of syphilis considers the family, associates, and community as well as the patient. As a public health measure, possible sources of infection must be sought out and controlled. Innocently acquired extragenital infections are especially dangerous to contacts, because frequently they are long unsuspected and therefore are unrecognized. Early syphilis menaces the community. Therefore, prompt treatment to heal infectious lesions is imperative. Latent syphilis may menace only the ofíspring. This danger is to be averted b y : (a) deferring marriage until medically safe; (b) avoiding conception until medically permitted; (c) thorough treatment during pregnancy unless this has been done before. Latent syphilis threatens the victim only because the infectious stage has passed. PROPHYLAXIS

FOR THE

INDIVIDUAL

Metschnikoff and Roux have shown that when calomel ointment, thirty-three per cent, has been thoroughly rubbed into the site of inoculation within an hour, syphiUs will not develop. This procedure should always be employed by physicians or others in case of cuts, abrasions, needle-pricks, etc., occurring while caring for known or suspected syphilitics or by anyone after venereal exposure. The ointment should be applied with the least possible delay.

130

PRINCIPLES OF MEDICAL TREATMENT

Arsphenamine has also been used after exposure to one subsequently found to be infectiously syphilitic. A course of three to five weekly injections of 0.3-0.4 Gm. of arsphenamine or its equivalent has been given with apparent success. PRINCIPLES OF T R E A T M E N T 1. A positive diagnosis is a prerequisite for treatment. In all cases of primary lesion a dark-field examination and Wassermann test should be performed, not only for confirmation, but also for record. They are useful as well to convince the patient, and this is important. 2. A complete physical examination should always precede treatment, because lesions of the heart, aorta, lungs, kidneys, or liver, whether or not of syphilitic origin, demand caution and judgment in the use of arsphenamine or mercury. 3. Hygiene, diet, rest, care of the skin and teeth, nutritious food, and abstinence from alcohol are as important in the treatment of syphilis as of tuberculosis. 4. Medication should be more or less vigorous and prolonged, with regard to the stage of the disease and other circumstances of the case. METHODS OF T R E A T M E N T I. Early syphilis. Having proved to yourself and satisfied the patient that he has syphilis, treatment should begin at once. The chancre ordinarily needs no attention aside from application to it of calomel powder or mercurial ointment (Unguentum Hydrargyri Fortius, U. S.). Extensive induration in lesions situated in the sulcus behind the corona, together with enlargement of the dorsal lymphatic, may cause a phimosis, but circumcision is seldom, if ever, necessary. Hot soaks and subpreputial injections or irrigations with "black wash" (Lotio Nigra, N. F.) or other mercurial solution, together with the general treatment, are usually sufficient. One rarely sees inflamed or painful regional lymph nodes, and they seldom suppurate except in mixed infections. The application of heat or of an ice-bag, followed by local inunction with mercurial ointment (Unguentum Hydrargyri Fortius, U. S.), is of value.

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131

As a protection to the public, a mercurial dressing should be used for all primary lesions. It is considered an advantage to the patient to take a short course of mercury before receiving arsphenamine; but, in early syphilis, with infectious lesions, arsphenamine should be given as soon as possible, because the danger to the community from withholding such treatment far outweighs the possible gain to the individual from following the other course. Syphilis cannot be aborted by excision or destruction of the chancre. Removal of the primary lesion interferes seriously with Nature's mechanism for building up resistance, so that subsequent constitutional symptoms may tend to be severe. This fact should be remembered when giving intensive arsenical treatment in early primary syphilis. Sufficient treatment must be given to make up for any interference with the natural development of defense. 2. Late syphilis. Strive to prevent or allay an insidious attack on the vital organs. In late cases, in which the infection is often from twenty to forty years old, toleration between the invader and the host is well established. Treatment should then be directed not so much toward the reversal of a positive Wassermann test and the hope of complete cure by medication, as toward building up the resistance of the individual. Strive by the promotion of comfort, Ughtening the physical and mental load, attention to diet, regulation of work and of exercise, and wisely planned medication, to prolong the "expectancy of life." A prolonged course of mercury and iodides, not too vigorously employed, producing a gradual repair of damaged tissues, may be preferable to the more rapid action of arsphenamine. A wise combination of these drugs is often the best treatment. In syphilitic disease of the heart or aorta it is particularly important that treatment should be gradually and cautiously applied. Fresh manifestations and complications must be treated according to circumstances as they arise. 3. Congenital syphilis. As a preventive, treatment of the mother should be begun as early as possible during pregnancy, and should be continued with careful super-

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vision until delivery. Both arsphenamine and mercury should be used in all cases, and the condition of the kidneys must be closely watched. The blood of the syphilitic infant, and moist lesions, such as ulcerated fissures and papules, are infectious during the first few years of life. They may be treated with "black wash,"' calomel powder, or calomel ointment (calomel Sii in vaseline ξϋ, 4 Gm. in 30 Gm.). Congenital syphilis is treated with the same drugs as are used for the acquired form. Syphilitic children should be kept under observation and treated intermittently for several years and the results of treatment checked by Wassermann tests and X-ray. When the vein at the elbow cannot be entered, the temporal or jugular wiU usually serve. Use of the longitudinal sinus is not safe. Cardiac disease is not uncommon in these children and calls for the usual management with the addition of antisyphilitic medication. Such babies should be breast-fed, if possible, because they often present difficult feeding problems. USE OF ARSPHENAMINE

I. Toxic Effects (a) Certain phenomena including nausea, vomiting, chUls, fever, headache and diarrhea may occur after the first injection and not subsequently. These are due probably to the rapid killing ofi of Treponema and subsequent absorption of toxins from the dead organisms. Reactions may often be avoided by attention to the patient's diet and bowels before and after the injection. A saline laxative should be taken the morning after the injection. (δ) The Herxheimer reaction, so-called, may be shown by a temporary increase in brightness of the eruption. Similar phenomena probably occur in the viscera and may lead to exaggeration of symptoms and serious results, particularly when vital organs, such as the nervous system, are involved. (c) The nitritoid crisis (so-called because of its resemblance to the effect of amyl nitrite) is perhaps the most 1 Lotio Nigra (N. F.).

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133

frequent reaction occurring during administration of injections. It is seldom seen before the third or fourth injection, usually develops soon after the injection has been begun, and is characterized by flushing of the face and neck, suffusions of the eyes, edema of the lips and eyelids, and sometimes by swelling of the whole face and the appearance of giant urticaria. A short cough with a feeling of constriction of the chest like suffocation, tingling of the skin, a sensation of heat and fullness in the head, dilatation of pupils, nausea, vomiting and unconsciousness may occur. There have been fatalities. These crises are less frequent but just as severe when neoarsphenamine has been used. In case of nitritoid crises 10 min. (0.6 cc.) of a 1:1000 adrenalin solution should be injected subcutaneously and repeated, if necessary. Adrenalin should always be at hand when using arsphenamine. Bicarbonate of soda taken by mouth may be of value. The nitritoid crisis is considered a sort of anaphylactic reaction and in patients for whom further use of the drug is considered imperative an anti-anaphylactic method of using it has been successful; that is, o.oi Gm. of the drug is injected slowly into a vein and half an hour later the remainder for the usual dose is administered. (d) Occasionally nausea persists for several days after a treatment with arsphenamine. Cathartics, aromatic spirits of ammonia, sodium bicarbonate and free use of liquids usually bring relief. (e) Jaundice due to the toxic action of arsenic on the liver cells occurs occasionally. It appears about six or eight weeks after the last dose of arsphenamine. Recovery is the rule but the condition may be rapidly fatal, the liver closely resembling that of acute yellow atrophy. Signs of toxic effect on the liver call for immediate cessation of arsenical medication. if) Dermatitis of a severe character occasionally develops after the use of arsphenamine but seldom after the first injection. An erythematous eruption most conamonly localized on wrists, forearms and legs may precede the dermatitis by a week but this warning is not constant. When present it should be regarded as a danger signal. Many cases of dermatitis have profuse desquamation

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and are seriously ill for several months. The condition has proved fatal. Universal desquamation is the rule and arsenic has been recovered from the scales. The patient should remain in bed, should be lightly but warmly covered and elimination by the bowels and kidneys should be aided by a diet low in protein, forced fluids and wise use of saline cathartics. The intake and output of fluid should be measured and recorded. When the output of urine is normal or increased there is little cause for alarm. The intense burning and itching of the skin can be relieved by starch tub-baths or calamine lotion. Greasing the skin with boric ointment usually promotes comfort when the dermatitis is dry, but when there is much vesiculation or large bullous lesions profuse dusting with finely powdered corn starch (Amylum, U. S.) may be tried. (g) Renal irritation and diminution of renal function may be caused, and contraindícate continued use of the drug until some time after they have subsided. 2. Antidotes for Arsenical Poisoning Sodium thiosulphate has been highly recommended for dermatitis as well as for other severe types of arsenical poisoning. It should be used early and administered intravenously and by mouth in repeated doses. J.

Contraindications

{a) Sensitization to arsenic absolutely contraindicates the use of arsenicals of any kind. When a patient has had arsenical dermatitis, arsenicals must be prohibited for at least three or four years. (¿>) Contraindications dependent upon pathology are relative rather than absolute. The use of arsphenamine in ordinary dosage is dangerous particularly in aneurism, coronary sclerosis, myocarditis, or when there is evidence of angina pectoris or of other serious defects of the circulatory system. (c) There is danger as well in the presence of nonsyphilitic nephritis, in some cases of disease of the central nervous system, liver, pancreas or adrenal glands, and when there is a severe lesion of the lungs, pronounced anemia or cachexia, chronic alcoholism, old age, or marked physical weakness from any cause.

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I3S

The above-mentioned conditions call for caution in the use of arsphenamine and, as a rule, preliminary treatment with mercury and iodide is indicated. It can be followed later, perhaps, by small doses of arsphenamine. 4. Precautions A patient undergoing treatment with arsphenamine should abstain from alcohol, at least on the days of the injection, and should avoid fatigue from physical or mental exertion at such times. When these conditions cannot be fulMed it is well to postpone the injection or to rely on other drugs. 5. Administration Details are given on page 208. Use of the longitudinal sinus for injections in infants is not safe. 6. Dosage The attempt is no longer made to sterilize the patient with a massive dose, but rather to bring about fractional sterilization and to build up constitutional resistance. It is safer to begin with a dose below the normal and to increase as tolerance is established. Subsequent injections should be given at intervals of three to seven days and, if there is no contraindication, full dosage should be employed. Dosage is estimated at 0.1 Gm. for each forty pounds of body-weight. A normal man of one hundred and fifty pounds should receive 0.40.5 Gm. of arsphenamine or its equivalent of one of the other arsenicals, for example, neoarsphenamine. A "course" of arsphenamine consists of eight or ten injections. Mercurials should be administered coincidentally and after each course of arsphenamine the patient should have a course of fifteen mercurial injections at intervals of a week. After this course no treatment is given for five or six weeks. A physical examination is then made, a blood Wassermann test performed and an examination of the spinal fluid made if there is any indication for so doing. During the administration of arsphenamine and of mercury careful watch should be kept for signs of renal irritation or damage to the liver and, should either appear, the treatment should be suspended. Arsphenamine is more likely to afíect the liver and mercury the kidneys.

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Should the Wassermann test still be positive, the courses of arsphenamine and of mercury are repeated. If the tests be negative, four or six weekly injections of arsphenamine and ten or twelve of mercury should be given and then no further medication for from four to six months. Another physical and serological examination should then be made. When results are positive, repeated courses of arsphenamine and of mercury must be given; and, when negative, intermittent treatment with mercury should be used and the patient kept vmder observation for two years. Life can be prolonged and comfort promoted by longcontinued treatment even when the Wassermann reaction remains positive and many cases that seem to be Wassermann-fast respond to long-continued treatment. Shortening the interval between injections improves the result at times. 7. Newer arsenicals, such as neoarsphenamine, sodium, silver, or sulpharsphenamine are less potent than the original "606," and their content of arsenic is less. The toxic effects which they produce are Ике those of arsphenamine, but are apt to be less severe. None of these preparations is "fool proof" but they have the advantages of ease of preparation and lessened liability to cause untoward results. They do not require the addition of an alkali and they can be injected in concentrated solution. The newer arsenicals are suitable particularly for the treatment of ambulatory patients, persons coming from a distance, cases of visceral or cardio-vascular syphilis and for infants or children. The difference of efficiency can be made up by larger dosage or by a greater number of injections. Neo- or sulpharsphenamine can be given intramuscularly without danger of producing severe pain or necrosis. For congenital syphilis the injections should be repeated at weekly intervals until eight or ten have been given. The average dose for an infant is from 0.05-0.15 Gm. according to age and size of the child. USE OF MERCURIALS, IODIDES AND BISMUTH

Toxic effects and contraindications as well as other information will be found on pages 211, 215, and 237.

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INDICATIONS AND DOSAGE

1. For prophylaxis after exposure to SJφhШtic infection, calomel ointment, thirty-three per cent, should be rubbed vigorously into the part with the least possible delay. 2. As a public health measure to protect others, chancres or other moist ulcerated lesions should be dressed with powdered calomel or with calomel ointment, thirty-three per cent, or "black wash." 3. During a course of treatment with arsphenamine, mercury should be used either by mouth, inunction or intramuscular injection. For use by mouth Vie gr. (0.004 Gm.) of the bichloride, made up in pill or tablet with the powdered extract of licorice, is satisfactory. The protiodide of mercury is much used in pill form. 4. A course of fifteen mercurial injections should follow the course of arsphenamine. A properly prepared mercurial cream, 5 min. (0.3 cc.) of which represent i gr. (0.065 Gm.) of metallic mercury, should be injected weekly. The injections should be given deep into the gluteal muscle and the site of injection should be thoroughly massaged. This preparation, so used, is therapeutically efiective and has little tendency to cause pain or to produce subcutaneous nodules. Salicylate of mercury can be used instead. The dose is one or two grains (0.065-0.13 Gm.) suspended in Ыту olive oil. A soluble preparation such as the bichloride, the cyanide, or the oxycyanide may be preferred. Two or three injections per week should be given for three or four months. Following the course of arsphenamine and mercury injections no treatment is given for five or six weeks. Every subsequent course of arsphenamine should be followed by ten or fifteen injections of the mercurial cream. During administration of arsphenamine and mercury careful watch should be kept for signs oí liver damage or renal irritation. Should either appear the treatment must be discontinued until it can be resumed with safety. Arsphenamine more often affects the liver and mercury the kidneys. 5. When arsphenamine would be dangerous, mercurials can often be administered cautiously with advantage. Iodide is useful, too, in these cases.

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6. Mercurials and iodides can often be used advantageously as a preliminary to treatment with arsphenamine and also in cases of old syphilis of twenty years'duration or more in which rapidly produced effects might be dangerous. 7. For congenital syphilis mercury should be used as well as arsphenamine. It may be administered by inunction as mercurial or calomel ointment, by mouth as gray powder (Hydrargyrum Cum Greta, U. S.), or by intramuscular injections of bichloridol, Metz, Ую gr. (0.0065 Gm.) for a child or i gr. (0.065 Gm.) for an adult. Iodide also is useful with arsphenamine and mercurials: for example, to clear up periostitis, synovitis or keratitis. During the acute stage of keratitis the pupil must be kept dilated, and local application of an ointment containing yellow oxide of mercury (Hydrargyri Oxidum Flavum, U. S.) aids in clearing the cornea. Iodides of potassium or sodium are generally employed, but when a small dose only is required the former can be prescribed as syrup of hydriodic acid. They are not spirocheticidal but aid in the absorption of syphilitic products. They are particularly useful in endoarteritis, aortitis, hepatitis, mediastinitis, iritis, interstitial keratitis, and for other syphilitic granulomatous or gummatous conditions. They are of great value for the relief of pain in early syphiUtic nocturnal headache or periostitis. In conjunction with arsphenamine and mercury they hasten the absorption of the induration of large primary lesions and help greatly in healing mucous patches. Bismuth has recently been added to the Ust of antisyphilitic remedies. It was first suggested many years ago, but was not used to any extent. Although it is too soon to give it a therapeutic rating, it may be said that there have been many promising reports of its favorable action on primary and secondary lesions, and of its ability to reverse the positive blood reactions, even in some cases which appeared to be Wassermann-fast to arsphenamine and mercurials. The action of bismuth in causing the disappearance of Treponema from primary lesions and in bringing about resolution of the lesions is slower than that of arsphenamine, the organisms usually disappearing in four or five days.

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Bismuth is of service in cases of intolerance to arsenicals and mercurials and in arsenic and mercury-fast cases. Although it may never come into universal use, it should be borne in mind as a valuable supplement to other drugs in certain cases. C R I T E R I A OF C U R E Freedom from clinical signs and symptoms over a period of four or five years, with persistently negative Wassermann tests repeated at frequent intervals and a spinal fluid showing no abnormalities, has, until recently, been considered satisfactory. The demonstration by Warthin of spirochetes in tissues obtained at autopsy from individuals who had shown neither clinical nor serological evidence of syphilis indicates that new methods must be found to determine when a cure has been accomplished.

CHAPTER Χ LEAD POISONING BY J O S E P H C . A U B , M . D . Associate Physician, Massachusetts General Hospital Assistant Professor of Medicine, Harvard Medical School

DIAGNOSIS THE diagnosis of lead poisoning is difficult, because there may be evidence of absorption without symptoms of intoxication, and also, occasionally, intoxication without much evidence of absorption. The important signs and symptoms are: pallor, anemia, lead-line on the gums, general debility and weakness, colic, constipation, weakness of extensor muscles, palsy, encephalopathy, arthralgia and gout. Significant laboratory findings are: stippling, secondary anemia, a high reticulated count, and a high percentage of large mononuclear cells in the blood, lead in urine and stools, and, as reported by German writers, a high hematoporphyrin content in urine. TREATMENT Treatment differs according to the severity and type of symptoms, but certain general rules should be observed. GENERAL

RULES

1. When there are acute symptoms, do not attempt to promote elimination of lead because so much is already in circulation that it is safer temporarily to favor further storage. 2. The first step should then be to prescribe large quantities of calcium in the form of calcium lactate, 2 Gm. (30 gr.), and a quart and a half of milk daily, an adequate diet, and exposure to plenty of sunshine. When the diet has been sufficiently rich in calcium most of the lead is stored in the bones and the patient presents no symptoms.

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3. The possibility of continued exposure to lead should be prevented promptly and for the future as well because repeated attacks are common. 4. After subsidence of the acute symptoms the elimination of lead from the body should be facilitated. A diet with a very low calcium content favors release of lead from the bones. This means, essentially, elimination of all milk, green vegetables and eggs. Such a diet may contain: Meat or liver Potato Rice Tomatoes • cooked without milk Canned corn Bananas Apples (peeled) Tea, coffee, without milk Butter fat (prepared by melting butter in hot water and skimming off the butter fat) Bread (prepared without milk such as salt-free nephritic bread or "soda biscuits") Sugar Salt Pepper

With this diet ammonium chloride should be prescribed up to the physiological limit, usually about i Gm. (15 gr.) in a glass of water six to ten times daily, to produce a mild acidosis. Phosphoric acid may be used instead, 20 cc. (5 drach.) of the dilute acid (Acidum Phosphoricum Dilutum, U. S.) ten times daily. It is most easily taken when mixed with a large glass of water sweetened to taste and sucked through a straw. The addition of a little gin or whisky makes it much more palatable. Loss of appetite and headache signify the limit of tolerance for such treatment and dosage should be somewhat relaxed when these symptoms appear. 5. After about four weeks of treatment there should be a rest period of about a week with normal diet and abundance of milk to correct the calcium deficiency. The deleading régime should then be reinstituted. It is improbable that all the lead wiH thus be eliminated from the body although, in general, this treatment increases the excretion of lead more than four times. 6. Potassium iodide, the classic agent for eliminating lead from the body, may be used but it is not as effective as

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POISONING

143

the acids. Its chief advantage is ease of administration, doses of 0.324 Gm. (5 gr.) t. i. d. being gradually increased to I Gm. (15 gr.) t.i.d. Its physiological effectiveness appears to diminish progressively after the first few days of treatment. 7. Treatment to stimulate elimination of lead and to regulate the bowels should be continued for a long time, for the disappearance of the acute symptoms does not mean that the disease is cured. SYMPTOMATIC TREATMENT

1. Gastro-intestinal disturbances are the most common symptoms and lead colic often demands considerable therapeutic ingenuity. Local application of heat, pressure and moisture are often effective in relieving the spasm. Enemas and, when diagnosis is certain, drastic cathartics like magnesium sulphate may be tried. The pain decreases usually when constipation has been relieved. Atropine, nitroglycerine, and benzyl benzoate may be employed freely to relieve the intestinal spasm. Morphine administered hypodermically in a severe attack of colic will relieve the pain and may act as a cathartic but is usually not necessary. 2. The treatment of lead palsy is massage and application of galvanic current over the affected muscles. This should be continued for months. Strychnine in large doses has also been recommended.

CHAPTER XI ANEMIA BY G E O R G E R . M I N O T , M . D . Assistant Professor of Medicine, Harvard Medical School Physician and Chief of Medical Laboratories, Collis P. Huntington Memorial Hospital of Harvard University Associate in Medicine, Peter Bent Brigham Hospital Special Consultant in Diseases of the Blood, Massachusetts General Hospital

INTRODUCTION АХЕША is a symptom, often relatively insignificant, but which may be prominent, as in some cases of idiopathic pernicious anemia. In order adequately to advise a patient with anemia the pathologic physiology and natural history of his morbid state should be, so far as possible, understood. There are many possible causes for anemia and there may be contributing factors. The causes of the lesser grades of anemia are often ill-defined. The principal types of anemia are: 1. Defective blood formation. 2. Excessive blood destruction. 3. Acute or chronic blood loss. A combination of these factors may be operative in the individual case. P R I N C I P L E S OF T R E A T M E N T 1. tient 2. 3. 4. 5.

Recognize that no two cases are identical. Each pamust be treated individually. Remove or combat the cause when possible. Remove or combat contributing factors. Give careful attention to hygiene and nutrition. Employ special measures with intelligence. M E T H O D S OF T R E A T M E N T Ш

GENERAL

A cause for anemia must be searched for always and if found treatment must be directed toward it. Sometimes, as in pernicious anemia, a local diseased state, such as focal

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PRINCIPLES OF MEDICAL TREATMENT

sepsis, oral and otherwise, may contribute to the ill health of the patient but not be the cause of the anemia. Under such circumstances septic foci should be removed unless the disturbing effect of such a procedure in the individual case is likely to counterbalance the probable gain. Detailed attention to nutrition and to hygiene, including rest, environment, mode of life, and mental state and bodily mechanics are often of paramount importance, and particularly so for ill-defined types of anemia. Lack of attention to these essentials often causes failure of other forms of treatment. Rest. For severe cases complete rest in bed with the maximum obtainable mental serenity is of the utmost importance. This also offers for milder cases the best chance of rapid improvement. The period of complete rest must vary according to circumstances such as the patient's condition, the rate of improvement, and the future prospects. When in doubt choose the longer rather than the shorter period. Recognize that it takes weeks for the marrow to regenerate the blood to normal from a level of fifty per cent of hemoglobin and 3,000,000 red blood corpuscles per cubic millimeter. This is true even when the anemia is due to the simplest cause, namely, acute hemorrhage. When there is fever complete rest is imperative. The resumption of physical activity must be very gradual, and exercise must be intelligently prescribed and regulated. Patients not confined to bed should rest for some stated time, or times, each day and must scrupulously avoid excess of fatigue. Relapse may result from neglect of this precaution. Hygienic environment. The patient should have an abundance of fresh air and sunshine. Tanning of the skin by the sun's rays or ultra-violet rays may be beneficial. The anemic individual is particularly susceptible to cold so that he must be warmly clad to avoid chilling. An equable, dry, moderately warm climate is ideal for him. High altitudes may be recommended in certain instances of chronic anemia associated with defective blood formation because the relative deficiency of oxygen dependent upon altitude can act as a stimulant to the marrow.

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Diet and care oj the digestive system.^ An improper diet may be the cause of anemia and disorders of the digestion may not only cause, but result from, anemia. Adequate amounts of suitable foods are of prime importance for all patients with any impoverishment of their red blood corpuscles. Prescribe a generous (high caloric), properly balanced diet simply prepared, well cooked and tastefully served. Arbitrarily selected diets are to be avoided and idiosyncrasies of the patient, as well as his condition, at any given time should be regarded. Animal food rich in protein, and especially cooked beef liver, seems to accelerate regeneration of the blood and many patients do well upon taking liberally such substances. Green vegetables, fruits, and iron-containing foods in generous amounts are beneficial. Although, on somewhat theoretical grounds, excess of fat, especially animal fat, indeed may be undesirable in pernicious anemia and certain hemolytic anemias, as well as when the biliary apparatus is not functioning normally, no class of food need be excluded. Those who are overweight may do well to take sparingly of fat and carbohydrates. When there is intestinal fermentation, a condition common in anemia, concentrated carbohydrate foods are to be taken sparingly because they aggravate fermentation, and under these circumstances the dextrinated ones are the most suitable. Powdered charcoal in large doses (2-3 drams, 8-12 Gm., two to four times a day) or Merck's Kaolin in similar amounts is of value to lessen an excess of intestinal gas, and these substances may in some further manner be beneficial for patients with pernicious anemia. Each case presents a feeding problem in itself, and the menu must be adapted to the individual case. Six small meals per day are often better than three larger ones. Achlorhydria is common in anemia, and achylia is a feature of pernicious anemia. It is often advantageous to administer as large doses of dilute hydrochloric acid (Acidum Hydrochloricum Dilutum, U. S.) as the patient can tolerate. Five cubic centimeters in a large tumbler of water flavored with fruit juice and sipped during each of three meals a day often suffices. 1 Since this article was written, more information concerning the importance of diet in pernicious anemia has been obtained. Consult article by G . R. Minot and W . P . M u r p h y , 1926, Jour. A.H.A.

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In the presence of achylia the form in which food is taken is usually important. The food should be soft and vegetables should be very thoroughly cooked and "puréed" to avoid flatulence. the case is severe frequent small feedings of readily digestible semi-soHd food are best. Excess of liquid with food is to be avoided because it handicaps digestion, but adequate fluid intake is desirable in all cases of anemia. Measures which improve the appetite are valuable and procedures which improve the gastro-intestinal function, such as pharmaceutical preparations or irrigations for the bowels, may be used as in other conditions, but a properly prepared and well-regulated diet is of much greater importance. Massage is often valuable as an aid in restoring the muscles which are impaired by prolonged rest and anemia. Digitalis is helpful in some cases because the muscle of the heart, like other muscles, is weakened by anemia. Other symptoms and complications should be treated according to general principles as in other conditions. SPECIAL METHODS OF TREATMENT

Iron and arsenic. The administration of iron seems valuable in chlorosis and may be looked upon as a serviceable therapeutic agent in many anemias having a low colorindex. I t will hasten convalescence from the iron-deficiency anemia of infancy, but proper food alone cures this condition, while eating cooked beef liver improves these patients with striking rapidity. Iron does not seem to hasten blood regeneration in anemia due to acute hemorrhage, but may be of advantage in anemia due to chronic blood loss. It is not of value in pernicious anemia or hemolytic anemias where the body is well supplied with iron and biliary pigments. Iron is best prescribed in capsules, as Blaud's mass, freshly prepared. Five grains (0.324 Gm.) t. i. d. often suffices, but sometimes it seems desirable to increase gradually to much larger doses, even to 90 grs. (5.85 Gm.) a day. As improvement occurs, the dose should be gradually diminished. For children, an admirable preparation is saccharated carbonate of iron 1-3 grs. (0.065-0.2 Gm.) t. i. d. Sometimes intermittent administration of iron is better

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149

than continuous. The constipating effect of iron must be met by customary measures. Gastro-intestmal disturbances may necessitate a modification of iron therapy. Intramuscular injections of green citrate of iron^ ^ gr. (0.048 Gm.) two to three times a week then may be used. Iron given in this manner may, perhaps, yield more rapid results than when taken by mouth. The effect of arsenic on anemia has not been shown to be striking. It has been used particularly in pernicious anemia, and to enhance the effect of iron in simple anemias. I t appears to be more effective when not used continuously, but intermittently for periods of two to three weeks. I t is best given as Fowler's solution, beginning with 2 minims (0.12 cc.) t. i. d. and the dose gradually increased, but avoiding if possible even slight toxic symptoms. Arsenic may be given intramuscularly as sodium cacodylate 0.5I gr. (0.032-0.065 Gm.) every two to three days. There are various trade preparations of mixtures of iron and arsenic for hypodermic use that may occasionally be used advantageously. With anemia due to, or associated with, syphilis, arsenic should be given intravenously as arsphenamine or one of its allied preparations. Other pharmaceutical preparations and unusual procedures. Extracts of bone marrow and spleen, preparations of hemoglobin, manganese, germanium, and procedures such as small bleedings to stimulate the marrow, artificially induced deficiency of oxygen, so-called stimulative doses of Roentgen rays and radium, and a host of other remedies have been advocated. None of them have yielded striking results, but some of those mentioned as well as others may, in time, prove valuable. In this connection it is to be noted that the use of Roentgen rays and radium emanations to benefit patients with chronic leukemia, lymphoblastoma, etc., may permit the concomitant anemia to decrease markedly. BLOOD TRANSFUSION

Methods. When transfusion is decided upon, select a donor who is healthy, has a negative Wassermann reaction, Ï P u t up in ampules by various manufacturers, NQt official.

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PRINCIPLES OF M E D I C A L

TREATMENT

and who can readily afford the reduction of blood volume. His blood must be shown b y proper tests to be compatible with that of the patient. A n average amount of blood to be given an adult is 700 cc. A larger amount is required when replacement of blood volume is imperative. T h e method of administration is not of fundamental importance, but blood not mixed with any foreign substance is ideal. Transfusion, properly performed, is not dangerous but it should be recognized that even with the best technic, it m a y cause reactions which rarely are severe, particularly in patients having a fundamental blood disease. T h e rather dramatic character of transfusion has led to an over-estimation of its beneficial possibilities, particularly in chronic conditions. Uses. Transfusion m a y be utilized to restore, in part, all or a n y of the elements of the blood, or for its possible stimulating effect on the marrow. I t can produce the following effects: 1. Increase the power of the recipient's blood to carry oxygen. T h e foreign cells m a y live only for a few days or for several weeks. 2. Increase the blood volume b y increasing the corpuscles and increasing the plasma volume when it is diminished. 3. Favorably influence factors associated with pathologic hemorrhage. T h e blood platelets live but a few days, so that transfusion checks symptoms associated with their deficiency but for that amount of time. 4. Favorably influence blood formation. 5. Probably favorably influence metabolism, and perhaps the production of immune bodies. 6. Alleviate symptoms of anemia. Indications. Transfusion m a y be a necessity or a procedure of choice. CONDITIONS IN WHICH T R A N S F U S I O N MAY B E A NECESSITY

These states are accompanied b y anemia but its degree is seldom the criterion to determine whether or not the procedure should be undertaken.

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1. Hemorrhage and shock when the blood volume is markedly reduced. Serious reduction of blood volume exists when approximately 2000 cc. of blood have been lost, and especially when the loss has been rapid. The criteria upon which to judge the necessity for transfusion are the amount of blood lost, the rate of loss, the clinical state of the patient, the pulse rate, and the systolic blood-pressure. A persistent fall, or a pressure remaining below about 85 mm. of mercury, usually indicates a necessity for transfusion. Accurate hemoglobin determinations give information of value. A falling hemoglobin, after the bleeding has been stopped, is indicative of plasma dilution. No absolute indication for transfusion in hemorrhage exists, so far as the oxygen capacity is concerned, when the hemoglobin remains above thirty per cent. The dividing Une between death and recovery after sudden reduction of blood volume is narrow, yet in retrospect twenty-four hours after blood loss the relative well-being of many non-transfused cases is striking. When in doubt, transfuse; but do not too hastily undertake transfusion. 2. Hemorrhagic disease of the new-born, and control of serious hemorrhage due to pathologic blood defects. Blood given in sufficient amount intravenously, intraperitoneally, or intramuscularly, as a rule cures hemorrhagic disease of the new-born. Usually one or two doses of 40 cc. are enough. In other conditions associated with blood defects leading to pathologic hemorrhage, transfusion may be necessary owing to the amount of blood lost. It also alters favorably the abnormal blood state and thus checks hemorrhages. This beneficial effect lasts but a few days. During this time a wound may heal sufficiently to prevent further bleeding, as in hemophilia, or the abnormality of the blood may become corrected as in some cases of acute idiopathic purpura hemorrhagica, or the cause removed, as by surgery in a case of jaundice due to stone in the common duct. 3. Anemia due to severe marrow injury when the cause has been removed; that is, benzol poisoning. The patient can then be kept alive by repeated transfusions until the marrow regenerates sufficiently to supply an adequate number of formed blood elements.

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PRINCIPLES OF MEDICAL T R E A T M E N T CONDITIONS IN wmcH TRANSFUSION MAY BE DESIRABLE

Transfusion in all severe cases of anemia is to be decried. Pressure to perform it unnecessarily is often brought upon the physician by the patient and his relatives. I t should not be advised for many patients with uncontrollable disease such as cancer, septicemia, aplastic anemia, most cases of leukemia, etc. 1. In anemia from hemorrhage of both acute and particularly chronic types in which no emergency exists. Benefit follows this procedure in many such cases. 2. In other forms of chronic anemia especially associated with defective blood formation when the patient is not doing well, and particularly when the cause has been removed or when transfusion may diminish the activity of the cause. 3. To strengthen patients with anemia prior to a surgical operation. 4. Pernicious anemia. Transfusion can give temporary relief to these patients and may aid Nature to initiate a remission. It does not cure or fundamentally alter the course or duration of the disease. The desires of the patient and his family are to be considered in each case, together with the probability of remission and the state of the patient and that of his blood at the time. The most favorable cases for transfusion are those in which remissions are to be expected in any event. If the procedure has been decided upon, do not delay until the patient is moribund. However, no case is too sick to receive blood intravenously, and the marrow of some seems to respond better when the hemoglobin has fallen below a level at which a previous transfusion produced little benefit. The continued performance of transfusion in pernicious anemia is always a considerable problem, to be decided on the merits of each case. Repetition will often depend upon the result of two transfusions a week apart. More often advise against than for transfusion in this disease, yet recognize that a sufficient amount of blood often gives marked symptomatic benefit. Avoid transfusion during an active hemolytic crisis.

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153

5. In forms of hemolytic anemia other than pernicious anemia. Transfusion is valuable in the severer cases of the hemolytic anemia of pregnancy. It may hasten convalescence of cases due to parasites or other causes that have been removed, or enable such patients to be put in a state to make removal of the cause safe. Transfusion is of no value in chronic hemolytic jaundice, Banti's disease and the like, except to meet an emergency or to improve the patient's condition prior to splenectomy. SPLENECTOMY

Effects. Removal of the spleen alters favorably blood formation and diminishes red-cell destruction. It also probably decreases the abnormal destruction of blood platelets; and while there are other effects of splenectomy they are of no momentous importance to the patient. The operative mortality for all forms of cases is about ten per cent. Indications. Splenectomy is markedly beneficial to and may be curative for cases of chronic, hereditary or acquired, hemolytic jaundice having anemia sufficient to warrant operation, and for idiopathic cases of chronic hemolytic anemia of ill-defined character with splenomegaly. Splenectomy results in distinct benefit to many cases of splenic anemia, including those of the late stage known as Banti's disease. The earlier in the disease the operation is performed, the better are the results, yet splenectomy can produce marked benefit even after ascites has developed. Certain cases of cirrhosis of the liver with anemia and splenomegaly, as well as a rare case of splenomegaly with considerable anemia due to syphilis, chronic infection, and unknown causes, are definitely benefited by splenectomy. It may be worth while in Gaucher's disease, and in very chronic cases showing Von Jaksch's syndrome. Splenectomy benefits very markedly cases of idiopathic chronic purpura hemorrhagica (thrombopenic or thrombocytopenic purpura) with anemia and with or without splenic enlargement. These patients should not be hastily submitted to this operation. A t present splenectomy in acute thrombopenic purpura is to be advised cautiously. It may be valuable in atypical cases with marrow depres-

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sion resembling closely typical cases of chronic thrombocytopenic purpura. In pernicious anemia splenectomy is followed rather consistently by a remission, but the progress and duration of the disease remain essentially the same as with other methods of treatment. This form of palliative treatment is too serious to consider in pernicious anemia except in an occasional selected case. It may be advised in those rather chronic cases with large spleens, without severe anemia, that approach in character cases of chronic acquired hemolytic jaundice. Contraindications. The spleen should not be removed when splenomegaly and anemia are associated with erythremia (polycythemia vera), myelogenous leukemia, various forms of lymphoblastoma, symptomatic thrombopenic purpura or forms of purpura without reduction of blood platelets, or acute infections and most cases of chronic infections, such as endocarditis. Final statement. Numerous aspects concerning the subjects mentioned as well as others referable to the treatment of anemia have not been referred to because of their debatable significance. The detailed care of the individual patient, especially as pertains to his mode of life and nutrition, remains essential and thus is emphasized again.

CHAPTER DIABETES

XII

MELLITUS

BY B E N J A M I N H. R A G L E , M . D . Assistant Physician to Out-Patients, Massachusetts Gineral Hospital

DEFINITION DIABETES is a disease in which there is a diminution in the internal secretion of the pancreas. It makes itself manifest by the appearance of sugar in the urine, caused by a deficiency of this internal secretion, now called insulin. The normal individual can utilize a large amount of carbohydrate. A diabetic can utilize less in direct ratio to the impaired function of the pancreas.

(1) (2) (3) Ù) (5) (6) (7) (8)

ETIOLOGY Obesity. Infections and Toxemias. Arteriosclerosis. Menopause. Heredity. Prolonged Excess of Sweets. Mental Worry and Aluciety. Hyperthyroidism and Enteroptosis.

(1) Obesity. Just as the obese person becomes the victim of cardiac and kidney disease because of the excessive burden of extra weight, so he may find himself a victim of diabetes. Fortunately, in many cases, with the removal of the extra burden, the organism recuperates partially, and with strict adherence to a specified regimen, little difficulty is encountered. However, I have never had a patient so completely recover that he could with safety eat normally. (2) Infections and Toxemias. I believe that the most serious cases of acute diabetes have infection as the chief etiological factor. It is just as logical to expect a pancreatitis as a nephritis following a septic sore throat.

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Glycosuria is not infrequently noted simultaneously with a temporary albuminuria, both of toxic origin. (3) Arteriosclerosis. Just as arteriosclerosis lowers the function of the kidney, so may it lower the function of the pancreas. (4) Menopause. The disturbance of metabolism that takes place at menopause is little understood. I t is most likely due to an imbalance of the internal secretory chain. The onset of diabetes during this period is so frequent that it is a wise precaution to have medical supervision at this time. (5) Heredity. An improper balance in diet during the early years, or self-indulgence in the rich carbohydrates that favor glycosuria, may be more important than the hereditary factor. (6) Prolonged Excess of Sweets. Prolonged indulgence in sweets is too often a part of a diabetic's history to be ignored as a factor in etiology. (7) Mental Worry and Anxiety may be a factor in etiology. I t is without doubt a large factor in hastening the process of the disease once it is established. (8) Hyperthyroidism and Enteroptosis. Sugar is known to occur frequently in the urine of patients with exophthalmic goiter, and occasionally in the urine of all ptotics. Neither condition has proved to be of much importance in etiology. COURSE OF THE

DISEASE

If diagnosis is made early, proper treatment begun at once, and strict adherence to the regimen carried out, in most cases the patient's tolerance for food may be maintained for some time. If the onset is sudden, polyuria, polydipsia, polyphagia, dry mouth, pruritis, rapid wasting, and loss of strength are likely to cause the patient to seek relief. The reverse holds true invariably if the disease is allowed to run on without any attempt to control it. Unfortunately, when the onset of the disease is gradual, there may be no symptom in the early months that will lead the patient to seek medical advice. The rapidity of decline depends somewhat upon the age of the patient, the etiology of the disease, and the natural dietary habits.

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DIAGNOSIS

Diagnosis is usually very easily made. The patient's story, if the onset has been acute, is almost pathognomonic; otherwise, we must depend upon the examination of the urine. Blood-sugar estimations help us in determining the degree of diabetes, but are of more aid in the treatment. R E C E N T A D V A N C E S IN

DIABETES

Before the advent of insulin, our sole recourse was in the adjustment of dietary to the patient's tolerance or need. Institutional treatment a few years ago was almost necessary in all cases. Even to-day it is highly advisable, and the wise doctor will do his best to have his patient get this institutional training and adjustment that will not only teach him how to take care of himself, but will impress upon him for all time the wisdom of the proper precautions. The research of Drs. Banting and Best gave us insulin and took away the haunting fear of both diabetic patient and diabetic doctor. I t will not cure the disease, but it wiU control it and permit the patient to live a life of normal interest and activity. He has no handicap as long as he carries out the good hygiene that is prescribed in the regimen outlined for him. PRINCIPLES OF T R E A T M E N T

1. Establish a well-balanced maintenance diet. 2. Give the patient as thorough an understanding of the dietary as is advisable in the individual case and teach him to do the simple qualitative test on his own urine. 3. Establish a general hygienic regimen that will make for efficiency. 4. See that all functions and organs are kept in the best possible condition. METHODS

I. Whereas formerly it was necessary to render the patient sugar free and reduce his blood-sugar to the normal level, it is well now during the first day of treatment to give him a test diet, following either the very admirable scheme which Dr. E. P. Joslin has adopted in the treatment of his

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PRINCIPLES OF MEDICAL T R E A T M E N T

cases, or giving him 50 grams carbohydrate, 50 grams protein, and 50 grams fat as follows: Breakfast Orange Egg Oatmeal 20 % cream Coffee

100 Gm. I 10 Gm. 60 cc. Dinner

Broth Meat S % vegetable 10% vegetable 20% cream Gelatine

60 Gm. 150 " 150 " 30 cc. Supper

Broth Chicken, white S % vegetable 10% vegetable Butter Cream

60 Gm. 150 " 150 " 10 " 30 cc.

Should the patient become sugar free on this diet, increase gradually to a maintenance diet by adding to the carbohydrate until it reaches 90 Gm.; by adding to the protein until the patient is getting 1-1.5 ^ i " · P^r kilogram of body weight; and by adding to the fat up to the calories needed. If the patient is not sugar free after one day on the test diet, on the second day give two to three units of insulin fifteen to twenty minutes before each meal. If the patient becomes sugar free in mid-morning or mid-afternoon, shift at once to 30 calories per kilogram of body weight, with carbohydrate 75 Gm., protein 1-1.5 Gm.; fat to complete the 30 calories, as indicated. If he is not sugar free at the end of the second day of treatment, on the third day give him the maintenance diet as above outlined; gradually work insulin up to cover it by moderately forcing fluids, as we do in all cases in the beginning, and by testing each single specimen. The proper amount of insulin can be very quickly determined. It has now become my habit to take blood-sugars on a patient in the hospital if at any time he feels any symptom that might

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indicate an abnormally low blood-sugar. I t helps us with the insulin adjustment and also permits us to reassure the patient, especially if there is any question of an insulin reaction having taken place. 2. With each tray the diet slip comes to the patient, on which the food is carefully outlined in grams. T h e first few slips are figured for him, but as soon as possible we have the patient estimate the calories for himselt from the dietary slip. He also on the second or third day follows the nurse to the laboratory, where he tests, or sees tested, the single specimens voided. This testing procedure becomes a game with him, and the sooner a proper adjustment is made, the sooner is he permitted to leave the hospital. 3. Quite early in his training make him see the necessity for the following: (a) Strict adherence to the proper diet. (b) Careful regulation of activity and exercise. (c) Abundance of rest and sleep and avoidance of fatigue. (d) Regular and proper bowel habits. (e) Philosophical acceptance of the regimen outlined if he wishes to live efficiently and permit those around him to live in peace and happiness. So often a diabetic undermines his own morale b y cursing the fate that gave him diabetes, thereby lowering the morale of those around him. On the other hand, he has the opportunity, by being steadfast, to encourage self-control in those with whom he deals. There is no finer example of manhood than is exhibited in the young man who with a moderately severe diabetes can go to school or college, withstand all the temptations that beset him, make a place for himself on the football team, basketball team, or track team, and become a real hero in his little world. 4. During the glycosurie period, the diabetic organism becomes much less resistant to the pyogenic and other infections, and convalesces slowly after injury. Therefore, we should investigate the respiratory, circulatory, and gastro-intestinal systems, and endeavor to correct any disorders that are found. Acute visual disturbances usually clear up when the urine becomes sugar free, but, inasmuch as good vision becomes a more valuable asset in a person whose activities and diversions are limited, glasses should

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PRINCIPLES OF MEDICAL T R E A T M E N T

be ordered or corrected as indicated. The teeth and gums should always be examined carefully, because dental sepsis has all too often been a serious factor in retarding the progress of a patient. ACIDOSIS

A mild acidosis practically always disappears during the first or second day. As soon as the organism begins to utilize carbohydrate, the fat, from which ketone bodies are made, is burned completely. If the acidosis has gone on to the point where coma is impending, the following procedure is used: 1. Insulin. once.

From 5 to 20 units of insulin are given at

2. Bed. The patient is put to bed and kept warm. 3. Enema. Repeated if necessary, to empty and cleanse the colon. 4. Fluids. Hot diabetic broths, tea, weak coffee — up to a tumblerful each hour. 5. Nourishment. The juice of a 150 Gm. orange, or a cup of hot oatmeal gruel (30 Gm. of oatmeal to 500 cc. of water), every two hours, beginning at once, or as soon as the patient begins to recover if the coma has been quite deep. If coma is really impending and the patient not able to take noiurishment, or so nauseated that he cannot retain it, resort at once to 500 cc. of warm, freshly prepared normal sahne solution intravenously; warm rectal saline may be given instead. 6. Sugar. Accurate knowledge of the amount of sugar in each single specimen is essential in order that you may know when to diminish or omit the insulin. 7. Stimulants. I have had little success with the use of stimulants, such as caffeine or strychnine. The diuretic effect of coffee and tea is worth while, and the comfort that it gives the patient has made it seem useful. 8. As soon as the danger of coma is past, the principles of treatment as suggested above are applied.

DIABETES MELLITUS

I6I

COMPLICATIONS IN DIABETES

(1) (2) (3) (4)

Infections, Furuncles, and Sepsis. Gangrene. Nephritis. Pregnancy in Diabetes.

(1) Infections, Furuncles, and Sepsis. Here, again, insulin has been of great value. It has not only done away for the most part with the complications in diabetes that we formerly had to fight, but has become the most valuable instrument in control of them. I have observed no contraindication to the careful administration of insulin in any infection. (2) Gangrene. Avoidance of gangrene is possible. T o elderly patients with endarteritis obliterans, has been emphasized the wisdom of careful trimming or filing of the toe nails. Never draw blood. Woolen socks, warm foot-baths, massage, leg and foot manipulation, and short walks should be prescribed. After gangrene has set in, bed, diet, insulin, and the best surgical advice are necessary. (3) Nephritis. There is no contraindication to the usual diabetic procedure. One-half gram to 0.75 Gm. of protein per kilo of body weight is quite sufficient to maintain nitrogen equilibrium. Salt and intake of liquid may also be limited. (4) Pregnancy in Diabetes. Insulin has made it safe for the mild diabetic to become pregnant and go through pregnancy. The utmost skül is required in management. Cooperation between the obstetrician and the physician is necessary at aU times. DIABETES IN CIHLDREN

Even though we have insulin, diabetes in children is still serious. Sufficient time has not yet elapsed to permit of an accurate prognosis. All of us should take courage, however, and treat to the best of our ability any child with diabetes. These young diabetics are particularly brave. They learn very quickly the principles of treatment, and often are most expert in giving themselves insulin. All the stimuli and courage possible should be given to them.

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PRINCIPLES OF MEDICAL TREATMENT

Who knows but that the islands of Langerhans may recuperate somewhat, or what new advances may be made in the treatment of diabetes? TRANSITORY GLYCOSURIA

It is safest and wisest to consider every person excreting any amount of sugar as a diabetic until proved otherwise. The burden of proof rests with the physician, and I am always reluctant to take the responsibility of making the diagnosis of temporary glycosuria. Every such case is a potential diabetic. RENAL DIABETES

So-called renal diabetes exists, but it is rare. A great responsibility rests on the physician who, without the most careful study, classifies any individual in this group. EXCEPTIONAL DIABETES

There is an irregular type of diabetes, the time of onset of which can usually be traced to middle age. The disease goes on for many years without causing serious symptoms, and this class of individual may experience no handicap that he considers unassociated with oncoming age until there takes place a fairly rapid loss of weight and strength, accompanied by moderate increase of thirst, appetite, and frequency of micturition. An injury, sepsis, or an acute infection may be the cause of this fairly rapid decline. I t is not unlikely that this group comprises the majority of those diabetics who late in life suffer from carbuncles and gangrene. The latter trouble is probably the result of a marked arteriosclerosis which is almost invariably present. The basis of their glycosuria may be arteriosclerosis of some of the vessels of the pancreas analogous to the changes of this character which occur so commordy in the kidney with advancing years. The best method of treating these patients is to keep them sugar free. They have true diabetes.

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163

MANAGEMENT OF MODERATELY SEVERE AND SEVERE DIABETICS, W H O CANNOT AFFORD INSTITUTIONAL C A R E

Have the patient, with some other responsible person, come to the office early in the morning before breakfast, after having been on the above test diet the previous day; that is, 50 Gm. carbohydrate, 50 Gm. protein, and 50 Gm. fat. Have him bring with him single specimens which have been saved during the preceding twenty-four hours. 1. A blood-sugar is taken and tests made on the single specimens collected during the previous twenty-four hours. 2. The patient is taught the use of gram food scales. 3. A diet consisting of 30 calories per kilo is given him; usually 75 Gm. carbohydrate, 75 Gm. protein, and the remainder in fat. 4. The patient is taught how to give himself insulin. An ordinary empty insulin ampule is filled with sterile saline solution. Syringe and needle are sterilized in the usual way by boiling three minutes. The instructor, with the patient watching each step closely, sterilizes the rubber stopper of the insulin bottle with alcohol, and uses the same pad to sterilize the outer side of the leg midway between the hip and the knee. Two-tenths of a cubic centimeter of sterile saline solution is drawn up into the usual tuberculin type syringe, or an insulin type syringe, and administered subcutaneously at a proper depth. (We use a I cc. tuberculin type syringe adapted for insulin, with a one-half inch 24 or 25 gauge Luer type needle.) The patient proceeds with the help of the instructor to give himself several doses, until he is quite competent and able to do it for himself. 5. He is then instructed to take from 2 to 8 units of insulin fifteen to twenty minutes before each meal, and is sent home to do this the following day. He and the person with him are instructed as to what an insulin reaction is and told to watch for it. Ordinarily, however, insulin is adjusted so that there will be no danger of this. 6. During the following twenty-four hours he again collects single specimens, and comes to us two hours after breakfast on the next day, at which time the blood-sugar is taken and the single specimens of the previous day tested.

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PRINCIPLES OF MEDICAL TREATMENT

7. Again the patient is sent away, with insulin adjustment as indicated, and asked to report in forty-eight to seventy-two hours; if he must be at his work, either early in the morning or after work in the evening. 8. He is then seen once every week for two or three visits, and thereafter less frequently, as indicated. PROPER DOSAGE OF INSULIN

So-called insulin reactions may occur in the best-regulated case. For example, a man of sedentary habits may during a snow-storm decide to shovel his own driveway. He works steadily from ten o'clock in the morning until noon, and suddenly is aware of hypoglycemia. Immediately he will eat an orange, an apple, or whatever he has been instructed to take under such circumstances. Not infrequently insulin is given too long before a meal. Sometimes an acute upset will occasion the vomiting of a meal. This must be covered with a proper amount of carbohydrate in some form, or a serious reaction may take place. Generally weakness, nervousness, and sweating are the premonitory symptoms of overdosage. If something is not done promptly, numbness creeping from the extremities toward the trunk, stiffness and numbness of the lips, stupor, inability to articulate, and occasionally a real unconsciousness ensue. Unfortunately, first manifestations may be severe. Very rarely do we hear of a temporary psychosis resulting. Therefore some one in the family, or someone with whom the patient is closely associated, should be instructed along these lines, so that he may help out in the emergency, if necessary. A tablespoonful of corn syrup, an orange, an apple, two or three lumps of sugar, or any of the usual procedures will quickly restore normality. NOTES

We have insisted upon exercise for diabetics. In one case recently we found that an hour of actual physical exercise, such as chopping wood, shoveling snow, or gardening, took the place of 6 to 8 units of insuUn. Inasmuch as this patient was putting on a little too much weight, the substitution was made to great advantage for the patient.

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165

Alcohol is no longer used either as a food or as a therapeutic measure with diabetes. It is much better to adhere to total abstinence, especially if the diabetic must take insulin. Surgery can be performed on diabetics now without danger. Precaution must be used in administering insulin during the period after an operation when very little food is taken. It is still advisable to use local anesthesia when convenient. Ether or ethylene, however, should be used in major operations. There is no contraindication to gas and oxygen. Saccharin may be used at the discretion of doctor and patient. I should ordinarily discourage its use. It is difficult to build a well-balanced diet when the carbohydrate in the diet is in excess of 75 Gm., unless potato or bread is allowed. There is no difficulty in controlling the diabetic's appetite for bread, when it is permitted. In certain cases where the high residue diet is contraindicated, either due to colitis, stomach or duodenal ulcer, or ptosis, I find that the conscientious diabetic is perfectly able to have all of his carbohydrate in the form of bread, potato, rice, marcaroni, crackers, and fruit juice. In my opinion, the insulin diabetic should be permitted to gain weight up to ten or fifteen pounds of what would be considered his normal.

CHAPTER ENDOCRINE

XIII

DISORDERS

BY C H A R L E S H. L A W R E N C E , M . D . Chief of the Endocrine Service, E v a n s Memorial Lecturer in Medicine, Boston University Medical School

I. THE THYROm GLAND ETIOLOGY THE cause of disordered function of the thyroid is not definitely known. Infections, especially of the focal variety, and prolonged or severe physical or nervous strain often precede the thyroid derangement. Puberty and pregnancy are etiological factors in certain cases. CLASSIFICATION The following varieties of thyroid disfunction are recognized clinically: 1. Simple goitre. 2. Colloid goitre. 3. Adenomatous goitre. 4. Thyrotoxicosis (Exophthalmic goitre). 5. " H y p o f u n c t i o n " (Myxedema). 6. N e w growths. 7. Inflammations. Colloid goitre, adenomatous goitre, new growths, and inflammations of the thyroid are conditions which respond only to surgical treatment. I. SIMPLE GOITRE This condition is due to a lack of iodine in the thyroid, and probably represents a compensatory enlargement. It appears usually during adolescence, and characteristically only in the female. Diagnosis. The following points are usually sufficient to estabhsh the diagnosis: The enlargement of the thyroid is

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PRINCIPLES OF MEDICAL

TREATMENT

slight to moderate. It is symmetrical and firmly elastic. It appears at or soon after puberty. Constitutional symptoms are absent. The basal metabolic rate is normal, though tending toward the lower limit. Prophylaxis. In "goitre districts" the routine administration of small doses of iodine is of proven value in preventing simple goitre. The dose for this purpose is 3 gr. (0.2 Gm.) of sodium iodide daily for a period of ten days every six months. Thyroid extract is not indicated. Treatment. Although simple goitre causes no constitutional symptoms, it demands treatment because of the possibility that it will later develop into one of the more serious disorders. Treatment consists in supplying iodine in sufñcient amounts to the patient. This may often be accomplished by sending her to the seashore, where there is sufficient iodine in air, food, and water to make up the deficiency, or by giving iodine in small doses. Iodide of sodium or potassium, 1-5 gr. (0.065-0.324 Gm.) given well diluted once daily, is efficient in most cases. If the iodides cause a rash, small doses of thyroid extract may be substituted. Thyroxin should not be used in simple goitre. During treatment the patient should be seen frequently, and a careful record of the pulse rate and neck circumference should be kept. The possibility of producing thyrotoxicosis by giving too much iodine must be kept in mind. If protracted treatment is necessary, it is advisable to omit the iodine one week in every four to prevent over-dosage or intolerance. When the goitre has disappeared, medication should be omitted. The patient should then be given for several years the prophylactic treatments already described. 2.

COLLOID GOITRE

The treatment is surgical. 3. ADENOMATOUS GOITRE

The treatment is surgical. The administration of iodine or thyroid extract is contraindicated in both colloid and adenomatous forms. Removal of the goitre is usually advisable because of the possible development of thyrotoxi-

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169

cosis or malignant disease. However, no operation on the thyroid should be performed without first accurately determining the basal metabolic rate, for hypothyroidism and goitre may coexist. It is better to forego removal of the goitre than to risk aggravating or producing hypothyroidism through over-enthusiastic surgery. 4. THYROTOXICOSIS

This condition, also called hyperthyroidism or exophthalmic goitre, appears characteristically between the ages of twenty and fifty, though a small percentage of cases develop earlier or later. It effects women six or eight times more frequently than men. Any preexisting thyroid disorder may change to the toxic type without known cause, or the toxic symptoms may appear without preëxisting derangement. EHagnosis. The four cardinal signs of thyrotoxicosis are: goitre, exophthalmos, tremor, and tachycardia. It must be remembered, however, that in the early stages of the condition goitre and exophthalmos may be absent. Nervous instability, loss of weight and strength, palpitation and tremor are often the only signs of a moderate thyrotoxicosis. The diagnosis may be suspected from the history and physical examination but frequently cannot be confirmed without further information. Incipient tuberculosis, endocarditis, and certain psychoses must be ruled out. The estimation of the basal metaboUc rate may furnish evidence of value in so doing. But the value of that evidence depends upon obtaining a true basal rate, and it is often necessary to repeat the test several times before the true rate is obtained. Estimations which are obtained under improper conditions may be entirely misleading, and an increased rate without physical signs or symptoms is not sufficient basis for the diagnosis of thyrotoxicosis. Leukemia causes an increase in metabolism, and an examination of the blood is therefore a necessity in all doubtful cases. X-ray examination of the chest wül also be necessary in such cases, to furnish evidence of pulmonary tuberculosis or substernal goitre, if either be present. Treatment. The ideal treatment of thyrotoxicosis will restore normal function without destroying the gland. Un-

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PRINCIPLES OF MEDICAL T R E A T M E N T

til such a method is available, treatment must consist in: (a) reducing toxemia by destroying or depressing the thyroid; (δ) increasing the resistance of the body to the efíects of the toxin. (1) Medical Treatment. There is at present no medical treatment which will permanently control thyrotoxicosis. In that due to hyperplasia of the gland, as distinguished from toxic adenomata, the administration of Lugol's solution will bring about a marked but temporary drop in basal metabolic rate and symptomatic improvement, but the effect is of short duration. The dosage of the solution is 10-15 min. (0.6-1 cc.) daily, well diluted. This treatment is useful as a preliminary to surgical operation as it apparently prevents the postoperative "thyroid crises" which may occur in patients not so treated. Aside from this preoperative iodine therapy, medical treatment is not successful in diminishing thyrotoxicosis, so that in the majority of cases recourse must be had to surgical treatment or roentgenotherapy. The details of these two forms of treatment do not belong in a treatise on medical care, but their respective merits may be briefly discussed. (2) Surgical Treatment. The great advantage offered by surgical removal of part of the thyroid lies in the rapidity with which this maneuver reduces the toxemia. Its effects are seen in days or weeks while the effects of X-ray treatment are demonstrable only in weeks or months. Surgical intervention diminishes the time during which the body is exposed to the thyrotoxicosis more certainly than does any other form of treatment, and for that reason is certainly preferable for those patients who resist the toxemia poorly. Patients showing evidence of cardiac damage, rapid loss of weight and strength, or profound nervous disturbance are more suitably treated by surgery than by means of the X-ray. The objections to surgical treatment are its mortality rate in the hands of any but the most expert, the interference with work entailed, and the scar produced. On the other hand, the mortality can be reduced by the preoperative use of iodine already mentioned ; the interference with work is often necessary because of the patient's general

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condition; and the scar is less noticeable than exophthalmos or well-developed goitre. (3) Roentgenotherapy. This form of treatment requires time to produce its results, and there is, therefore, introduced the element of possible serious effects from the prolonged toxemia. The end result may be as satisfactory as that obtained by operation. It leaves no scar, and does not entail confinement in a hospital. Its effects, however, are less certainly satisfactory than those of operation. The main objection to this form of treatment lies in the danger that, while waiting for its beneficial effects, the heart may become permanently damaged from the persisting toxemia. Another objection sometimes advanced is that it may bring relief enough to decide the patient against operation, but not enough to protect from the ultimate effects of the thyrotoxicosis. In deciding which form of treatment is advisable for a particular patient, two factors are most important: the first is whether the patient probably can withstand safely the longer period of toxemia incident to X-ray treatment, and the second concerns the relative ability of available surgeons and roentgenologists. X-ray treatment has no immediate mortality. Surgery has. It is small, however, in the hands of those expert in thyroid surgery. Therefore, the patient's life will be safer with skilled X-ray treatment than with operation except by an especially competent surgeon. The best surgery offers more rapid relief from the thyrotoxicosis and a greater certainty of ultimate complete cure. If surgical operation is elected, special medical preoperative care is not usually required unless cardiac damage has already occurred. If decompensation be present, it should be treated by the methods described in the chapter on Circulatory Diseases. After operation, and during the intervals if the operation be divided into several stages, medical treatment should be carried on as follows: Effort should be restricted to the amount which does not cause fatigue. The diet should be as nutritious as possible to meet the demand made by the increased metabohsm. The weight should be used as a guide in determining the diet.

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TREATMENT

Toxemia should be combated by increasing elimination. This is done by making certain that a sufficient amount of fluid is ingested, and that elimination through kidney and bowel is brought to the most efficient possible level. Adequate rest should be obtained by requiring the patients to lie down where they will be undisturbed, for at least an hour daily, and by making possible satisfactory sleep at night by means of hydrotherapy, massage, or, if necessary, sedatives. It must be remembered that when patients leave the hospital after operation they are not well but only in a position to get well, and that medical care during that period can do much to hasten and to complete the return to normal health. If X-ray treatment is elected, medical care as outlined above is necessary throughout the treatment. Patients should be required to report frequently for examination in order that progress may be determined. The pulse rate, the temperature, the weight and the heart condition should be noted frequently, and the basal metabolic rate should be determined at regular intervals. Lack of improvement within a reasonable time, continued loss of weight, or increase in pulse rate should be regarded as sufficient proof of the inefficiency of the treatment and the necessity for surgical intervention. 5. HYPOFTINCTION OF THE THYRORO

Three separate clinical pictiu-es may be identified with thyroid hypofunction. Congenital failure causes cretinism, failure during adult life causes myxedema, and failure during adolescence may give rise to a cUnical picture in which myxedema is not apparent, but which is characterized by malnutrition, fatigability, and general physical subefficiency. Diagnosis. The diagnosis of cretinism and myxedema is usually possible by inspection, provided physical examination shows no organic disease. The diagnosis is confirmed if the basal metaboUc rate is found to be below — 25 %, as no other condition save starvation wiU cause so low a rate. The diagnosis of the adolescent type of failure is much more difficult, since the typical myxedematous ap-

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pearance is lacking. I t may, however, be suspected from the history, and confirmed b y determining the basal metabolic rate when physical examination reveals no other cause for the malnutrition and malfunction. Treatment consists in supplying the patient sufñcient amounts of thyroid secretion to maintain the metabolic activity a t a normal level. This m a y be done b y administering thyroid extract or thyroxin. T h e latter is preferable when v e r y rapid results are necessary. I t can be given intravenously. For all but exceptional cases, however, thyroid extract is efficient, and being less concentrated, is safer. T h e dose of either preparation can be determined only b y observing its effect on each individual patient. A s a rule, those with low metabolic rates can tolerate a larger dose than those with less evidence of thyroid deficiency, but there are exceptions to this rule. Care must be exercised to avoid giving larger amounts than the body can utilize and thus producing symptoms of thyrotoxicosis and necessitating suspension of medication. All patients receiving thyroid medication should be seen at least once a week until their personal requirement is determined. As an initial dose 3 - 5 gr. (0.2-0.324 Gm.) daily is safe and usually sufficient to give demonstrable results. T h e pulse rate, the temperature and the weight furnish evidence of the efficiency of the medication, and regular estimations of the basal metabolism are extremely helpful as they furnish a numerical measure of progress. T h e amount of thyroid extract or thyroxin necessary to restore the patient to normal is usually greater than that required to maintain normal function after i t has been regained, so that it is often necessary to reduce the dose slightly as the patient approaches the normal. Once necessary, thyroid is probably always necessary, but not always constantly needed. A f t e r a patient having thyroid failure has been under medication for some time it is usually possible to omit the treatment for gradually increasing periods and this is useful in preventing the production of artificial hyperthyroidism. I t is, however, not proven that the patient with thyroid failure ever becomes completely independent of substitutive treatment.

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The effects of administering thyroid to those who need it is so satisfactory that little else in the way of treatment seems necessary. If thyroid extract does not cause prompt improvement, the most likely explanation is that the preparation is inert. Care should always be taken to insure the use of a fresh, active extract. If that causes no improvement, the dose should be increased and if even then no improvement occurs, thyroxin should be substituted. In a small percentage of cases additional small doses of iodine, such as are used in the treatment of simple goitre, increase the beneficial effect of the thyroid medication. In addition to the specific treatment, patients with thyroid failure should be rid of any coexistent focal infections, because the latter have a depressing effect upon thyroid function. Arteriosclerosis is a common condition in long-standing or severe cases of hypofunction so that it may be necessary, in certain cases, to treat an arteriosclerotic renal or cardiac condition iq. V.) in addition to the thyroid failure. Because of this association of arteriosclerosis and hypothyroidism, thyroid extract has been recommended in the treatment of arteriosclerosis in general. This is poor logic. Thyroid extract may be expected to cause improvement of any symptom or condition due to thyroid insufficiency, but its use in the treatment of that symptom or condition, when due to some other underlying derangement, is unjustified and dangerous. II. THE PITUITARY GLAND Disease or disturbed function of the pituitary gland gives rise to several different clinical pictures, depending upon the age at which the disturbance appears, which lobe is involved, and whether the derangement of function be in the direction of overactivity or failure. The clinical conditions at present ascribed to interference with normal pituitary function are: (i) Dwarfism; (2) Fröhlich's Syndrome; (3) The Levi-Lorraine Type of Infantilism; (4) Giantism; (5) The Neurath-Cushing Type ; (6) Acromegaly. These various types represent various combinations of malfunction of the lobes at various age periods. Giantism and acromegaly represent "hyperfunction" of the gland,

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for which there is as yet no medical treatment. The other conditions enumerated represent failure of the secretion of one or both lobes, and such failure, if it can be identified, is susceptible of benefit from medical treatment. ETIOLOGY Nothing definite is known concerning the cause of disordered pituitary function. Heredity is a probable factor, the importance of which cannot at present be accurately stated. Possibly the more severe infectious diseases may also be factors in bringing about deranged function. In a small percentage of cases the symptoms appear after pregnancy. DIAGNOSIS From the point of view of treatment, the important question is whether the clinical picture represents a past or present malfunction. Giantism and acromegaly frequently represent a previously existing overactivity of the gland which has since become normal or even changed to an underactivity. Failures of pituitary function, however, rarely correct themselves spontaneously, and once established persist through life. Nevertheless, treatment is not justified until a definite diagnosis of the nature of the disturbed function has been established by means of the history, physical examination and such vital function tests as are indicated. Determination of the basal metabolic rate and of the threshold of tolerance for sugar will distinguish pituitary failure from that of the thyroid, and plotting the visual fields will often disclose the typical "cutting" due to the pituitary enlargement which not infrequently accompanies functional failure. In the light of our present knowledge it is not justifiable to treat a patient for pituitary disease without using all available methods for establishing the diagnosis. U S E OF P I T U I T A R Y E X T R A C T S There is, at present, no effective medical treatment for overactivity of the pituitary. Surgical treatment is indicated only when there is also present enlargement of the glajid causing increased intracranial pressure.

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1. The treatment of failure of pituitary function consists in administering an active extract of the lobe involved, in adequate doses. The dosage required to relieve symptoms is larger than that usually suggested. It often requires 20-30 gr. (1.3-2 Gm.) daily to compensate for the failing glandular function. The dose at first should be 6-8 gr. (0.4-0.5 Gm.) daily, because some patients seem easily affected. If this amount produces no effects the dose should be courageously increased until results are obtained. The production of headache, vertigo or slight nausea indicates that the patient's tolerance has been reached. Pituitary extract administered orally is effective if given in sufficient amount. 2. Diabetes insipidus was formerly believed to be due to functional failure of the posterior lobe of the pituitary gland. Pituitary extract given orally had no effect upon the urinary output in that condition. It was, therefore, believed that the extract was inert unless given subcutaneously. It is now known that diabetes insipidus may be due to injury to the base of the brain in the region of the pituitary gland. The action of pituitrin in controUing the diuresis is, therefore, pharmacological and not physiological, and the failure of pituitary extract given orally to limit the urinary output does not disprove a possible physiological action in conditions due to pituitary failure. In diabetes insipidus the administration of pituitrin diminishes the urinary secretion in a dramatic manner. To accomplish this effect, it must be given intramuscularly or intranasally. The latter method consists in spraying the solution into the nose with an atomizer, or introducing into the nostrils pledgets of absorbent cotton soaked in pituitrin. Intramuscular injection is more certain to give results, but is objectionable to many patients, especially as the injection must be frequently repeated. The dose is 15 min. (i cc.) of the solution repeated two to four times in twenty-four hours, according to the duration of its effect in the individual patient. 3. In addition to its employment in substitutive therapy, the extract of the posterior lobe is used in certain conditions because of its effect on urinary excretion and smooth muscle. Because it stimulates the contraction of smooth muscle

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Pituitrin is extremely useful in abdominal distention when the condition is due to paralysis of the bowel as distinguished from mechanical obstruction. In pneumonia and postoperative ileus it is probably the most efficient method of combating tympanites. I t should be used with caution if the patient has a high blood pressure or cardiac decompensation, because of its eSect on the circulation. The contraindication is not, however, absolute if the distention is serious and stubborn. Pituitrin is also used in obstetrics to stimulate uterine contraction and control hemorrhage during deUvery. III. THE ADRENAL GLANDS The only clinical entity known to be caused by disease of the adrenals is Addison's disease. As described by Addison, the pathological process was due to tuberculous infection. Rarely, syphilis or tumor of the adrenals may produce the symptoms of Addison's disease. Failure of adrenal function not associated with destructive processes involving the glands has not been convincingly demonstrated. T R E A T M E N T OF ADDISON'S

DISEASE

When the disease is due to tuberculosis, it is nearly always fatal, but administration of adrenalin and extract of the cortex of the gland will delay the issue and promote the patient's comfort. The weakness which is such a distressing symptom can be mitigated and in the rare cases due to syphilis or tumor, life may be prolonged until the syphilis has been scotched or the tumor removed, if that be possible. Adrenalin must be administered intramuscularly, as it has no effect when given by mouth. The usual dose is from 10-15 (o.6-i cc.) of a I :iooo solution, but the amount given depends upon the individual patient's need. Administered by rectum, it is effective, but its local action upon the mucous membrane prevents its administration by this route for more than a short time. Adrenal cortex is effective when given by mouth. It is best administered in the form of fresh gland substance, but is more easily available in the form of tablets or capsules of the dried extract. The dose is from 8-20 gr. (0.50-1.3 Gm.) daily. T h e cortical extract is an important part of the

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treatment of Addison's disease, for it is the cortex, not the medulla of the gland, that is essential to life. If the patient with Addison's disease has syphilis also, this should be vigorously treated in connection with the glandular therapy. Rarely, tumors of the adrenal are recognized during the stage when operative removal is possible. Operation is then indicated, but forms only a part of the treatment. Adrenalin and cortical extract should be administered before and after operation. Other Uses of Adrenalin. Like pituitrin, adrenalin has certain uses because of its specific effects. Thus in asthma (g. ï).) it controls bronchial spasm more successfully than any other drug. It has been recommended also in the treatment of shock, but its value in that condition seems to have been overestimated. This is due to the fact that its action in raising the blood pressure is too evanescent to be of real service. Its chief use at present is as a local hemostatic in surgical operations, especially those on the nose and throat. IV. THE OVARIES

Organic disease of the ovaries should not be treated medically. Derangement of function, typically that which occurs at the menopause or as the result of oophorectomy, may be properly treated by the use of extracts of the gland. Occasionally, delayed or painful menstruation or menorrhagia may respond to the use of ovarian extracts, but in every case such treatment should be instituted only after careful pelvic examination, by rectum in the unmarried, has excluded the presence of organic disease. TREATMENT There are three forms of ovarian extract representing theoretically three different active substances: ovarian extract is said to contain the entire secretion of the ovary; corpus luteum extract represents the secretion of that structure only; ovarian residue is made from the ovary after removal of the corpus luteum. As these extracts are sold under various trade names, it is advisable to make certain just what any particular preparation represents.

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Theoretically the whole ovarian extract or ovarian residue should be most efficient in controlling the nervous and circulatory symptoms of the menopause, whereas corpus luteum extract should be more effective in the treatment of dysmenorrhea or menorrhagia not due to organic disease. Practically, this rule holds in the majority of cases, but it should not prevent the use of any extract in any given case until our knowledge of ovarian function is more exact. Careful experiment with the various preparations is the only method of determining which will be most useful to the patient. All ovarian extracts can be administered orally. For control of menopausal symptoms they should be taken continuously over a period of months. In the treatment of dysmenorrhea they are usually administered for ten days, more or less, before the expected period, and omitted as soon as it has become well established. For controlling menorrhagia administration is generally begun three or four days before the expected period, and continued until the flow has become definitely checked. T h e administration of ovarian extract for delayed puberty is efficient in fewer cases than might be expected. This is because delayed puberty may be but a symptom of malnutrition in its largest sense, the entire sexual apparatus suffering incidentally. Unrecognized thyroid or pituitary failure is quite as frequently the cause of infantilism as is faulty ovarian function. Anemia, cardiac disease or tuberculosis m a y delay the appearance of menstruation. Proper treatment of these conditions, therefore, involves careful general and pelvic examination to detect any systemic disease which m a y be the cause of the condition. Treatment of any such condition, or of thyroid or pituitary failure if they are definitely proven to be present, will give more satisfactory results than the routine administration of some ovarian preparation when puberty is delayed. T h e dosage of the ovarian preparations cannot be definitely stated, as there is no w a y of knowing how much active principle is represented. If given at all, they should be given with courage.

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PRINCIPLES OF MEDICAL TREATMENT V. THE TESTES

There is no satisfactory evidence that there is any efficient treatment for the results of castration, or so-called testicular failure. The use of testicular extract in the treatment of impotence, senility, neurasthenia, and so forth, is not at present justified. VI. OTHER ENDOCRINES Various other endocrine extracts, or alleged endocrine extracts, are recommended for the treatment of conditions not proved to be due to malfunction of any known internal secretion. Preparations containing several different gland extracts are recommended for almost any symptom known to medicine. The use of such endocrine extracts can be expected to benefit only the manufacturer. They are further to be condemned because they befog the situation, and bring into disrepute a field in medicine which is as yet little explored, but which has great possibüities. Only by carefully controlled research can these possibilities be realized.

CHAPTER X I V PREOPERATIVE AND POSTOPERATIVE MEDICAL TREATMENT BY CHARLES H. LAWRENCE, M . D . Chief of the Endocrine Service, Evans Memorial Lecturer in Medicine, Boston University Medical School

INTRODUCTION S U R G I C A L operation is a therapeutic measure necessary, under certain circumstances, to combat or to eliminate a morbid process which is not self-limited and which the resistive processes of the patient cannot overcome. I t is, therefore, only one means, though often an absolutely necessary means, for restoring health. Its direct effects are restricted to a limited area but indirectly it affects the entire body. Consequently, the results depend in part upon the technical ability and surgical judgment of the operator, and in part upon the abiUty of the patient's bodily economy to meet the shock of operation and to readjust itself to the changed conditions brought about by the surgical procedure. The severity of operative shock depends upon details of technic, such as the time consumed by the operator, his manual dexterity and that of his assistants, the skill and judgment of the anesthetist, and other factors which are the responsibility of the operator. The ability of the patient to meet the operative shock, and to compensate for the new bodily conditions which obtain after operation depends, in contrast, upon his reserve of strength at the time of operation. The final result of operative treatment depends upon the ability of the bodily machine to readjust itself so that it functions normally in spite of the new conditions which result from operation. The ability to do this depends in no small measure upon the care of the patient before and after operation and it is with the purpose of bringing

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bodily efficiency to its highest level, and of preventing energy waste through unnecessary demands, that preoperative and postoperative care are instituted. T h e details of such treatment are usually left to the physician — the surgeon's responsibility beginning with the "preparation for operation" and often ending when the patient recovers from the direct effects of anesthesia and of operation. T o most patients, and to some surgeons, this latter event signifies complete return to health, whereas the fact is that it marks only the beginning. Certain conditions which increase operative risk may be so benefited by preoperative treatment that the risk is enormously decreased. Cardiac decompensation, inadequate kidney function, obesity, diabetes, anemia, and acute respiratory infection demand postponement of operation, when possible, until medical treatment has done all that is possible to lessen the added danger. In a considerable number of cases, sufficient improvement results from proper treatment to make operations of necessity successful and operations of election justifiable. T h e surgeon should decide whether or not time can be allowed for medical treatment. PREOPERATIVE

TREATMENT

The purpose of preoperative treatment is to furnish the patient an ample reserve on which to draw during and immediately after operation. T o this end an adequate history and complete physical examination are essential. T h e history will furnish evidence of the functional efficiency of the bodily machine, and is often as valuable in quantità ting any departure from normal as are the various " f u n c tion tests" of organic integrity. T h e physical examination will disclose organic lesions: the history will give evidence concerning their effect on the individual. I t will also give information concerning the function of the bowels, kidneys, and digestion, the patient's habits and temperament. A n essential part of the examination is that of the urine and blood. Except in emergency, no patient should be operated on without such a thorough examination, and it is the duty of the medical adviser to see that these details are not overlooked. If history, physical and laboratory examinations disclose nothing remediable which increases operative

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risk the details of preoperative treatment will depend upon the amount of time available before operation. When the operation is to be performed immediately, or within twelve hours, there is little to be done which is not included in the preparatory measures generally required by the surgeon. When a night is to intervene, it is important that the patient's sleep be assured by the use of some sedative, or narcotic. Triple bromides 15-30 gr. (1-2 Gm.), adalin 10-20 gr. (0.65-1.3 Gm.), or sodium veronal 5 - 1 0 gr. (0.324-0.65 Gm.) are among the most efficient sedatives. For pain, some form of opium is necessary. If the patient is excited by morphine, whole opium J í to gr. (0.0160.032 Gm.) or paregoric И to i drachm (2-4 cc.) may be combined with the sedative. Many patients who are excited by morphine react normally to opium. If several days are to elapse before the operation no attempt should be made to change the patient's habits unless they are unusually pernicious. Intemperate use of alcohol during the preoperative period should, of course, be forbidden; but the wisdom of tabooing the temperate use of alcohol, if the patient is accustomed to it, is questionable. If the diet agrees with the individual no change is advisable beyond moderate curtailment of the amount of fat ingested. A diet low in fats for several days before operation tends to reduce postoperative vomiting. Five details are important in the preoperative treatment of the organically sound patient: 1. The ingestion of plenty of water. The only way to get this done if the patient is ambulatory is to prescribe it at definite times. A glassful of water on rising, another on retiring, one with each meal and two between each two meals will assure that the requirement is fulfilled. If the patient is under the care of a nurse she should be required to chart the fluid intake and output each twenty-four hours. 2. Exercise in the fresh air if the patient's condition permits. 3. The maintenance of normal elimination through the bowel. If the patient has a normal habit of defecation no laxatives are indicated. If dependent upon a laxative, it should not be omitted. Constipated and careless patients should take a gentle laxative and should add fresh fruit to the diet.

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4. An adequate amount of sleep is to be insisted upon during the time that elapses before operation. It is often necessary to do more than insist. The fear of operation or habit, or both, may prevent sleep. In such cases outdoor exercise, if permissible, a hot bath or massage before going to bed, or a light meal on retiring may suffice to induce sleep. If these measures and reassurance as to the outcome of the operation fail, some mild sedative is indicated. For the patient about to undergo operation a night's sleep far more than counterbalances the depressing effect of a mild sedative. Bromide 5 gr. (0.324 Gm.) after each meal often "takes the edge o f f " so that the patient does not get nervous and wakeful. Adalin 10 gr. (0.65 Gm.) given with plenty of water an hour before retiring is frequently sufficient and has no unpleasant after-effects. For the more intractable cases sodium veronal 5-10 gr. (0.324-0.65 Gm.) with a hot drink, will usually be effective. Many patients have their favorite remedies for insomnia which, because of their psychological effect, will be more effective than any new prescription. 5. Patients should be advised not to tell their friends of the proposed operation until they go to the hospital. Everyone knows of surgical accidents, and there seems to be an uncontrollable desire among the laity to cheer the patient with stories of sudden death. No matter how sensible a patient may be the contemplation of operation causes a certain amount of anxiety which is frequently augmented by the conversation of well-meaning but thoughtless friends. Aside from the poihts just mentioned there should be as little interference as possible with the patient's normal activities. CARDIAC DECOMPENSATION

Cardiac decompensation is one of the most serious conditions encountered in an individual for whom operation is either necessary or desirable. It is not always, however, an absolute contraindication to operation. The decompensation may have been caused by the surgical condition present, or may be found to be due to lack of intelligent care on the part of the patient. In the first situation digitalization by use of the massive dose (see Digitalis, p. 222) will often reestablish compensation sufficient for the oper-

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a t i v e demand, while rest a n d digitalis will, in the m a j o r i t y of cases, greatly i m p r o v e patients of the second group. E v e n if the decompensation does n o t respond well t o treatment, the risk of depriving the p a t i e n t of surgical aid m a y , in serious situations, be graver than t h a t involved in operating. I n such desperate situations liberal use of morphine, to control pain a n d restlessness, o f t e n has a n effect more beneficial than t h a t of digitalis. Cardiac irregularities or murmurs existing w i t h o u t signs or s y m p t o m s of circulatory disease are n o t contraindications to operation, a n d need no preoperative treatment. T h e choice of anesthetic for a p a t i e n t w i t h cardiac d a m age should be left to the surgeon or anesthetist, b u t the physician should furnish his estimate of the increased risks due to the circulatory condition. M a n y damaged hearts stand the administration of ether surprisingly well. If the decompensation is of the congestive t y p e , operation should either be postponed until p u l m o n a r y congestion has disappeared or should be performed under local or spinal anesthesia. Failure of the anginal t y p e is associated with arteriosclerosis and myocardial weakness. T h e latter, if present, c a n usually be detected in the history and, even though there be no physical signs of decompensation, the circulation is often benefited b y digitalis before operation as shown b y the resultant diuresis. HYPERTENSION

Hypertension, unless associated with signs of circulatory or renal insufficiency, is a less serious contraindication to surgical treatment than is usually supposed. T h e r e is no more efficient w a y of reducing blood pressure than b y " l e t t i n g b l o o d , " and surgical operation usually causes a reduction rather t h a n a n increase in arterial tension. T h i s reduction m a y cause the p a t i e n t to feel w e a k , b u t it does not o f t e n depress circulatory efficiency. NEPHRITIS

W h e n evidences of d a m a g e to the kidneys are found in a jatient w h o needs surgical treatment, their importance can зе properly estimated only b y determining as a c c u r a t e l y as possible the a m o u n t of functional loss associated w i t h the damage. T h e ability of the k i d n e y s to excrete a n d the

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amount of retention existing in the body are far more important than the amount of albumin or the number of casts in the urine. Therefore, the response to a test meal, the output of phenolsulphonephthalein, and the amounts of the nitrogenous constituents of the blood should be carefully determined, and evaluated in relation to the patient's symptoms and condition. If, at the first examination, the renal function is found to be so impaired as to contraindícate operation, final decision should be reserved until the effect of treatment is determined (see Nephritis, Chap. II). Careful treatment will frequently result in improvement in function sufficient to meet the demands of the operation. Unless edema be present an effective method of increasing elimination is by greatly increasing the patient's intake of fluid. When restricting the diet, it should be remembered that a demand upon the patient's general strength is contemplated and that too rigid restriction is, therefore, unwise. DIABETES

Patients are frequently advised to forego an operation because sugar is found in the urine. Glycosuria is not necessarily diabetes and although it demands postponement of the operation until its significance can be determined, the presence of sugar in the urine does not justify forbidding operation. For the significance of diabetes in surgical conditions, see Diabetes, Chap. XII. A determination of the blood-sugar from a specimen of blood obtained under proper conditions will aid enormously in properly evaluating the significance of glycosuria. The presence or absence of "acidosis" is also important and should be determined. The nondiabetic glycosurias may be grouped into two classes: alimentary glycosuria, due to the ingestion of abnormally large amounts of carbohydrate by a patient with normal tolerance, and glycosurias due to derangement of some other internal secretion than that of the pancreas. The former usually responds quickly to dietary regulation, which should be enforced before operation is performed. The latter, if the amount of sugar in the urine is small, the blood-sugar normal and acidosis absent, may be disregarded in advising for or against operation.

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OBESITY

In acute conditions requiring surgical treatment, there is no time to treat obesity and no attempt should be made to do so although it does add to the risk of operation. If operation is advisable, but not immediately necessary, the patient's extra weight should be eliminated b y proper diet and exercise. More than usual care must be exercised to avoid interfering with nutrition and health. Consequently, it is important to avoid too rapid reduction. Loss of weight should always cause increase of energy and should never be allowed to cause weakness. ЛКЕША

Definite anemia should always be corrected before an operation is performed. When the anemia is due to the condition for which operation is necessary, transfusion is often the only successful method of combating it. Transfusion is also the only effective treatment if immediate results are necessary. Whether transfusion is to be used just before or just after operation depends on the gravity and nature of the anemia, and its cause. The decision in this situation belongs to the operating surgeon. If time allows, and if the cause of the anemia can be temporarily checked or is no longer operative, diet, sunshine, cod hver oil and iron will generaUy restore the blood to a sufñciently normal condition if the anemia is of the secondary type. The iron is most efficient when given intramuscularly. The dosage is i cc., every second to fifth day depending on circumstances, of a solution prepared for the purpose. The site of the injection should be the buttocks in thin people, while the arms and legs can be utilized safely in the better nourished. The site of injection should be varied as much as possible to avoid causmg soreness. In pernicious anemia, if operation is necessary during an exacerbation, transfusion is the only method which will be of benefit. Whether or not it is necessary depends upon the condition of the blood and the nature of the operation.

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SYPmus Latent syphilis may delay the healing of surgical wounds and should be treated in so far as time permits (see Syphilis, Chap. IX). FOCAL INFECTION

Focal infections should not be tampered with near the time set for operation. They should either be left severely alone or, if treatment is necessary, should be taken care of several weeks before the date of operation so that all possibility of blood-stream infection from them at the time of operation is eliminated. RESPIRATORY INFECTION

If there be any absolute contraindication to surgical operation it exists in the infections of the respiratory tract. \ ^ e n they are severe the patient is unfit to stand the shock' of operation. When they are mild, operation, even with local or spinal anesthesia, may so far depress bodily resistance that they become severe. Except from stern necessity operation should not be undertaken upon a patient with an acute respiratory infection however mild it may be. Chronic infections constitute a less serious menace since the patient has usually developed an increased immunity to the infecting organism and if an anesthetic can be used which does not irritate the mucous membrane of the respiratory tract the danger from operation is less than it is in acute infections. Even in chronic infections operation should be avoided when this can be done without too great harm to the patient, and ether anesthesia should be strictly avoided. If surgical intervention is necessary for a patient who has, or has just had, a respiratory infection special care should be taken to prevent chilling of the body during the operation. During the preparation of the skin no more surface should be exposed than is absolutely necessary and the remainder of the body should be wrapped in light woolen blankets, which should be changed if they become wet. The patient should be put back into a warm bed as quickly as possible after operation and kept wrapped in a light, dry, woolen blanket for several hours. Hot-water

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bags or heaters should be kept in the bed during this period and the patient should be disturbed only to change the blanket if it becomes wet. Fluids, when given, should be hot. Too much stress cannot be laid upon the importance of preventing the chilhng of the body which so frequently accompanies operation. POSTOPERATIVE

TREATMENT

The immediate postoperative treatment is usually conducted by the surgeon, but the cooperation of the physician is often of great value. The purposes of this treatment are as follows: 1. T o prevent waste of the patient's energy. 2. T o dilute and eliminate the poisons absorbed during operation. 3. T o reëstablish normal digestion and nutrition as soon as possible. C O N S E R V A T I O N OF

ENERGY

To conserve energy the elimination of pain and restlessness is essential. For this purpose there is nothing so useful as morphine. With the possible exception of intracranial operations, the contraindications to its use are few and are continually growing fewer. The theoretical objections to its use are of little significance when compared with its practical benefit during the period immediately following operation. The conditions which call for morphine are usually of short duration so that there need be no fear of forming a habit. The constipating effect may be safely ignored because enemata or laxatives will move the bowels when it becomes desirable to do so. The depressing effect on metabolism and elimination is neutralized by the stimulating effect of pain. The danger that morphine may prevent proper pulmonary ventilation or may eliminate "productive cough" is a purely theoretical consideration if the dosage is determined with regard to existing conditions. In almost every instance these theoretical objections to the use of morphine are entirely outweighed by its beneficial effect. B y controlling pain it eliminates restlessness and allows sleep, thus conserving energy. It likewise eliminates reflex inhibitions which pain often produces, allowing.

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rather than preventing, the normal reactions of the body. Frequently morphine has a quieting and stabilizing effect upon the circulation, rendering it much more efficient. Not uncommonly a patient's pulse is satisfactory during anesthesia but becomes rapid and of poor quality as consciousness returns and pain is appreciated. In such circumstances morphine is a more valuable "stimulant" than digitalis, caffeine or any other drug. T o obtain the best effect from the use of morphine it should be given before the patient becomes conscious, so that as the effect of the anesthetic wears off, that of the morphine will supplant it. B y this maneuver, a moderate dose is often more efficient than a large dose given later. The morphine should be used repeatedly in sufficient amount to control pain until the patient has recovered from the immediate effects of anesthesia and operation. Usually, the effect lasts for a period of hours but with highly organized patients, or after operations causing severe pain, it may be necessary to continue its use for two or three days. Occasionally an individual is encountered who, instead of being quieted by morphine, is made more restless and uncomfortable. For such patients opium often succeeds where any of its derivatives fail. I t may be given by mouth in the form of a pill, or as the deodorized or the camphorated tincture, or it may be administered by rectum in enemata or suppositories. For pelvic pain suppositories are frequently more effective than morphine used hypodermically. If morphine and opium fail to control the pain, pantopon Уб gr. (0.0108-0.021 Gm.) or allonal' two to four tablets, may be successful. If the patient be one who appreciates pain keenly a combination of codeine gr. (0.016 Gm.) and bromide 15-30 gr. (1-2 Gm.) ,is often more effective than a narcotic alone. DILUTION AND E U M N A T I O N

During any major operation there is an accumulation of toxic substances in the body. T o aid in their elimination an adequate supply of fluid is necessary. Therefore, it should be given in generous amounts immediately follow1 Referred to, but not described in N e w and Nonofficial Remedies, ig2S·

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ing operation. Four routes are available for administering fluid: ( i ) b y mouth; (2) b y rectum; (3) subcutaneously; (4) intravenously. (1) T h e custom of withholding water b y mouth during the period of postoperative nausea is rapidly disappearing. Vomiting at that time is usually due, a t least in part, to gastric irritation caused b y mucus and anesthetic swallowed b y the patient during operation. Water b y mouth aids in diluting these irritants and if it is vomited, helps to wash out the stomach. Moreover, it quiets the patient b y quenching, a t least temporarily, the great thirst. Unless there are special contraindications, therefore, the patient should be given fluid by mouth as soon as consciousness is sufficiently established. H o t water, or hot weak tea, is better borne at first than cool or cold fluids. T h e first drink should be generous, 4-6 oz. (120-180 cc.), and sufiicient to stimulate normal peristalsis if it be retained, or to wash out the stomach if it be vomited. In either case, it is well to wait an hour or two before again giving fluid. T h e subsequent doses should be smaller, 1 - 2 oz. (3060 cc.) until nausea has ceased. Ginger ale often controls postoperative nausea better than anything else. Hot, weak tea with sugar and lemon juice is also well borne and m a y be more suitable when there is renal impairment. Once the nausea has ceased, water should be given in generous quantities so that the output of urine in each twentyfour hours for several days will be from 60-100 oz. and not less than the former. (2) Fluid should be given by rectum when the nature of the operation makes swallowing difficult or impossible, or when the patient has obstinate postoperative vomiting. I t may also be given by rectum once or twice after operation to supplement the amount taken per os. A pint of tap-water or glucose solution given b y rectum before the patient has regained consciousness will almost always be retained and it diminishes the postoperative thirst. When the patient is conscious, the amount given by rectum must usually be smaller, 6-8 oz. (180-240 cc.), and the injection can rarely be repeated to advantage oftener than every six or eight hours. Patients v a r y enormously in their ability to retain enemata. T h e success or failure of this method also de-

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pends greatly upon the technic of introducing the fluid into the bowel. The enema tube should be of moderate size and well lubricated. No attempt should be made to force it far into the rectum. The container should not be elevated more than three feet above the buttocks so that the fluid will run into the bowel slowly enough not to produce spasm or peristalsis. The fluid should be at body temperature when given. If the patient complains of discomfort the flow should be stopped until the discomfort has ceased. When the bowel is abnormally irritable, deodorized tincture of opium, 15-30 min. (1-2 cc.), in the enema may make it more tolerant. Attention to these details is important when it is desirable to use enemata repeatedly. The character of the fluid introduced varies somewhat according to circumstances but in postoperative conditions the most important point is to supply water. Ordinary tap-water and a five or ten per cent solution of glucose are the two most valuable enemata under such circumstances. Caffeine 3-5 gr. (0.2-0.324 Gm.) may be added if shock is present. (For treatment of shock, see section on Circulatory Failure, p. 18.) (3) As a rule, it is impossible adequately to supply the body with fluid by rectum alone. Therefore, when oral administration is impracticable recourse must be had to hypodermoclysis. B y this method a large amount of fluid, 30-50 oz. (900-1500 cc.), can be given at one time. The maneuver is painful, so that, if needed, it should be employed if possible before the patient regains consciousness. Care should be exercised to keep the solution warm while it is being given. When a large amount of fluid has been introduced in this way immediately after operation, and when the patient retains fluid given by rectum, it is not usually necessary to repeat the hypodermoclysis. Under special conditions, however, it may be repeated every twenty-four hours. I t should not be employed in patients whose condition is hopeless and whose circulation has become so ineflicient that the saline solution will not be absorbed. Under such circumstances, to disturb the patient for hypodermoclysis is merely purposeless activity. If fluid is to be given at all under these circumstances it should be introduced directly into the circulation.

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(4) Intravenous injection of saline solution has been supplanted to a great extent by transfusion. It is still useful, however, when the latter is not available, for a patient in profound shock; and also in uremia or eclamptic coma. Its effect is more prompt and less enduring than that of h5φodermoclysis. For most situations in which saline solution was formerly employed, transfusion is preferable. DIET

When a patient has been given sufñcient fluid promptly after operation the nausea is usually of short duration, so that food can be retained within a few hours. Unless the surgical condition demands it, the patient should not be restricted to "soft solids" even at the beginning. There is no more certain way of causing distention than by filling the stomach with gruels, soups, and milk. Whenever possible, solid food in small amounts should be given as soon as feeding is resumed in order to take advantage of the stimulating effect which mastication has upon digestion and of its cleansing effect upon mouth and teeth. A thin slice of bread baked in the oven until it is hard and brown or one or two hard, crisp, salty crackers should be given with the soft food. Wien two or three such small meals have been retained, a slice of toast without butter may be given. Honey or marmalade may be used in place of butter. Within twenty-four to forty-eight hours after most surgical operations the patient should be taking any simple food that is easily digested by the individual in question. As long as the patient is confined to bed the diet should be simple, although variety is highly desirable. Special dietetic restrictions may be necessary, however, because of the nature of the operation. When the situation is complicated by any disease of metabolism (Diabetes, Nephritis, etc., q.v.) the diet should be suited to that condition. MANAGEMENT OF BOWELS

After any major operation, especially upon the digestive or pelvic organs, there is apt to be interruption of normal defecation. This can usually be controlled by enemata during the early postoperative period, and as a normal diet is resumed the bowels usually regain their normal activity.

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If this does not occur, due to lack of exercise, the liberal ingestion of fluid and water may successfully overcome the intestinal stasis. In habitually constipated patients a laxative will often be necessary and it is usually best to use the one to which the patient is accustomed unless it be a saline. Except when it is desirable to withdraw fluid from the system, vegetable laxatives are preferable to salines. ABDOMINAL

DISTENTION

Abdominal distention may be a serious postoperative complication. It is, however, less common than in the days of preoperative purgation and postoperative starvation. Etiology. The most common cause is operative trauma to the digestive tract, producing paralytic ileus. Less commonly there may be actual mechanical obstruction following operation. Renal insufficiency, postoperative pneumonia or septicemia may cause abdominal distention as their first symptom. Diagnosis. I t is often extremely difficult to determine the cause of the distention promptly. The important point is to differentiate intestinal obstruction from intestinal paralysis, because the treatment of these conditions differs radically. The former is a surgical problem, the latter responds to medical care. There is more apt to be pain, more or less localized tenderness and active vomiting in obstruction than in paralysis of the bowel. Visible peristalsis, if present in these cases, means obstruction. Its absence is less significant. Treatment. The omission of violent preoperative catharsis and the early return to a normal diet requiring mastication do a great deal to prevent intestinal paralysis and resultant abdominal distention. When the condition does occur, its treatment consists in combating the paralysis of the bowel by the use of enemata, laxatives and heat applied to the abdomen, and of combating any renal impairment or intercurrent infection by appropriate methods. (i) Enemata in distention should be of smaU bulk, and irritating in nature. Large bland enemata are not useful,

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and may even be retained by the inert bowel, increasing the patient's discomfort. Pure glycerine, 2-4 oz. (60120 cc.), is an excellent enema for distention. Milk and molasses, 4 oz. ââ (120 cc.), is likewise valuable. (2) Laxatives should never be used until the possibility of intestinal obstruction has been eliminated. Mild laxatives in small frequently repeated doses are usually more effective than drastic catharsis. A teaspoonful of milk of magnesia diluted with a tablespoonful of water given every hour until the bowels move is frequently efficient when other measures fail. I t often reHeves nausea as well. (3) Heat to the abdomen is valuable if properly used. It is best applied in the form of turpentine stupes or flaxseed poultices. Care must be taken that the applications are kept hot, not merely warm. This can only be done by changing them frequently. The applications should be continued for twenty minutes to an hour, according to the patient's condition, then discontinued for two hours, and reapphed if necessary. A rectal tube used during the application of heat often aids in reducing distention. (4) Pituitrin (i cc.) given hypodermically is extremely valuable in distention due to intestinal paralysis. It should be given cautiously if the patient has a high blood pressure, but hypertension is not an absolute contraindication to its use when other measures have failed. If the Pituitrin reduces the distention, the dose may be repeated every three or four hours if necessary. When the first dose is not effective, there is usually nothing to be gained by further administration of this drug. A C U T E INFECTIOUS

DISEASES

The treatment of these diseases following operation is the same as when they occur without operation, modified only by the special conditions of the case. UNCOMPLICATED

CONVALESCENCE

When no complications occur, the convalescence from surgical operation is a process of reestablishing the reserve strength of the patient to the normal level. During the first week or ten days this is done largely by rest. If the

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rest is to be efficient, it must be mental as well as physical. The former is often harder to obtain. Some patients are tranquil if alone, others spend their time worrying when their minds are not otherwise occupied. For the latter type, the early admission of properly selected visitors is advisable. The effect of each visitor, however, should be watched by the nurse and any who weary or overstimulate the patient should be tactfully excluded. It frequently happens that members of the patient's family do not make the best visitors. During the later days of confinement to bed the patients should have massage and active and passive motion of the legs. Before being allowed to get out of bed they should be allowed to sit on its edge and swing the feet back and forth, in order that the circulation may accommodate for the vertical position. ALLOWING THE PATIENT TO GET UP

As a rule, the time a patient is kept in bed after operation is determined by the nature of the operation rather than the nature of the patient. While it is true that a certain surgical procedure may require a definite minimum time of rest in bed, it is illogical to proceed on the theory that all patients should get up as soon as that period is completed. The physical feelings of the patient, if honestly presented, form the best basis for a decision as to the optimum time for allowing increased activity. Some patients wish to get up because of their ambition to make a rapid recovery, not because they are physically ready to do so. Such wishes should be disregarded, for these are the patients whose end-results are often unsatisfactory because insufficient time was taken for postoperative readjustment. Few patients need to be urged to get up, and such are generally easily recognized. If the patient be overweight or has had previous foot strain, it is often advisable to support the feet by strapping them properly before they are called on to support the patient's weight. This strapping may usually be taken off in a few days, but its early use holds the arches of the feet in proper position until the muscles have regained sufficient tone to do so. (Some of the numerous cleansing fluids on

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the market, such as Carbona, will remove the plaster better than ether or alcohol.) Once the patient is out of bed, the question of returning to the usual activities of life is raised. Men are anxious to get back to work, women wish to resume their household duties. If in a hospital, both want to go home. The advisability of their doing so depends much on the nature of their normal activities, but in making the decision it must be remembered that it is usually impossible for the average patient to "take it easy" at home. This is especially true of women whose household cares are ever present. If possible, patients should be urged to complete their return to health by going away for a time before resuming their normal routine. The place to which they go should be one that furnishes available amusement, preferably out of doors, but which imposes no demands. Freedom from routine and opportunity for ample rest are the essential requirements. Patients should be urged to report for examination on their return, and should be seen at intervals of four to six weeks until recovery is complete beyond question. This part of the postoperative care is usually the responsibility of the family physician and careful oversight on his part will do a great deal to insure optimum postoperative results.

CHAPTER XV VACCINE ТНЕБШ>¥ B ï CHARLES H. LAWRENCE, M.D. Chief of the Endocrine Service, Evans Memorial Lecturer in Medicine, Boston University Medical School

Definition. Vaccine therapy may be defined as the attempt to produce, for therapeutic purposes, active immunity against a specific organism by injecting suspensions of the dead organism under the skin of the individual. The term is a loose one, since vaccine properly means cowpox lymph. It is, however, generally used in the sense defined above, and will be so used in this chapter. Vaccination against smallpox, and the use of serums will not be discussed. Purpose. It must always be remembered that the purpose of vaccine treatment is to raise the resistance to infection of the individual, and that it is onJy one method of accomplishing this result. Therefore advantage should be taken of all other measures likely to improve the patient's general condition. Careful regulation of diet, rest, and exercise, insistence upon proper elimination through bowels and kidneys, and upon a reasonable amount of recreation, fresh air, and sunlight, are necessary measures in successful vaccine treatment. Indications. Vaccine therapy may be used as a prophylactic measure to protect a healthy patient against possible future infection, or in the treatment of infection which has already occurred. PROPHYLACTIC IMMUNIZATION The number of diseases to which this is applicable is not large, but in a few its results are briUiant. Typhoid Fever offers a striking example of the results of prophylactic immunization. The immunity conferred persists certainly for one year, probably for from two to three

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years. There is no objection, however, to repeating the immunization at yearly intervals, and this should be done if an individual lives in, or is going to, a district in which typhoid fever is at all prevalent. A mixed vaccine made from typhoid and paratyphoid organisms is recommended. The technic of the immunization is simple. Three doses of the vaccine are given, the interval between doses being seven to ten days. The first dose contains 500 million killed bacilli, the second and third doses one billion each. The vaccine should be injected subcutaneously. In poorly nourished patients it is best given in the thigh or subscapular region, but in well-nourished individuals it can be injected into the arm. The site of injection should be cleansed with alcohol or iodine. The syringe and needle should be sterilized by boiling rather than by immersion in alcohol. After the needle is withdrawn the site of injection should be massaged gently for a minute or two, to distribute the vaccine in the tissue, and to prevent leakage of the fluid through the puncture. No dressing of the puncture is necessary. Constitutional Reaction. This varies considerably in different individuals. A few feel no discomfort from the inoculations. The majority are conscious of slight soreness at the site of injection and slight languor for twelve to twenty-four hours after the first injection. In a small percentage of cases the reaction is more vigorous, causing headache, backache, slight elevation of temperature and, rarely, nausea for twenty-four hours after the first injection. The subsequent injections usually cause little or no reaction. The severity of the reaction depends somewhat upon individual idiosyncrasy and somewhat upon the patient's activity following the inoculation. Violent exercise immediately after receiving an injection increases the severity of the reaction, and patients should be cautioned to avoid active exertion on the days on which the injections are given. Aspirin 5-10 gr. (0.324-0.65 Gm.) will usually allay the unpleasant symptoms following inoculation. If the reaction following the first dose is unusually severe, dividing the amount remaining to be given into three doses instead of two will usually prevent a repetition of discomfort.

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Contraindications. Patients who have had typhoid fever are practically immune from a second attack, and do not need artificial immunization. Elderly individuals also seem immune and do not need inoculation. Immunization should not be attempted in the presence of acute infections, and it is advisable to avoid giving an injection during the catamenia in women. Childhood is not a contraindication. Pertussis. Immunization against pertussis has afforded less certain protection than is obtained with typhoid vaccine, probably because in the majority of cases it is not begun until infection has taken place. If instituted early, however, it either gives complete protection or greatly reduces the severity of the attack in the majority of cases. In children the initial immunizing dose varies from 5 to 20 million, the subsequent doses from 20 to 50 million according to age. Three doses should be given at five-day intervals. Common Colds. Attempts have been made to develop a vaccine which would successfully immunize against the upper respiratory infections classed under the head of "common colds." Inasmuch as such infections are caused by a great variety of organisms, the success of prophylactic treatment is always doubtful. In individuals who are subject to frequent "colds," the successive acute attacks often represent exacerbations of a chronic infection of some portion of the upper respiratory tract, such as the tonsils, or the nasal accessory sinuses. EHmination of these possibilities should always precede the use of vaccines. If, however, no focus of infection can be found and if there is no bodily condition present to account for the individual's lowered resistance, immunization by vaccine treatment should be attempted. For this purpose an autogenous vaccine is best. It can often be obtained by making cultures from the nose and throat, preferably during the early stages of an attack. If a streptococcus or pneumococcus is found to predominate in these cultures, a vaccine made from it wiU frequently give satisfactory results. The initial dose in these cases should be small (20 to 40 million streptococci; 25 to 100 million pneumococci) and should be gradually increased until the maximum dosage (250 to 500 million streptococci;

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500 miUion to I billion pneumococci) is reached. The interval between doses should be four or five days. If any dose causes general malaise, or the appearance of local symptoms, this dose should be repeated at subsequent treatments, and not increased until it fails to cause a reaction. When no autogenous vaccine can be obtained, a " s t o c k " or commercial mixed vaccine may be used, though its success is problematical. The dosage of such a vaccine depends upon its bacterial composition, and is usually indicated by the manufacturer. THERAPEUTIC

TREATMENT

The diseases which may be treated by vaccines are those in which the individual reaction to infection is not maximal. When the individual response is maximal, vaccine therapy is not only useless but dangerous. Therefore in such conditions as lobar pneumonia, septicemia, and peritonitis it is contraindicated. It is usually more efficient in subacute and chronic conditions than in those which are acute and self-limited. It is also advisable to limit vaccine treatment to those conditions in which the products of infection can be easily discharged from the body, as distinguished from those in which they must be absorbed or carried away by the blood stream. In endocarditis, for example, vaccine treatment has been followed by embolism and is contraindicated. In acute infectious arthritis its usefulness has never been proved. There are, however, many conditions which fulfill the requirements stated above, and in them vaccine treatment often gives dramatic results. Boils and Carbuncles respond satisfactorily, as a rule, to vaccine treatment. Autogenous vaccines are preferable, but stock vaccines give surprisingly good results. Staphylococcus areus alone, or combined with albus and streptococci, may be obtained in " s t o c k " solutions. The dosage depends somewhat upon the history of the case and the patient's general condition: the more severe the infection, the smaller the initial dose should be. If the vaccine contains staphylococci only, the initial dose in a case of moderate severity should be 50 to 100 million. The injections should be repeated every three to five days and the dose

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gradually increased according to the patient's reaction. Treatment should be continued for several doses after the appearance of the last boil. The anemia so common in patients subject to boils should also receive attention. Acne, particularly the pustular type, is not infrequently benefited by vaccine treatment in connection with other measures. Either a vaccine of B. acne alone, or one containing in addition Staphylococcus areus and albus, may be used. The latter is said to be more efficacious in the pustular type of the disease. The initial dose is usually 50 milUon, to be gradually increased according to the effect observed. The interval between doses should be from two to five days. If a marked reaction occurs after any dose, the same or a smaller dose should be used at the next treatment. Chronic Diseases of the Respiratory Tract are often amenable to treatment with an autogenous vaccine. Before resorting to it, however, the primary focus which is feeding the respiratory infection should be sought for, and eliminated if found. Many cases of chronic bronchitis and bacterial asthma are secondary to infected tonsils, teeth, or sinuses, more rarely to cholecystitis or pyelitis. Elimination of these foci of infection is of primary importance in the cure of the respiratory diseases. A vaccine made from the organism found in the infected focus is far more efficacious than any " s t o c k " preparation. Chronic Bronchitis, with persistent cough and large amounts of sputum, is often greatly benefited by vaccine treatment. The cough becomes less imperative and the amount of sputum is diminished. Complete cure is rare, however, if the condition is of long standing. Lung Abscess, if small, may sometimes be successfully treated by vaccines. Those which result from tonsillectomy are often single, of small size, and so situated that surgical drainage is extremely difficult. Under such conditions, the use of an autogenous vaccine and general tonic measures is justified for a limited time, and may result in cure. This treatment should not be continued if the patient continues to lose weight or if the abscess increases in size. The dosage of the vaccine varies according to the organism used.

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Bacterial Asthmas wHch are not relieved by the elimination of focal infection may respond to the use of autogenous vaccine, obtained from the infected focus or from the respiratory tract. The dose depends upon the organism employed. The interval and rate of increase in dosage depend upon the patient's reaction. Chronic Infection of the Nasal Accessory Sinuses, persisting in spite of adequate surgical drainage, may be treated with autogenous vaccines. The rules for dosage are the same as for other infections of the respiratory tract. (See above.) Pertussis. The severity and frequency of the paroxysm is often diminished by the use of vaccines during the height of the disease. A mixed vaccine containing, in addition to B. pertussis, a variety of organisms commonly found in the respiratory tract, is preferred by many physicians to that made from B. pertussis alone. The interval between doses is three to five days. The injections should be continued until the severity of the paroxysms has definitely abated. The initial dose, increase per dose, and maximum dose depend upon the age and reaction of the child and the severity of the infection. Osteomyelitis. When surgical drainage has been established, the use of an autogenous vaccine wiU often hasten the "cleaning up" of the infection and lessen the febrile reaction of the patient. Pyelitis. Autogenous vaccines are occasionally of use in pyelitis of the recurrent type. As a rule, cultures from the urine yield only B. coli, which is not the primary infecting organism. B. coli vaccine, therefore, does not often give good results. When, however, a streptococcus or pneumococcus can be isolated, a vaccine made from that organism may prevent recurrence of the attacks.

CHAPTER XVI MEDICATION BY GEORGE CHEEVER SHATTUCK, M.D.

FOREWORD He who masters the use of a few good drugs will succeed better than he who tries many at random. Before prescribing a drug, let the indications for its use be clear. Prescribe drugs singly when expedient. Ascertain whether an idiosyncrasy to the drug you wish to prescribe is known to the patient. When a drug has been given, watch for its good or for its toxic effect. Increase dose until the one or the other is apparent. If neither results, change either the preparation or the drug. If toxic effects occur, omit the drug for a time and resume it later in smaller dosage or try a substitute. P U R P O S E OF D R U G

LISTS

The purpose of the lists which follow is to indicate the relative importance of drugs and the preparations of each believed to be the most useful in general medical practice. The dosage recommended is suitable for the average adult man and may require modification for the individual. Much useful information is contained in the United States Dispensatory. It describes the drugs of the principal pharmacopoeias, the preparations of the National Formulary, and many unofficial preparations. "New and Nonofficial Remedies" gives information about many proprietary drugs. My information about patents and trademarks was derived from the latter book. A new edition is published yearly by the American Medical Association.

2o6

PRINCIPLES OF MEDICAL T R E A T M E N T LIST I VERY

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11.

VALUABLE

DRUGS

Arsphenamines. Mercurials. Iodides. Diphtheria Antitoxin. Opium and its Derivatives. Digitalis and other Heart Tonics. Nitroglycerin and Nitrites. Magnesium Sulphate and other Purgatives. Salts of Quinine. Salicylates. Insulin. Arsphenamina {U. S.)

Preparations. Arsphenamine is marketed in this and other countries under various trade names such as Arsenobenzol, Diarsenol, Salvarsan, Arsenobenzol-Billon and Karsivan. Arsphenamina (U. S.) contains not less than thirty per cent of arsenic and does not exceed in toxicity the standard set for arsphenamines by the U. S. Public Health Service. The Public Health Service licenses manufacturers i and importers whose arsphenamine meets the standard requirements. Such products are labelled with the license number. Properties. Because it is rapidly decomposed upon exposure to air, arsphenamine is marketed in vacuum tubes. It is soluble in water, forming an acid solution. Upon the addition of alkali in sufficient amount a series of reactions take place which result in the formation of the disodium salt of arsphenamine. This salt is far less toxic to man than the intermediate products. Arsphenamine is less subject than neoarsphenamine to deterioration with age and is more uniform in therapeutic effect. Action. Arsphenamine is more powerfully parasitotropic and less organotropic than are the inorganic arsenicals. In the body it soon undergoes partial oxidation and becomes changed in some way which greatly enhances its parasitotropic effect. ' Listed in: Reprint No. 774, U. S. Public Health Reports, August 4,19га.

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Use. No equally valuable remedy for syphilis has yet been discovered. Yaws, relapsing fever, and rat-bite fever yield with remarkable promptness to arsphenamine. This drug has an important place in the treatment of chronic malaria, and beneficial action has been reported in many other parasitic diseases. Its use in syphilis is described on page 132. Excretion. Recent work ' indicates that the liver plays an important part in the modification of arsphenamine in the body and in the excretion of the resulting arsenical products. Arsphenamine disappears within a few hours from the circulating blood and most of its arsenic, after a single injection of the drug, is excreted in the urine and feces within forty-eight hours. In process of excretion it attains a high concentration in the bile but considerable amounts are retained, at least for several weeks, in most of the internal organs and particularly in the spleen and liver. Untoward eßects are attributable generally to errors of technic, poor judgment in the selection of cases, failure properly to examine the patient before beginning treatment, to excessive dosage, to lack of preparation of the patient, or to failure by him to follow directions. A few patients are hypersusceptible to the drug. Serious and even fatal accidents have been numerous but they can and should be avoided nearly always. T o this end the U. S. Public Health Service has issued detailed instructions to Medical Officers in the Public Services and has published them in a small pamphlet ^ containing most useful information about preparation of the solution, etc. Types of reaction and their treatment are described in the chapter on Syphilis, page 132. Errors of technic include: 1. Inadequate alkalinization of solution. 2. Too rapid injection of solution. 3. Use of distilled water containing impurities derived from the still or the proteins of dead bacteria. ' Voegtlin: Pharmacology of Arsphenamine and Related Arsenicals. Physiol. Rev. 1 9 2 s , 5 , 63. ä Reprint N o . 774. U. S. P. H . Repts., Aug. 4, 1922, is obtainable by application to the office of the Surgeon General, U. S. P . H . S., Treasury Dept., Wash,, D . C .

2O8

PRINCIPLES OF MEDICAL TREATMENT

4. Injection through a new rubber tube not properly cleansed before use. S- Decomposition of solution through excessive delaybefore use or to excessive heating. 6. Excessive strength of solution. 7. Use of arsphenamine of unreliable quality or of a deteriorated drug. Contraindications. The presence of exfoliative dermatitis or knowledge of its occurrence within three years absolutely contraindicates the use of arsphenamine. Relative contraindications include: 1. Pronounced disease of liver, heart, pancreas, adrenal glands, lungs, nonsyphilitic nephritis, and severe anemia. 2. Marked physical weakness, cachexia, chronic alcoholism, and old age. 3. Inability or unwillingness of the patient to avoid physical or mental fatigue and to abstain from alcohol at least on the day of injection. 4. Lack of the usual preparation of the patient. He should take a mild cathartic the night before and should abstain from food for several hours before the injection. The solution. After preparation of the solution in distilled water it should be diluted with distilled water or with normal saline solution to the strength required for injection. The U. S. Public Health Service recommends use of 25 cc. of fluid for each decigram of the drug. After being properly alkalinized, filtered, and diluted, the solution should stand for at least thirty minutes to allow completion of the chemical reactions and to reduce its toxicity thereby. It may stand as long as three hours provided it is protected from air, not shaken, and kept at a temperature not exceeding 30° C. (86° F.). Administration. Because of the locally irritant properties of arsphenamine care is required to prevent leakage of the drug into the tissues around the vein. A sharp needle of 19 gauge, an infusion apparatus consisting of a glass receptacle with an opening at the bottom to which is attached a rubber tube having a glass window near the lower end, and a clamp will suffice. Saline solution should be used to establish the flow and when nearly all the saline solution has left the receptacle the arsphenamine should

MEDICATION

209

be poured in. Saline solution should again be poured in before the needle is withdrawn, care being taken to prevent the entrance of air into the vein. Not less than five minutes should be allowed for the passage of the arsphenamine, the rate of flow being regulated by the height of the receptacle. The patient, as a rule, should lie flat upon the back throughout the procedure lest dizziness supervene. Dose is 0.1 to 0.6 Gm. Antidote. Sodium thiosulphate, page 242. Preparation of Alkaline Solution of Arsphenamine for Intravenous Use Printed instructions for preparing the solution are provided by the various manufacturers. The strength of solution used at the Massachusetts General Hospital is greater than that recommended by the U. S. Public Health Service and saline solution is used as the solvent instead of distilled water. Technic of Mr. Godsoe at the Massachusetts General Hospital 1. Everything used for preparing the solution is sterilized beforehand, and is handled under strictly aseptic precautions 2. The drug is dissolved in the mixing bottle with 120 cc. of 0.9 per cent saline solution instead of distilled water. Solution takes place without the aid of beads. 3. T o a dose of 0.6 Gm. of arsphenamine thus dissolved 5 cc. of normal sodium hydroxide solution is added and the mixture is shaken until perfectly clear. The dispensing bottle is rinsed with the solution; the solution is filtered back into the dispensing bottle, and after insertion of the stopper, the neck of the bottle is covered with sterile gauze, which is held in place by a pin. The drug is then ready for use. Arsphenamine may decompose within a few hours. It should be kept cool until needed, and should then be warmed only a httle. List of articles required for preparing solution: I. Burette graduated to cubic centimeters containing normal sodium hydroxide solution.

210

PRINCIPLES OF MEDICAL T R E A T M E N T

2. Flask of 0.9 per cent normal saline solution. 3. Glass funnel and filter paper. 4. One graduated and one plain eight-ounce bottle having glass stoppers. 5. Sterile sheet and sponges. Neoarsphenamina (U. S.) Uses. Neoarsphenamine is used as a substitute for arsphenamine when toxic effects of the latter are feared, or because of the ease with which the solution of the former can be prepared. It contains about two-thirds as much arsenic as does arsphenamine, its toxic effects are similar but milder, excretion more rapid, and therapeutic efficiency less. Excellent results are obtained in yaws and the drug can be injected intramuscularly. Its use in syphiUs is described on page 136. Precautions. The greater tendency of neoarsphenamine to deteriorate demands careful inspection of the drug for change of color or consistency of the powder before use. Integrity of the ampule should be tested by immersion for fifteen minutes in ninety-five per cent alcohol. Because contact with air causes rapid decomposition, everything else should be entirely ready before the ampule is opened. The drug should then be completely dissolved, filtered, and injected immediately. Discard any product which is incompletely soluble or in the solution of which haziness develops before using. Shaking increases toxicity. used.

Saline solution should not be

The solution. The U. S. Public Health Service recommends the use of 12.5 cc. of distilled water for each o.i Gm. of the drug and injection by the gravity method. Under field conditions, however, concentrations up to 0.1 Gm. in 0.5 cc. of distilled water can be injected with a syringe. Dose is from 0.3 Gm. to 0.9 Gm. Antidote.

Sodium thiosulphate, page 242.

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211

Mercurials Action of the various mercurials is essentially the same: antisyphilitic, local irritant, and antiseptic. Mercurials kill the Spirochaeta pallida. Elimination. Chiefly by intestines and kidneys; also in saliva. Excretion is slow. Toxic Effects. Acute poisoning: stomatitis, salivation, renal irritation, diarrhea, abdominal pain, and gastric disturbance. Chronic poisoning: cachexia and anemia. Indications. Syphilis. The choice of a mercurial preparation depends on the stage and severity of the disease, the condition of the patient, and the circumstances under which the treatment is to be carried out. The use of the various preparations is described in the chapter on Syphilis. Contraindications. syphilis.

Nephritis;

unless due to

active

Caution. When mercurials are being used, the mouth must be kept scrupulously clean to avoid stomatitis. Teeth should be brushed and throat gargled after every meal. If there is pyorrhea alveolaris, the gums should be scrubbed with castile soap or swabbed daily with a one per cent solution of potassium permanganate applied with a cotton stick and the mouth rinsed or sprayed with hydrogen dioxide. When using the protiodide of mercury and sodium or potassium iodide as well, give the protiodide before meals and the potassium iodide after meals to prevent formation of the biniodide of mercury. When using large doses of any mercurial, the bowels should be kept clear, and the food should be readily digestible, nutritious, and ample in quantity. Antidote. Sodium thiosulphate ' ("Hyposulphite Soda") used as in arsenical poisoning, page 134. Ï Dennie and McBride, 1924, Jour. A . M . A . 3j, 2082.

of

212

PRINCIPLES OF MEDICAL TREATMENT More Important Mercurial Preparations

(a) Hydrargyrum {U. S.). Metallic Mercury. Formula for mercurial cream: MetaUic mercury CMoretone Anhydrous lanolin Heavy olive oil

3v 3ss 3i 5iii

or 20.0 Gm. or 2.0 Gm. or 30.0 Gm. or 100.0 cc.

Dose is I gr. (0.065 Gm.) contained in 5 min. (0.3 cc.) of this cream. I t should be injected once a week until ten or fifteen doses have been given. The injection should be placed deep in the gluteal muscle but not close to the bone and the site of the injection thoroughly massaged. Absorption is slow because the preparation is insoluble but little pain or discomfort results from its proper use. Unless this cream is extremely well made some of the mercury will settle out into the bottom of the bottle. Use of an irido-platinum needle one and a half inches long is recommended because it does not corrode. {b) Hydrargyri Salicylas (U. S.). I^ Mercuric salicylate Heavy olive oil

Mercuric Salicylate. 3v or 20.0 Gm. Siii or 100.0 cc.

Because the mercury tends to settle out this emulsion should be thoroughly shaken before using. Dose. The average is i gr. (0.065 Gm.) once or twice a week administered intramuscularly. Five minims (0.3 cc.) of this emulsion contains i gr. (0.065 Gm.) of the drug. The preparation is insoluble and therefore slowly absorbed. (c) Hydrargyri Chloridum Corrosivum {U. S.). Bichloride of Mercury. Corrosive Sublimate. The bichloride is soluble in water, forming a powerfully antiseptic and disinfectant solution having markedly irritating properties. Strong solutions damage even the unbroken skin. Uses. I. As an antiseptic in watery solutions from 1:1000 to 1:5000. Only the latter should be used on dressings. 2. In syphilis, pills or tablets containing ^»j gr. (0.004 Gm.) may be prescribed by mouth.

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3. In syphilis the best preparation for intramuscular injection is Bichloridol (Metz). This preparation contains bichloride in a base of palmitin and does not cause pain. {d) Cyanide of Mercury (Official in 1870). I t is soluble in water but less irritating than the bichloride. A one per cent watery solution can be used for intramuscular injection. Doseis 10-Г5 min. (0.6-1 cc.) of the one per cent solution. A good substitute preparation, the oxycyanide, is marketed by the Heyden Chemical Company. A one per cent solution is used and the dose is 10-15 (ο·6-ι ce.) of the preparation. (e) Unguentum Hydrargyri Fortius {U. S.). "Stronger Mercurial Ointment." Contains about fifty per cent of metallic mercury by weight and should not be confused with Unguentum Hydrargyri Mite {U. S.), Mild Mercurial or "Blue Ointment," which contains about thirty per cent of mercury. Administered by inunction daily using different parts of the body in rotation each week in order to avoid excessive irritation of the skin. Hairy parts should be avoided so far as possible. Efficacy depends much on thoroughness of application. Dose is one-half to one drachm (2-4 Gm.). (/) Hydrargyri lodidum Flavum {U. S.). "Protiodide." "Yellow or Green Iodide of Mercury." Administered in pill form by mouth. Dose. One-sixth grain (6.0108 Gm.) /. i. d. and upward increasing gradually until the first signs of intolerance appear. Then reduce dose by half and continue. (g) Hydrargyri CMoridum Mite {U. S.). Mild Mercurous Chloride or "Calomel." Uses. I. As a prophylactic against syphilis by inunction locally in the form of "calomel ointment," thirty to thirtythree per cent. This ointment is not official. 2. As an application to small infectious syphilitic lesions, either as undiluted powder or as "calomel ointment," thirty per cent.

214

PRINCIPLES OF MEDICAL TREATMENT

3. As a purgative and intestinal antiseptic in tablet form by mouth. When prompt action is desired Л" gr. (0.0065 Gm.) can be administered every fifteen minutes until ten doses have been taken and followed, an hour after the last dose, by a mild sahne cathartic. Otherwise from 1-3 gr. (0.065-0.2 Gm.) can be taken as a single dose at bedtime and followed by the saline an hour before breakfast. Large quantities of water should be taken after a dose of calomel. 4. As a diuretic for cardiac edema in 3 gr. (0.2 Gm.) tablets, one to be taken every four hours for twenty-four to forty-eight hours. When diuresis begins the calomel should be stopped. Nephritis contraindicates the use of calomel as a diuretic and when these large doses are used the usual precautions against poisoning are required. {h) Lotio Nigra {N. F., içi6). Black Lotion or "Black Wash." Used externally for dressings, apphcations, or irrigations for syphilitic lesions. {i) Hydrargyrum Cum Creta {U. S.). "Gray Powder" (Metallic Mercury with Chalk). Used in tablet form, particularly for congenital syphilis in young children, page 132. Dose. Adults 1-4 gr. (0.065-0.26 Gm.) t. i. d.; children 1-2 gr. (0.065-0.13 Gm.) t. г. d. (J) Unguentum Hydrargyri Oxidi Flavi (U. S.). "Ointment of Yellow Mercuric Oxide." Note. The strength of this ointment has been reduced to one per cent. Use. As an application to the eyelids in syphilitic keratitis, page 138. {k) Unguentum Hydrargyri Ammoniati {U. S.). Ointment of Ammoniated Mercury. Contains ten per cent of the drug and is used as a mild antiseptic application chiefly for skin eruptions. Iodides (а) Potassii lodidum (U. S.). Potassium Iodide. (б) Sodii lodidum {U. S.). Sodium Iodide.

MEDICATION Properties. water.

215

White crystalline powder, very soluble in

Action. The mode of action is unknown but the effects are as follows: 1. Gummata are caused rapidly to disappear (but a lesion which disappears while iodide is being taken is not necessarily syphilitic). 2. Thyroid activity seems to be increased. 3. Simple goitre is preventable by routine use of the drug. 4. Expectorant: by increasing fluidity of mucus in the respiratory tract. 5. The secretion of urine is generally increased. Elimination. Rapid, chiefly in the urine as salts, and partly in the saliva, from the nasal mucous membrane and into the stomach. Toxic effects may appear even after small doses but larger doses are generally tolerated. Acne, erythema, occasionally more severe skin lesions, catarrh of the respiratory tract, symptoms of gastric irritation, or rarely delirium. Chronic toxic manifestations are loss of weight, nervousness, and anemia. Indications, i . In syphilis when the use of arsphenamine would be dangerous, iodides are then generally used in conjunction with a mercurial, page 138. 2. As a preventive of simple goitre or for the treatment of simple goitre, page 168. 3. In the treatment of lead poisoning iodides have been largely displaced by other drugs, page 142. 4. As a stimulant expectorant in subacute or chronic bronchitis, page 78. 5. In asthma and particularly when associated with bronchitis iodides sometimes do good. Contraindications. Acute renal irritation, acute inflammation of the respiratory tract, and as a rule in thyrotoxicosis. The effects in phthisis may be harmful. Uses and Dose. For syphilis the iodide of potash is generally used in a saturated watery solution of which i min.

2i6

PRINCIPLES OF MEDICAL T R E A T M E N T

contains I gr. (or i cc. contains i Gm.). The usual dose is I0-2O gr. (0.65-1.30 Gm.) taken t.i.d. after meals in milk. For syphilis of the central nervous system increase the dose rapidly until benefit or iodism results. One hundred grains (6.5 Gm.) t. г. d. is large dosage. For other therapeutic purposes the usual dose is 5-10 gr. (0.324-0.65 Gm.) t. i. ά. As an expectorant iodide is generally prescribed as Syrup of Hydriodic Acid, 3i (4 cc.) t. i. d. after meals. For prophylaxis of goitre, 3 gr. of sodium iodide may be taken daily for ten days in every six months. Antitoxinum Dipkthericum {U. S.) Diphtheria Antitoxin ^ Note. The antitoxin should be kept at a temperature not exceeding 20° C. and preferably at 4.5° C. I t must be marked with the date beyond which appreciable deterioration may take place. The standard requirements have been changed in such a way that official diphtheria antitoxin contains a much smaller proportion of serum constituents than formerly. Action. The antitoxin neutralizes the toxins produced by the diphtheria baciUus but has no marked effect upon the bacillus. Absorption from the subcutaneous tissues is slow, the process lasting for several days. Toxic effects are caused by the foreign protein constituents. Urticaria, erythema, and joint-pains are common. Anaphylaxis appears rarely. Indications. Clinical diphtheria, or as a prophylactic for those exposed to diphtheria. See treatment of diphtheria, page 69. Contraindications are never absolute. It may be dangerous to sufferers from horse asthma rapidly to inject an ordinary dose without preliminary desensitization. I t is doubtful whether a single dose of antitoxin ever produces sensitization in humans sufñcient to cause anaphylactic shock on administering a second dose. 1 Manufactured by departments of health and b y pharmaceutical firms. It can be obtained from the State Board of Health in Massachusetts free of charge.

MEDICATION

217

Administration. Usually the serum is injected into the loose subcutaneous tissues of the abdominal wall or below the angle of the scapula, but intravenous injections are best for urgent cases. Dose. The dose should be gauged according to the severity of symptoms, duration of illness, and the extent and location of the membrane. Large doses are indicated when the larynx, trachea, or nasopharynx is involved, and especially in cases of virulent diphtheria. The therapeutic dose for adults is 5,000 to 10,000 units. That for immunization is 1,000 to 2,000 units. Opium and Derivatives The percentage and properties of the alkaloids present in opium vary, but as a rule its effects are essentially those of its most important constituent — morphine. Morphine acts especially on the central nervous system but also to some extent peripherally, as on the intestine. Opium takes longer to act than morphine and the action persists longer. The constipating effect of opium seems to be greater than that of morphine. The more important preparations and derivatives of opium are described below: (a) Morphinae Sulphas {U. S.). phia."

"Morphine" or " M o r -

Properties. White, crystalline, soluble in about sixteen parts of water; less soluble in alcohol. Effects. I. Diminishes sensibihty to lasting impressions and stimuli. 2. Relieves pain. 3. Slows respiration and heart action. 4. Diminishes metabolism. 5. Diminishes peristalsis; therefore constipating. 6. Gives relief in acute cardiac dilatation. 7. In lead cohc or intestinal spasm it may act as a cathartic. Elimination. Chiefly by gastro-intestinal tract. Some is excreted into the stomach very soon after the injection and some is oxidized in the body.

2I8

PRINCIPLES OF MEDICAL TREATMENT

Toxic Effects. I. Somnolence or stupor. 2. Respiration very slow and may become shallow and irregular. 3. Pupillary contraction. 4. Flushing or cyanosis of face. 5. Retention of urine. 6. During recovery from drug nausea is common. 7. Death results from depression of respiratory center. 8. Nausea or anorexia frequently follows the use of morphine. Used in acute conditions to relieve: 1. Severe pain. 2. Discomfort preventing sleep. 3. Acute cardiac insufficiency. 4. Internal hemorrhage (gastric, pulmonary, intestinal). 5. Persistent vomiting. 6. T o produce euthanasia. Contraindications. 1. Danger of forming habit. In chronic or recurring non-fatal diseases, and in conditions which can be relieved by milder means, use morphine with caution if at all. 2. When bronchial secretion is profuse and viscid, morphine may prevent necessary expectoration. See Pneumonia, page 76. It acts well in some cases of pulmonary edema: see Hypertension, page 16, and Toxemic Edema, page 25. 3. Idiosyncrasy. Causes excitement, vomiting, depression. 4. Relatively small doses should be used in childhood and for elderly persons. Morphine is seldom required and must be used with caution, if at all, when the respiration is much depressed by toxemia as in uremic conditions with Cheyne-Stokes respiration. 5. Morphine should not be used in acute dilatation of the stomach or when tympanites is a source of danger. Administration. For urgent conditions inject subcutaneously in the dose of | to ^ gr. (0.008-0.032 Gm.) with or without atropine sulphate ^ ^ to т Ь gr. (0.00032-0.00054 Gm.). Morphine is generally used by mouth in tablet, in watery solution, or in a mixture. It is more quickly absorbed from the mouth than from the stomach. Hypoder-

MEDICATION

219

mie tablets can be used for mouth absorption. T o diminish the gastric disturbance which may follow, atropine is generally administered with hypodermic injections of morphine but atropine produces toxic symptoms if repeated often in full doses. Alternative. When morphine alone fails to produce rest and sleep a small dose of morphine combined with xiir gr. (0.00065 Gm.) of scopolamine may have the desired effect (Scopolaminae Hydrobromidum, U. S.). (6) Tinctura Opa {U. S.). Tincture of Opium. Deodorized Tincture of Opium. Laudanum. Used to check persistent diarrhea, to promote rest and sleep or to relieve pain in acute illness, or in chronic disease past hope of cure. Dose is 5-15 min. (0.3-1 cc.). (c) Tinctura Opa Camphorata (U. S.). Camphorated Tincture of Opium. Paregoric. Used chiefly to check diarrhea. Dose (for adult) one to four teaspoonfuls (4-15 cc.). (d) Codeinae Sulphas {U. S.). Codeine Sulphate. Used chiefly as a sedative to check cough at night. It is not an efficient substitute for тофЬ1пе. Dose. One-quarter to one-half grain (0.016-0.032 Gm.). Digitalis and Other Heart Tonics T o the digitalis group belongs strophanthin, the action of which is very similar to that of digitalis. Other members of the group are unimportant. (a) Digitalis {U. S.). Digitalis Leaves. Foxglove. Action. Therapeutic doses have little effect upon the normal heart but, in circulatory disorders depending primarily upon disfunction of the heart itself, the beneficial effects of digitalis are marked. The following therapeutic effects may be looked for: 1. Slowing of the whole heart by vagus stimulation. 2. Depression of conduction between auricles and ventricles with slight lengthening of conduction time. This effect seems to be caused in part by vagus stimulation and in part by direct action of the drug.

220

P R I N C I P L E S OF M E D I C A L T R E A T M E N T

3. Increase of contractility of the ventricles through direct action. Absorption of a dose of digitalis should take place in from two to six hours but the absorbabihty of different products varies widely. High-grade tinctures, as a rule, are well absorbed.' T h e same is believed to be true of well-made pills. Excretion proceeds through the liver and kidneys, and much of the drug is destroyed in the intestine and not absorbed. Excretion is said to take place at a variable rate of about 2 gr. (o. 13 Gm.) per d a y ^ but the effects of digitalis may persist for two or three weeks. Hence, when the heart has been sufficiently digitalized a relatively small dose will maintain the good effect, but cumulative toxic action m a y follow the continued use of slightly larger dosage. Beneficial therapeutic effects m a y be secured in almost any form of essentially cardiac decompensation. I n the presence of normal rhythm the function of the heart m a y be improved even when the rate is not altered. In auricular flutter the rate of the ventricles is reduced b y depression of conduction; fibrillation of the auricles generally supervenes and m a y be followed b y a return to normal rhythm. In auricular fibrillation a pronounced slowing of the heart with decrease of irregularity is to be expected even when there is little or no decompensation and, in the presence of the latter, a marked or even dramatic improvement of function takes place with coincident relief of subjective symptoms, copious diuresis, and disappearance of edema. B l o o d pressure,^ whether too high or too low, in decompensation apparently tends to approach the normal when the cardiac function improves under digitaUs. When the good effects of digitalis fail in cardiac insufficiency four common causes of failure should be borne in mind: 1. T h e preparation m a y be of low activity. 2. T h e dosage m a y have been insufficient for the case. 3. T h e heart m a y lack recuperative power. 4. T h e circulatory disorder m a y be of extra-cardiac origin. > Eggleston and W y c k o f f , ig22, Arch. Int. Med. 30, 133. 2 Pardee, 1919, Jour. A . M . A . 73, 1822. " Luten had variable results, 1924, Arch, of Int. Med., Feb. 15, p. 251.

MEDICATION

221

Toxic eßects of a mild character are to be expected soon after digitalis therapy has been instituted, because the optimum therapeutic dose for severe decompensation coincides with the threshold of the toxic dose. As a rule the first definite symptom of toxic action is nausea or vomiting or, sometimes, the appearance of premature beats. Diarrhea, headache, coupled pulse-beats, oliguria, sinus arhythmia, heart-block, paroxysmal tachycardia, or fall of blood pressure may develop. Visual disturbances ' of slight degree may be an early sign of toxic effect. In a few cases pronounced disturbances of vision have been described. Indications, i . Myocardial insufficiency in general. 2. Chronic auricular fibrillation in particular. 3. Auricular flutter as a rule. Neither aortic regurgitation, high blood pressure, nor pulsus alternans contraindicates the use of digitalis. In paroxysmal tachycardia, in sinus arhythmia, in circulatory disorders of vascular origin, and in tachycardias unconnected with cardiac decompensation, digitalis is of httle or no value. Contraindications, i . In the presence of heart-block, digitahs may be either beneficial or harmful. Therefore, judgment and caution are required. 2. In cerebral hemorrhage caution is necessary lest harm result from increase of blood pressure. 3. In sudden cardiac failure due to such causes as coronary occlusion the intravenous injection of a large dose of a preparation of digitalis or of strophanthin may tend to bring on ventricular fibrillation and is, therefore, dangerous. 4. Pronounced nausea or vomiting prevents the use of digitalis by mouth but does not contraindícate its use by other channels unless the symptoms are attributable to toxic effects of digitalis administered previously. Selection of Preparation. Because of the great difference of activity of digitalis leaves it is essential that they should be assayed physiologically before being used for medicinal purposes. Two preparations, neither of which is official, are most commonly used; namely, a ten per cent tincture and a pill made from the powdered leaf. Assayed but ^ Sprague, White, and Kellogg, 1925, Jour, A. M. A. Í5, 716.

222

PRINCIPLES OF MEDICAL T R E A T M E N T

undated tinctures are marketed by many of the pharmaceutical houses. These tinctures apparently keep fairly well if protected from the air but probably deteriorate more rapidly after the bottle has been opened than do wellmade pills or capsules. Either the tincture or pills of the powdered leaf, if made from good leaves, is satisfactory for hospital practice. For private patients who are taking digitalis continuously for long periods the pills or capsules are advised. When made from drugs of equal potency l o min. (0.6 cc.) of the tincture corresponds to a one-grain (0.065 Gm.) pill of the powdered leaves. Administration. The older method of producing digitalization was to begin with 30 min. of the tincture (2 cc.) t. i. d. and if neither benefit nor toxic effects of the drug were manifested within forty-eight hours to increase the dose. Higher initial dosage was occasionally used in urgent cases to obtain results more promptly. This method is still satisfactory when symptoms are not particularly urgent and is to be preferred when the patient cannot be kept under close observation by a nurse. Eggleston's method 1 of rapid digitalization by mouth depends upon calculating the total amount of digitahs that will probably be required to obtain the full digitalis effect, and upon administering this amount or most of it in massive doses over a relatively short period of time. He figured dosage with reference to the average cat-unit activity of digitalis and the weight of the patient, and estimated a dose of 2.25 Gm. of the leaf (35 gr.) or 22.5 cc. of the tincture (3vi ss) for a man weighing 150 lbs.; that is, 0.15 Gm. (2.3 gr.) or I.s cc. per 10 lbs. of body weight. A t first from one-third to one-half of the total dose was administered and the remainder, if needed, in decreasing amounts at intervals of six hours during twenty-four hours or slightly longer. Full digitalization can thus be obtained within twenty-four hours and benefit in much less time. Experience in general favors White's modification of the Eggleston method. White ^ calculated on the basis of 0.1 Gm. (1.5 gr.) per 10 lbs. of body weight and prefers to administer one-sixth of the dose thrice daily for two days. ^ E g g l e s t o n , IQ20, J o u r . A . M . A . 74, 733. 2 W h i t e , ι ς 2 2 , J o u r . A . M . A . 79, 782.

O r i g i n a l l y d e s c r i b e d in

1015.

MEDICATION

223

Caution. These massive doses should not be given to a patient who has been taking digitalis within ten days or two weeks. The patient should be kept under close observation and the administration of digitalis should be stopped promptly when satisfactory therapeutic effects have been obtained or, failing the appearance of these earlier, when nausea, vomiting, or other definite toxic symptoms appear. Whatever method is used a maintenance dose of about 2 gr. (0.13 Gm.) daily or less may be sufficient for continued use when once the heart has been digitalized. Deaths have probably resulted from too persistent use of large doses, and beyond question they have produced unpleasant symptoms. When the use of digitalis by mouth is precluded by vomiting or for other causes, tincture of digitalis can be administered in saline solution by rectum with the expectation of good results. Dosage for rectal use of this drug is the same as that required by mouth (Levy 0· Doses of digitalis tincture should always be measured and never estimated by counting drops. Intravenous and intramuscular injections. It has recently been shown (Pardee that the effective dose of several of the most generally used digitalis products intended for intravenous or intramuscular injection is far above that recommended by the manufacturer. It further appears that promptness of action is related to mass of dose so that the therapeutic effects of small dosage by intravenous or intramuscular injections develop more slowly than do those of relatively large dosage administered by mouth. General References on Digitalis Therapy 1. Robinson: " T h e Therapeutic Use of Digitalis." Medicine, 1922, Vol. I, p. i . 2. Cushny: " T h e Action and Uses of Digitalis and its Allies." Lond. 1925. {b) Strophanthus {U. S.). Strophanthus. Action. Like that of digitahs but less reliable because absorption from the gastro-intestinal tract is very variable and uncertain, so that strophanthus is not satisfactory for oral administration. ' L e v y , 1924, Arch. Int. M e d . 33, 74г. « Pardee, 1925, Jour. A . M . A. Ss, J3S9.

224

PRINCIPLES OF MEDICAL TREATMENT

1. Strophanthinum (U. S.), the active principle of strophanthus, is an amorphous powder which is stable in air but liable to deterioration in solution. Very prompt digitaUs-like action results from the intravenous injection of a full dose of strophanthin. Excessive doses, however, cause a sudden rise of blood pressure soon succeeded by a marked fall. A number of deaths have resulted. Indications. Strophanthin should be reserved for emergencies. A full dose should neuer be used if the patient has taken any drug of the digitalis group within two or three weeks. Injections can be given intramuscularly or intravenously. Contraindications. As for digitalis. Dose. The full average dose is 0.5 mgm. (0.00075 gr.) once daily. It is advisable, as a rule, to administer half this quantity at first and the rest two hours later if needed. Preparation. Hypodermic tablets ^Ьл (0.00032 Gm.), тЬ (0.00043 Gm.), and тЬ gr. (0.00065 Gm.) are on the market. 2. Ouabain is a crystalline strophanthin. It is not official. Its action is like that of official strophanthin but probably more powerful in equal dosage. It is marketed in ampules which should bear the date of manufacture and the date of probable deterioration. The dose must be measured carefully. For further data see New and NonofScial Remedies, 1925. (c) Quinidinae Sulphas {U. S.). Quinidine Sulphate. Because of its tendency to bring about restoration of the normal rhythm in auricular fibrillation and to prevent recurrence of fibrillation, quinidine has won an important place during the past six years. Indications. The best results have been secured when the fibrillation was not of long standing or when the drug was used as a preventive of recurrent fibrillation. Cases of long standing, even when temporarily benefited, tend to relapse and their treatment with quinidine involves needless danger. Contraindications appear to be relative rather than absolute and not yet well known. Consequently, it would

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225

seem advisable at present to confine the use of the drug to cases in which the patient is under close observation at all times. Cases in which there has been congestive cardiac insufficiency or fibrillation of long standing seem particularly subject to death from embolism when the normal rhythm is restored. Such patients should be treated with digitalis and not with quinidine. Dosage, administration, and uses of quinidine were clearly described by White in 1922.* A few other interesting references are appended. White, Marvin, and Burwell, 1921. Bost. Med. & Surg. Jour. 185, 647. Lewis, 1922. Amer. Jour. Med. Sc. June, p. 781. Lewis, 1922. Ibid., July, p. i . L e v y , 1922. Arch. Int. Med. 30, 451. Hart, 1922. Ibid., 30, 593. *White, 1922. Jour. A. M . A. 79, 782. Reid, 1922. Ibid., 7p, 1974. White, 1925. Boston Med. and Surg. Jour. IÇ2, 185. Levine and Wilmaers, 1925. Ibid., 1Ç2, 388. White and Sprague, 1925. Ibid., i p j , 91. Smith and Clarke, 1925. Arch. Int. Med. 36, 838.

Nitroglycerin and Nitrites (a) Nitroglycerin. Glyceryl Trinitrate.' Action. Lowers blood pressure by dilating peripheral vessels. Acts within a few minutes. Effect lasts about one-half hour. In the presence of hypertension diuresis may result. Toxic Effect. Flushing, sense of fullness in head, throbbing headache, faintness. Reduction of urinary output. Indications, i. Angina Pectoris. 2. Cardiac embarrassment 1 , , ^ u· . 3. Headache j when due to high pressure. Contraindications. Low blood pressure. Administration. Generally used as a tablet triturate.' For quick absorption the tablet should be chewed and not swallowed. ' Official only in the form of Spiritus Glycerylis Nilratis (U. S.). ' Tablets are said to lose strength but may remain good for years. take one-half tablet yourself.

T o test them

22б

PRINCIPLES OF MEDICAL TREATMENT

Dose. Ordinary dose tU gr. {о.ооо6$ Gm.) ; may be repeated frequently unless toxic symptoms result. For some cases gr. (0.00032 Gm.) or (0.0013 Gm.) is better. Larger doses may be required. (b) Amylis Nitris {U. S.). Amyl Nitrite. Acts very rapidly. Effect very transient. May act when nitroglycerin fails. Marketed in "pearls" containii^g 3~S min. (0.2-0.3 cc.). Break pearl and inhale from handkerchief. Pearls ' should break easily but not spontaneously. Dose is 3-5 min. (0.2-0.3 cc.). (c) Sodii Nitris ({7. S.). Sodium Nitrite. Action like nitroglycerin but lasts longer. scribed in watery solution. Usual dose is 2 gr. (0.13 Gm.).

Best pre-

Magnesium Sulphate and Other Purgatives (a) Magnesii Sulphas {U.S.). "Salts," "Epsom Salts," or "Bitter Salts." Properties. Colorless, crystalHne, very soluble in water. Taste bitter. Action. Epsom salts in concentrated solution and full dose acts as an hydragogue purge, and in dilute solution and small dose as a cathartic. More or less of the salt is absorbed and excreted in the urine. Toxic Effects. Gastric irritation and vomiting. If given in too concentrated solution, especially when there is ulceration of the colon, an excess of the salt may be absorbed and may then cause severe poisoning characterized by oliguria, hematuria, slow respiration, paralysis of the intestines, extreme weakness, and collapse.^ The urine in poisoning shows a very high specific gravity owing to the excretion of the drug by the kidney. These effects are rare. Indications, i. Cardiac dropsy in particular, or 2. Uremic states with edema. 3. Sometimes used as a local anesthetic. > Allen and Hanbury's are good. 2 Boos, Jour. A. M. A. Dec. lo, igio, p. 2037.

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Contraindications. Weakness, emaciation, vomiting, menstruation, and pregnancy. Administration. Most easily taken in a cup of black coffee and most effective when taken one hour before breakfast or when the stomach is empty. Dose. From one-half to one ounce (15-30 Gm.) of salt or double this quantity of saturated solution in half a glass of water. Small doses with a full glass of water can be used for mild catharsis. (6) Oleum Tiglii (U. S.). Croton Oil. Used as a purgative for unconscious patients and particularly in severe uremia. If the oil is rubbed up with a bit of butter and placed on the back of the tongue it will be swallowed automatically by the patient. Dose is 1-3 min. (0.06-0.2 cc.). (c) Pulvis Jalapae Compositus {U. S.). Compound Jalap Powder. When to this powder an equal quantity of potcissium bitartrate has been added and the mixture administered in the dose of one teaspoonful (4 Gm.) it has an efficient purgative effect comparable to that of Epsom salts. (d) "Ten-Ten." Equal parts of calomel and powdered jalap make an efficient purgative in the dose of 10 gr. (0.65 Gm.) of each. Contraindicated in menstruation and pregnancy. (e) Elaterinum (U. 5.). Elaterin. This drug is used especially when nausea renders the use of Epsom salts impracticable. In the dose of y'^ gr., however, it cannot be counted on to produce watery catharsis. I have had better results from the use of the crude drug, Elaterium (Br. 1898), in the dose of j gr. (0.016 Gm.), but larger doses of elaterin might have served as well. Contraindicated in menstruation and pregnancy. ( / ) Oleum Ricini (U. S.). Castor Oil. Castor oil has a taste which is unpleasant to most adults and generally to children but as a mild purgative to rid

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PRINCIPLES OF MEDICAL T R E A T M E N T

the bowel of undigested and fermenting substances it is generally superior to the hydragogue purges. It cannot be used when there is nausea. Contraindicated in menstruation, pregnancy, and nausea. Dose. One or two tablespoonfuls for an adult or one to four teaspoonfuls for a child, best given with lemon juice or brandy one hour before breakfast. (g) Hydrargyri Chloridum Mite {U. S.). "Calomel." Used like castor oil but the action is somewhat more drastic. The administration has been described under Mercurials, page 213. Contraindicated in menstruation and pregnancy. Salts of Quinine The various salts in common use differ much in solubility but their action after absorption is essentially the same. Action. Parasitotropic in malaria, killing the younger forms of the parasite but not the gametes. Causes constriction of unstriated muscle and changes in the white cells of the blood. A polynuclear leukocytosis with diminution of lymphocytes generally results. Intramuscular injections cause necrosis. Absorption from the stomach is rapid, quinine appearing in the urine within fifteen minutes after ingestion. When injected intramuscularly some of the drug is deposited locally and but slowly absorbed. When injected intravenously it quickly disappears from the plasma and becomes attached to the corpuscles. Excretion. About one-third of the quinine ingested is excreted in the urine, most of it appearing within twentyfour hours. Much of the remainder is destroyed in the body. Toxic Eßects. Full therapeutic doses generally cause tinnitus with slight transient deafness, and sometimes gastric distress. Mental depression and muscular weakness are common. Larger doses may cause vomiting, dizziness, cardiac depression with slow pulse and fall of blood pressure, contraction of the visual fields, disorders of color sense, spasm

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of the retinal vessels with transient blindness, or even degeneration of the optic nerve with permanent blindness, or permanent damage to the hearing. The stimulant effect upon the muscle fibers of the uterus may cause abortion, but this result is more often attributable to the malaria than to the remedy. Similarly, cardiac disorders developing in severe malaria are generally caused by the disease and relieved by the drug. Idiosyncrasy. Few individuals are truly hypersusceptible to quinine but in some individuals tinnitus is produced by small dosage and various skin eruptions may develop. Of these, erythema is most common. Used to treat malaria, or, in dilute solution with urea, as a local anesthetic in very small doses at a time. In influenza and other infectious processes quinine is of doubtful value and other drugs serve better as antipyretics. Contraindications are relative. In advanced pregnancy quinine should be used cautiously but enough should be given to control the fever. Supposed idiosyncrasy can generally be overcome by beginning with small doses. (a) Quininae Sulphas (U. S.). Quinine Sulphate. This salt is commonly preferred because it is cheap. It generally acts satisfactorily when properly administered. Properties. White, crystalline, slightly soluble in water but readily in dilute acids. Taste very bitter. Administration. The sulphate is readily absorbed from the stomach, as a rule, when well-made soft tablets or capsules are used. Pills which are too hard pass through the bowel unaltered. In malaria the treatment should be begun with a brisk purge of calomel. Full doses of quinine should be given, beginning when the temperature is falling and continuing during the interval before the rise next ensuing. Five-grain tablets are in general use. When nausea or vomiting precludes the use of quinine by mouth, a more soluble salt should be used by intramuscular injection in concentrated solution or, in urgent cases, intravenously in dilute solution. The drug should be given, so far as practicable, after the taking of food, in order to minimize the irritative effects on the stomach.

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PRINCIPLES OF MEDICAL TREATMENT

Dose. Single dose 5-20 gr. (0.324-1.3 Gm.), usually 10 gr. (0.65 Gm.). Dosage for twenty-four hours 20-80 gr. (1.3-5.2 Gm.). In mild cases of malaria the fever can be controlled with doses of 10 gr. t. i. d. In severe cases 50-80 gr. (3.34-5.2 Gm.) may be required for a few days. (6) Quininae Bisulphas (U. S.).

Bisulphate of Quinine.

One gram is soluble in about 9 cc. of water. This salt is probably absorbed rather more quickly and easily than the sulphate. Dose is the same as for sulphate. (c) Quininae Dihydrochloridum {U. S.)} drochloride or bihydrochloride.

Quinine dihy-

One gram is soluble in about 0.6 cc. of water. This salt is often administered by mouth like those preceding and in the same dose, but its principal use is for intramuscular injection in concentrated solutions and for intravenous injections in more dilute solutions. Uses. The principal indication for using quinine intramuscularly is inability of the stomach to retain it. Intravenous injections should, I believe, be reserved for the most urgent cases. Because of the rapidity with which quinine is absorbed from the stomach, use of the drug by injection, unless for special reasons, would seem to be irrational. Dose for intramuscular or intravenous injection 10-15 gr. Ampules specially prepared for intramuscular use and others for intravenous use of the drug are on the market. Salicylates Action. The action and effects of the salicylic preparations in common use is similar. In some unknown manner they can exert a curative effect in rheumatic fever. They act in this and in other conditions also as analgesics and, in the presence of fever, as antipyretics and diaphoretics. Salicylates tend to cause gastric and renal irritation. Absorption from the gastro-intestinal tract is rapid. Salicylate circulates in the blood as the sodium salt. ' D o not confuse with Quininae Eydrochloridum

(U. S . ) , which is far less soluble.

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Excretion. Salicylate appears in the urine within an hour of administration by mouth and excretion is completed within forty-eight hours, seventy-five per cent passing out by the kidney and about twenty per cent being destroyed in the tissues. Toxic Effects. Tinnitus, headache, vomiting, erythema, or delirium, and, rarely, disturbances of sight. Albuminuria may result from irritation of the kidney even when moderate doses are taken. Very large doses may cause drowsiness and coma, or cardiac depression and fall of blood pressure. (a) Sodii Salicylas {U.S.). Sodium Salicylate. Indications. 1. Rheumatic Fever, page 46. 2. Rheumatic endocarditis and other complications of rheumatic fever may be prevented by timely use of salicylates in sufficient dosage, but the drug has little effect upon endocarditis after it has developed. Endocarditis in the presence of rheumatic fever does not contraindícate the use of adequate doses of salicylates, and rheumatic pericarditis seems to respond well to full doses of salicylate. 3. Useful as an analgesic in various kinds of arthritis, for headache, or for pain from almost any cause. Beneficial effects are not obtained in acute gonorrheal rheumatism. In many cases of chronic arthritis salicylates fail to cause improvement. Contraindications, i. Acute nephritis. 2. Idiosyncrasy. 3. Pronounced circulatory disorders. Administration. Compressed tablets of 5 gr. (0.324 Gm.) each are commonly used. They should be taken, when practicable, after meals and followed with a full glass of water to minimize possible digestive discomfort. When large doses of a salicylate are required it is well to prescribe with the salicylate enough sodium bicarbonate to render the urine alkaline. It is believed that when this is done renal irritation and other toxic effects are less common. Meanwhile, keep the bowels freely open. Dose. For rheumatic fever 10 gr. (0.65 Gm.) of sodium salicylate every hour until the patient is relieved of pain;

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PRINCIPLES OF MEDICAL T R E A T M E N T

then IO gr. (0.65 Gm.) every four hours until convalescence has been established; then 20-30 gr. (1.3-2 Gm.) daily for a month or more to prevent relapse. If toxic effects occur, the medicine must be omitted until they pass off. It can then be resumed in smaller dosage or in different form. A vehicle, such as essence of pepsin, may be helpful. For mild cases of arthritis smaller dosage may be sufficient. In chronic "rheumatism" 5-10 gr. (0.324-0.65 Gm.) taken two to four times a day may promote comfort. (b) Acidum Acetylsalicylicum {U. S.). Acetylsalicylic Acid or "Aspirin." Action. Like that of sodium salicylate but causes less gastric irritation. Alkalinization of the urine is not required for the small doses commonly taken. When sodium bicarbonate is administered with acetylsalicylic acid, sodium salicylate will be formed in the stomach. Therefore, these drugs should not be combined. Uses. Analgesic and antipyretic or as a substitute for sodium salicylate when the digestion is disturbed. In rheumatic fever when large dosage is required sodium salicylate is to be preferred. Indiscriminate use of acetylsalicylic acid by the laity is unwise because habit formation is a possibility and with it symptoms of chronic poisoning may develop. (c) Salicinum {U. S.). Salicin. Action. Like that of sodium salicylate but milder. the usual dose it does not disturb digestion. Used like acetylsalicylic acid.

In

{d) Methylis Salicylas {U. S.). Methyl Salicylate. "Oil of Gaultheria." "Oil of Wintergreen." Used, after mixing with equal parts of olive oil, especially for application to inflamed joints in acute rheumatism. The joint is then wrapped with cotton wool and loosely bandaged. Although some of the oil may be absorbed through the skin the effects are chiefly those of counterirritation and psychic suggestion through odor. Oil of gaultheria can be taken by mouth in milk or in capsules as a substitute for sodium saUcylate. Dose is 15-30 min. (1-2 cc.).

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Insulin Note. Insulin is not official but is made by various manufacturers. The strength is expressed in units (see N. N. R.). Action. Blood-sugar is reduced and the oxydization of carbohydrate greatly increased. Toxic efects, uses, and dosage are described in the chapter on Diabetes. L I S T II USEFUL DRUGS

1. 2. 3. 4. 5. 6.

Thyroid Preparations Diuretics Diaphoretics Laxatives and Cathartics Intestinal Astringents Analgesics and Antipyretics 7. Hypnotics 8. Tonics

9. 10. 11. 12. 13. 14.

Alcoholic Beverages Stimulants Sedatives Urinary Antiseptic Emetics Antiseptics, Gargles, Washes, Ointments, and Powders 15. Viruses, Vaccines, and Bacterial Extracts

Thyroid Preparations Note. A variety of dried products of the thyroid gland are made by various manufacturers. They have been supplanted to some extent recently by thyroxin, a purefied and much stronger preparation. The use of the extracts is described in the chapter on Endocrine Disorders under Thyroid Hypofunction, page 173. It is important to use the product of a reliable house. Preparations, (a) Thyroideum {U. S.). Thyroid. Dose. About i gr. (0.065 Gm.) daily more or less. (6) Thyroxinum {U. S.). Thyroxin. Dose. About jh gr. (0.00054 Gm.). Diuretics (a) Theobrominae Sodio-Salicylas {U. S.). Sodio-Salicylate.

Theobromine

Properties. White powder, very soluble in water, taste unpleasant, turns brown on exposure to air.

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PRINCIPLES OF MEDICAL T R E A T M E N T

Action. Diuretic; slightly irritating to the kidneys. Effect is produced in from twelve to forty-eight hours; lasts for from two to three days. Toxic Efect.

Vomiting.

Indications. Cardiac insufficiency with edema, page 6. Useless, or nearly so, in pure renal dropsy. Small doses sometimes act well for Angina Pectoris, page 13. Contraindications. Administration.

Acute nephritis. I n capsules or in a cachet, after meals.

Dose is 15 gr. (i Gm.) four times a day. If no result after forty-eight hours, double the dose. Never prescribe it in these doses for more than three days a t a time. (6) TheophyllinaiU.S.).

Theophylline.

Used as a substitute for theobromine. Dose is 3 - 6 gr. (0.2-0.4 Gm.) t. i. d. in powder with water, or in capsule, page 6. (c) Calomel. Described under Mercurials, page 214. id) Saline Diuretics. These include alkaline mineral waters, potassium citrate, and potassium bitartrate. T h e water taken with them itself has a diuretic effect. Use. T h e y m a y be tried in chronic nephritis with signs of chronic uremia when edema is slight or in other toxic conditions when diuresis is desired. Contraindications.

Acute nephritis.

(e) Potassii Citras (£7. S.). Potassium Citrate. Dose is 15 gr. (i Gm.) in a full glass of water t. i. d. ( / ) Potassii Bitartras (U. S.). " C r e a m of T a r t a r . "

Potassium Acid T a r t r a t e .

Dose is one teaspoonful (4 Gm.) in a pint (500 cc.) of water flavored with lemon juice. T h e mixture should be sipped through the day and can be used freely.

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Diaphoretics (a) Pilocarpinae Nitras {U. S.). Pilocarpine. Action. Very powerful sudorific and increases glandular secretions generally. Toxic Effects. Circulatory depression, nausea, vomiting or diarrhea, giddiness, mental confusion, and perhaps pulmonary edema. Contraindications, (a) Unconsciousness. {b) Circulatory weakness. Used to promote sweating in nephritis when the hot-air bath alone fails to induce it, page 28. Dose by subcutaneous injection 5 gr. (0.0108 Gm.). (b) Antipyretics and Analgesics. These generally cause diaphoresis when there is fever, page 82. Laxatives and Cathartics (a) Fluidextractum Cascarae Sagradae {U. S.). "Fluidextract of Cascara Sagrada." Action. Mild laxative, stimulating peristalsis by irritation. Taste.

Very bitter.

Toxic Effect. Excessive irritation of bowel. Dose is 10-30 min. (0.6-2 cc.) at bedtime with water or 5-10 min. (0.3-0.6 cc.) t. i. d. See Constipation, page 125. (i>) Extractum Cascarae Sagradae {U. S.). Extract of Cascara Sagrada. Three and five-grain tablets of the extract are marketed by various manufacturers. They are convenient and generally satisfactory. Dose is 3-10 gr. (0.2-0.65 Gm.) at bedtime or two to three times daily if needed. (c) Senna (U. S.). Senna Leaves. Action. A mildly irritating laxative. Use. The best method of using senna is described on page 125.

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PRINCIPLES OF MEDICAL T R E A T M E N T

{d) Petrolatum Liquidum {U.S.). Liquid Petrolatum or Liquid Paraffin. The United States Pharmacopoeia recognizes two varieties: a heavy and a light liquid petrolatum. Both are colorless, odorless, and tasteless when cool. Heavy liquid petrolatum corresponds to "Russian O i l " and is suitable for internal use. Action. Lubricant, passing unabsorbed and undigested through the intestine, page 125. Unlike olive oil, mineral oil is not a food and is less apt to disturb the digestion. Used chiefly in chronic spastic constipation in conjunction with other forms of treatment. Dose is one to two tablespoonfuls (15-30 cc.) once or twice daily, preferably several hours after a meal. (e) Agar {U. S.). Agar or Agar-Agar. Action. Swells tremendously by absorbing water, is not digested, and does not ferment in the intestinal tract. Its bulk stimulates peristalsis and helps to sweep out the bowel and render the motions soft. Used in chronic spastic constipation in conjunction with other forms of treatment, page 125. Dose is one-half to one tablespoonful (8-15 cc.) once or twice daily. Administration. In granulated form agar can be eaten with cereal or it can be mixed with and washed down with milk or water. Agar wafers are more attractive but expensive. (/) Cathartic Pills. Several convenient compound pills are very commonly used and are generally available. They are more suitable for occasional than for continued use. {i) Pilulae Hydrargyri Chloridi Mitis Compositae {U. S.). Compound Cathartic Pill. Composition. Calomel, colocynth, jalap, and gamboge. Action.

Vigorous catharsis by irritation of the bowel.

Dose. One or two pills at bedtime.

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(2) Pilulae Aloini, Strychninae et Belladonnae {N. F. 1Q16). " A . S. and B. Pills." Action. Mild catharsis by irritation of the bowel. Dose. One or two pills at bedtime. Mild Saline Cathartics {a) Pulvis Eßervescens Compositus (U. S.). Compound Effervescing Powder. "Seidlitz Powder." Composition. One paper contains sodium bicarbonate and sodium and potassium tartrate, and the other tartaric acid. Administration. Dissolve the contents of a white and of a blue paper separately in water, mix the solutions, and take at least one-half hour before breakfast. (¿) Sal CaroUnum Faclitium Eßervescens {Ν. F. Effervescent Artificial Carlsbad Salt.

içi6).

Composition. Chiefly sodium sulphate with sodium bicarbonate and tartaric acid. Dose. One or two teaspoonfuls (4-8 cc.) dissolved in a glass of water to be taken at least one-half hour before breakfast. Intestinal Astringents {a) BismutkiSubnitras (U.S.). "Bismuth." Action. Mild astringent and antifermentative. Combines with hydrogen sulphide in intestine to form a black, insoluble sulphide. Toxic Effect. None with therapeutic dose when a reliable preparation is used. Arsenic is a common impurity of bismuth of poor quality. Used for Diarrhea, page 1 2 1 , Peptic Ulcer, page 1 1 5 , and for intestinal fermentation. Dose. For diarrhea 10-30 gr. (0.65-2 Gm.) with water repeated after each loose movement. For peptic ulcer doses of I drachm (4 Gm.) are used before meals to coat the ulcer and to relieve distress. When using these large doses prescribe a pure preparation free from arsenic.

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PRINCIPLES OF MEDICAL TREATMENT

(Ò) Acidum Tannicum {U.S.). Used as the " C . O. T . Pill," which is not official, to check diarrhea, page 121. The opium in the pill has an important constipating effect. Composition. 2 gr.

Camphor i gr. ; opium \ gr. ; tannic acid

Dose. One or two pills repeated during the day if needed. Proprietary tannin preparations are described in New and Nonofficial Remedies. (c) Mistura Opa et Rhei Composita (Ν. F. içi6). Compound Mixture of Opium and Rhubarb. "Sun Cholera Mixture." Used. T o check diarrhea. Dose. Average 30 min. (2 cc.). The same active ingredients can be obtained in tablet form. Analgesics and Antipyretics (a) Acetphenetidinum(U.S.). nacetin." Action. sedative.

Acetphenetidinum or " P h e -

Analgesic, antipyretic, mild diaphoretic, and

Toxic Effect. Circulatory depression. Used especially for migraine and occasionally for other painful conditions. Dose is 5-15 gr. (0.324-1 Gm.). The smaller dose may be repeated in an hour or more if necessary. Prescribe with each s gr. (0.324 Gm.) of the drug caffeine citrate i gr. (0.065 Gm.) in tablet or powder. (¿>) Acidum Acetylsalicylicum See Salicylates, page 230.

{U. S.).

(c) Pulvis Ipecacuanhae et Opii (U. S.). Powder of Ipecac and Opium. " D o v e r ' s Powder." Action. Mild opiate, hypnotic, sedative, diaphoretic, antipyretic, and analgesic; slightly constipating. Toxic Effect. result.

When stomach is irritable vomiting may

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239

Used generally in single dose in the evening for malaise or insomnia in acute infections such as "grippe," tonsillitis, or the acute exanthemata. Dose is l o - i s gr. (0.65-1 Gm.) in powder or tablet by mouth. Hypnotics (a) Sulphonethylmethanum (U.S.). "Trianol." Action. Hypnotic and sedative. Soluble in 195 parts of water, more soluble in alcohol. Toxic Efect. Mental and physical depression. Used for wakefulness, sometimes for alcoholic delirium. Dose. For sleep 5 - 1 5 gr. (0.324-1 Gm.) in powder by mouth. Doses up to 30 gr. (2 Gm.) may be required for alcoholic delirium. Administered in powder or soft tablet by mouth with water, with a glass of wine, or in solution by rectum. {b) Barbitalum {U.S.). Barbital. "Veronal." Similar to the preceding and has, I beKeve, no special advantage. (c) Adalin (proprietary). A mild hypnotic and sedative said to act satisfactorily without causing depression or other unpleasant effects (N. N. R.). Tonics I. Iron Tonics. Action. Rubefacient, slightly constipating, turn stools black. Absorption from the gastro-intestinal tract is slow and incomplete. Uses. Specific in chlorosis and useful in various secondary anemias. (a) Pilulae Ferri Carbonatis {U.S.). Pills of Ferrous Carbonate or "Blaud's PiUs." Composition. Ferrous sulphate, potassium carbonate, and other ingredients. Dose. One or two piUs of 5 gr. each t. i. d. after meals. Much larger doses seem sometimes to be required.

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PRINCIPLES OF MEDICAL TREATMENT

(b) Ferri CorbonasSaccharatus (U.S.). rous Carbonate. Dose. About 4 gr. (0.26 Gm.).

Saccharated Fer-

(c) Ferrum Reductum (U.S.). Reduced Iron. A constituent of various tonic pills combined with arsenic and other ingredients. See Arsenical Tonics, below. Dose. About i gr. (0.065 Gm.). (d) Green Citrate of Iron. Used for intramuscular injection, page 149. 2. Arsenical Tonics Action. Small doses of arsenicals seem to have a tonic effect in anemia and in debility. Toxic effects are not seen when tonic doses are used. Toxic effects of large doses are those of arsenic; namely, weakness, languor, loss of appetite, vomiting or diarrhea, or conjunctivitis and symptoms like coryza with catarrh of the nasal passages and larynx. Uses. Arsenicals are often combined with or used in conjunction with preparations of iron in anemias. (a) Liquor Potassii Arsenitis (Z7. S.). Fowler's Solution. Contains arsenic trioxide and other ingredients. Used especially in the treatment of chorea. Dose. For chorea ascending doses are used. The initial dose is 3 min. (0.2 ce.) t. i. d. and the dose is increased at the rate of i min. (0.06 cc.) once daily until the limit of tolerance is reached. {b) ArseniTrioxidum {U.S.). Arsenic Trioxide. "White Arsenic." Dose. About ^V gr. (0.002 Gm.). Smaller amounts are contained in a variety of tonic pills. (c) Pilulae Ferri, Quininae, Strychninae, et Arseni Fortiores {N. F. 1Ç16). Stronger Pills of Iron, Quinine, Strychnine, and Arsenic. Each pill contains of arsenic trioxide Л gr. (0.0032 Gm.) and of reduced iron i gr. (0.065 Gm.).

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(d) Pilulae Ferii, Quininae, Strychninae, et Arseni Mites {N. F. IÇ16). Mild Pills of Iron, Quinine, Strychnine, and Arsenic. Each pill contains of arsenic trioxide Д gr. (0.0013 Gm.) and of reduced iron J gr. (0.045 Gm.). (e) Soda Cacodylas (U. S.). Sodium Cacodylate. Used especially for intramuscular injection in Anemia, page 149. Ampules containing various amounts are manufactured. Dose is gr. (0.32-0.065 Gm.). Larger doses may be tolerated. 3. Bitter Tonics Bitter tonics in common use include: (a) Tinctura Nucis Vomicae {U. S.). Tincture of Nux Vomica. (b) Timtura Gentianae Composita {U. S.). Tincture of Gentian. (c) Quininae Sulphas {U. SQuinine

Compound

Sulphate.

{d) Quassia (Z7. S.). Quassia. Used to increase appetite. They are generally prescribed in a mixture to be taken before meals; e.g., IJ Tr. Nux Vomica Tr. Gent. Comp D i s c e d water

ââSiv adsiv

Dose. One teaspoonful (4 cc.) in water t. i. d. before meals. 4. Tonics containing Hypophosphites Various formulae are found in the National Formulary. The choice depends chiefly upon personal preference. Action is vague but appetite and sense of well-being seem to be increased. Used in debiUty for a week at a time. Dose. One teaspoonful in water t. i. d. after meals.

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PRINCIPLES OF MEDICAL T R E A T M E N T

Note. Sodii thiosulphas (U.S.), "Hyposulphite of Soda," is used to combat poisoning by arsenicals (page 134) or by mercurials (page 136) and is useful in poisoning by certain other heavy metals. 5. Oleum Morrhuae (U. S.).

Cod Liver Oil

Action depends chiefly on abundant content of Fat Soluble Vitamine A, and partly upon nutritive properties of the oil itself. Taste unpleasant to most adults but not always to children. A flavored emulsion may be preferred. Used especially for ill-nourished children and in the treatment of rickets. Dose. One or two teaspoonfuls (4-8 cc.) once or twice daily for a child. Alcoholic Beverages (a) Spiritus Frumenti {U. S.).

Whisky.

(b) Spiritus Vini Vitis {U. S.). Brandy. Action. Transient stimulation followed by mild narcotic effect, with reduction of inhibition and of nervous tension. Small quantities taken with meals tend to favor digestion. Uses. T o improve appetite, to promote a sense of wellbeing, to relieve nervous tension and to favor sleep, for reflex stimulation or as a tonic food for elderly ill-nourished persons or in certain wasting diseases when other food cannot be taken in suflicient amount (pages 18 and 76). Dose for ordinary purposes is 2-3 ounces well diluted and taken with meals. For selected cases of wasting disease frequently repeated doses may be required. When the smell of alcohol remains on the breath for more than an hour the succeeding dose should be omitted. (c) Champagne is preferable when the stomach is irritable. id) Beer, Ale, and Porter. These tend to improve appetite and to promote increase of weight. They may be used as tonics for the ill-nourished. Dose. A glassful should be taken with meals once or twice daily.

MEDICATION

243

Stimulants 1. General Stimulants (a) Caßeinae Sodio-Benzoas Benzoate.

(U. S.).

Caffeine

Sodio-

Contains Caffeina (U. S.) and Sodii Benzoas (U. S.)· Action. Stimulant to central nervous system and thus acting on the respiration and circulation. Toxic Effects. Nervousness and insomnia. Dose by mouth 5 gr. (0.324 Gm.). Hypodermic dose 3 gr. (0.2 Gm.). (¿>) Hot Tea. Action is that of a hot drink (see below) plus that of caffeine. Toxic Effects. Those of caffeine and, in chronic cases of excess, there is obstinate constipation which is probably caused by tannic acid. Administration. When the stomach is disturbed tea should be sipped and no cream or sugar should be added. 2. Cardiac Stimulants (a) Strophanthinum (U. S.), page 224. (b) Cocainae Hydrochloridum (U. S.), page 16. 3. Powerful Vaso-constrictors (a) Pituitrin "S" (Parke, Davis & Co.). Preparation. Ampules for subcutaneous or intramuscular injection. Dose. Usually 8 min. (0.5 cc.) at first. This dose may be repeated every three or four hours and increased to 15 min. (r cc.) if required (N. N. R.). (b) Epinepkrina (U.S.). Epinephrine. "Adrenalin." Generally prepared in solution i : 1000. The effects on blood pressure are extremely rapid and so transient as to be of little value. The important use of epinephrine is in Asthma, p. 109.

244

PRINCIPLES OF MEDICAL T R E A T M E N T 4. Circulatory Stimulants

(a) Blood Transfusion. Action. Replaces losses of blood plasma or cells and refills the vessels when blood pressure is low and thus improves the circulation. Indications. Hemorrhage, severe secondary anemia, surgical shock. Dose. One pint (500 cc.) more or less. {b) Liquor Sodii Chloridi Physiologicus (U. S.). Normal Saline Solution. Action. B y refilling vessels and thus promoting return of blood to the heart. The effects in surgical shock are transient because the fluid rapidly leaves the vessels. Use. Very valuable in dehydration leading to circulatory weakness. Dose. One pint to one quart (500-1000 cc.). Inject very slowly intravenously and repeat in a few hours if needed. See Typhoid Fever, p. 43. (c) Glucosum (U. S.). Glucose or "Dextrose." Action is like that of normal saline solution but the fluid is retained longer in the vessels and it also has a nutritive effect. Administration. A pure preparation is required for intravenous injection. The use of Anhydrous D-Glucose (N. N. R.) is advised. Dose for intravenous injection is 250-300 cc. of 10 to 15 per cent of glucose dissolved in water. 5. Reflex Circulatory Stimulants These have a prompt but transitory effect on the circulation. They tend to raise blood pressure by vaso-constriction. (a) Spiritus Ammoniae Aromaticus {U.S.). Aromatic Spirit of Ammonia. Contains ammonia, ammonium carbonate, and volatile oils. Dose is one half to one teaspoonful (2-4 cc.) in one half to one glass of water.

MEDICATION

245

(b) Spiritus Aetkeris Compositus {N. F. IQ16). Compound Spirit of Ether. "Hoffmann's Anodyne." Used similarly. Dose is one teaspoonful (4 cc.) in water. (c) Ammonii Corbonas {U. S.). Ammonium Carbonate. This is the principal ingredient of "smelling salts." (d) Spiritus Frumenti (U. S.). Whisky. (e) Spiritus Vini Vitis (U. S.). Brandy. On account of their high content of alcohol doses of onehalf to one ounce taken by mouth undiluted produce vasoconstriction by irritating the gastric mucosa. A similar effect is produced by subcutaneous injection in the dose of 15 min. (i cc.). Injections are irritating and momentarily painful. (J) Spiritus Camphorae {U. S.). Spirits of Camphor. ig) Aether (U. S.)· Ether. Action. Like that of the foregoing when injected subcutaneously m the same dose. (Ä) A hot drink of almost anything has a marked stimulating effect on the circulation by virtue of its action on the mucous membrane of the stomach. Sedatives {a) Sodii Bromidum {U. S.). " Sodium Bromide." (b) Potassa Bromidum {U. S.). "Potassium Bromide." Action. Mildly sedative, lessens reflex excitability. Slightly irritating to the stomach. Toxic Effects. Vomiting, acne, coryza, and in large doses, somnolence. Used for nervousness, wakefulness, epilepsy, and to prevent or control alcoholic delirium. Prescribed in watery solution well diluted to be taken after meals and can be used by rectum in the same dosage. Dose. Usually 5-15 gr. (0.324-1 Gm.) t. i. d. A single dose taken at night acts too slowly to be efficient for producing sleep unless by suggestion. Much larger doses may be required for epüepsy and for alcoholic delirium.

24б

PRINCIPLES OF MEDICAL T R E A T M E N T

Note. When the larger doses are required it is, at least theoretically, preferable to prescribe the sodium salt because the potassium radical may perhaps act as a depressant to the circulation. (c) 'Tabloid: "Three Bromides, Effervescent" (Burroughs Wellcome & Co.) is a mixture of potassium, sodium, and ammonium bromide with a small quantity of an effervescing salt. A tabloid contains about 15 gr. of bromide and may not disturb a delicate digestion. {d) Codeinae Sulphas (U. S.). Described under Opium Derivatives, page 219. See also Bronchitis, page 78. Caution.

This is a habit-forming drug.

(e) Hypnotics are used for their sedative effects to prevent or to control alcoholic delirium. See Hypnotics, page 239· Urinary Antiseptic Methenamina {U. S.). Properties.

Methenamine.

Crystalline, readily soluble in water.

Excretion. Chiefly in the urine in the form of ammonia and formaldehyde, or unchanged. Action. When formaldehyde is set free it acts as a urinary antiseptic. This happens only in an acid urine. When the drug is excreted unchanged, it is ineffective. Toxic Effects. Renal irritation and hematuria, painful micturition, and pain in the region of the bladder. Indications. Especially useful in typhoid fever to prevent bacilluria and cystitis. It may act well in other cases of cystitis or pyehtis. Contraindications. Administered.

Acute nephritis.

In capsule or tablet after meals.

Dose is s - i o gr. (0.324-0.65 Gm.) t. i. d. with a full glass of water. When the urine is alkaline or neutral, sodium acid phosphate in the dose of 10 gr. (0.65 Gm.), or more if needed, should be prescribed to render its reaction acid; but this drug should not be administered with methenamine because they are incompatible (Bastedo).

MEDICATION

247

Emetics (a) Apomorpkinae Hydrochloridum {U. S.). "Apomorphine." Action as an emetic is very prompt and effective within a few minutes after subcutaneous injection and less promptly when taken by mouth. The action is central. In emetic doses apomorphine is a powerful sedative. Small doses have a mild sedative action and an expectorant effect. Toxic Eßect.

Ch-culatory disturbances.

Contraindications. weakness.

Circulatory disorders or physical

Used to empty the stomach in acute poisoning. Apomorphine is also of great value to calm acute alcoholics who threaten violence and to quiet hysterical patients. Dose. For a man of average size the emetic dose by hypodermic injection is about 5 gr. and for a woman about h gr. Caution. The drug must be rejected if it at once imparts an emerald-green color to 100 parts of distilled water when shaken with it in a test tube {U. S. X). (b) Fluidextractum Ipecacuanhae {U. S.). Ipecac.

Fluidextract of

Emetic dose about 15 min. (i cc.). (c) Household emetics, see Acute Indigestion, page 118. Antiseptics, Gargles, Washes, Ointments, and Powders I. Gargles (a) Liquor Antisepticus Alkalinus {N. F. 1Q16). Alkaline Antiseptic Solution. (δ) Liquor Sodii Boratis Compositus (N. F. içi6). Compound Solution of Sodium Borate. Dobell's Solution. Used as a cleansing gargle or mouth-wash. One or two tablespoonfuls can be added to one-half glass of warm or hot water.

248

PRINCIPLES OF MEDICAL TREATMENT

(c) Table Salt (Sodium chloride). Cooking Soda (Sodium bicarbonate). Used like the above in the strength of one-half teaspoonful to one-half glass of water. 2. Washes (a) "White

Wash"

(not official).

R Acidi carbolici Zinci oxidi Glycerinum Liquor caléis

3i

4 cc.

ââ 3i ââ 30 cc. ad Sviii ad 250 cc.

Sig. External use. Shake. on t. i. d. or as needed. Action.

or

Pour out a little and sop it

Mildly astringent, soothing, and antipruritic.

Used especially for dermatitis or to allay itching. (b) Lotio Nigra (N. F. içi6). curials, page 214.

" B l a c k Wash."

See Mer-

3. Ointments {a) Unguentum Zinci Oxidi (U. S.). Zinc Oxide Ointment. Action. Soothing, slightly astringent, and very mildly antiseptic. Used on dressings for minor skin lesions. (b) Unguentum Acidi ment. Action.

Borici

(U. S.).

Boric Acid Oint-

Mildly antiseptic.

Used on dressings for minor skin lesions. [c) Unguentum Hydrargyri Ammoniati (U. S.). curials, page 214.

See Mer-

4. Dusting Powder Ц Zinci oxidi Amylis

3iv or 15 Gm. 5iv or 120 Gm.

Action. Soothing and very mildly antiseptic. Used to allay irritation of the skin.

MEDICATION

249

Viruses, Vaccines, and Bacterial Extracts (a) Vaccinum Variole (U. S.). Smallpox Vaccine. Vaccine Virus. The living virus of cow-pox is used to produce cow-pox in man and thus to prevent smallpox by the production of active immunity. The virus should be fresh and a " take " or lesion of cow-pox is required to confer immunity. Administration, (i) Clean the skin with soap and water and then with ether. Antiseptics, if used, must be washed off lest they kill the virus. (2) When the skin has become dry apply the virus and scarify the skin under it very superficially through the drop of vaccine without causing bleeding. A needle or any sharp instrument will serve. (3) After scarification and after the virus has dried completely, cover the spot with a sterile pad and secure it with adhesive plaster. (4) When the inoculation has " t a k e n " the lesion should be bathed with antiseptics and dressed aseptically from time to time. Secondary infection and much pain can thus be avoided. Use. Every child should be vaccinated and every adult after the age of twenty-five should be revaccinated. Note. Virus is prepared by health departments nearly everywhere and is distributed free to physicians. (¿>) Antityphoid Vaccine (not official). Action. A killed culture of typhoid bacilli standardized by count and used to produce an active immunity against typhoid (page 38). In order to guard also against paratyphoid A and B, a mixed vaccine is advised. Administration. In general, three doses are given subcutaneously at intervals of a week or ten days as follows: 1,250 milUon; 2,500 million; and 2,500 million. The reaction is seldom severe, but there may be fever and malaise for twelve to twenty-four hours. The interval between injections should not be longer than ten days lest anaphylaxis result.

250

PRINCIPLES OF MEDICAL TREATMENT

Use. Inoculation is strongly recommended for persons who travel, for nurses, physicians, soldiers, and others who may be exposed to typhoid infection. Note. Prepared by health departments and pharmaceutical firms. (c) Tuberculin (not official). There are several kinds of tuberculin. Koch's old tuberculin is a glycerine extract of tubercle bacilli. Used for diagnostic tests and for treatment in selected cases of tuberculosis. ABBREVIATIONS U. и N. Br N. U.

S S. D. F N. R S. p. and t

United States Pharmacopoeia, X United States Dispensatory, 19th ed. National Formulary, 4th ed. 1916 British Pharmacopoeia, 1898 New and Nonofficial Remedies, 1925 United States patent and trademark

MEDICATION

RELATIVE

251

TABLES

WEIGHT Metric I Gm. 0.1 o.oi " 0.001 "

U. S. Apothecary 15.5 grains i.SS •iSS •oiSS

equals

Г ь т а в MEASURK I L I.О cc. O.I cc.

2 . 1 1 3 3 pints (approx. 2 pts.) 1 6 . 2 3 0 6 minims (approx. igmin.) 1 . 6 2 3 minims

equals

WEIGHT U. S. Apothecary 1 oz. I drachm 3 0 grs. IS " 10 " 5 " I gr. 1/4 " 1/6 " 1/8 " 1/30 " 1/60 " i/ioo "

equals и

tt и и и и и и и и а

Metric Gm. (approx. 3 0 Gm.) 31.10 " (roughly 4 Gm.) 3-88 и 1.94 ií 0.972 (approx. I Gm.) и 0.648 и 0.324 и о.об5 0 . 0 1 6 2 0 tí 0 . 0 1 0 8 0 и (approx. IO mgm.) 0.00810 и 0.00220 и 0.001I0 IÍ (approx. I mgm.) 0.00065 и

MEASURE I I 4 I 30 20 IS IO 5 I

pint fluidounce fluidrachms " minims " " " "

equals и и

tí tí tí tí tí tí

473.11 30. IS· 370 i.8s 1.23 0.92 0.61 0.30 0.06

cc. " " " (roughly 4 cc.) " " " (roughly I cc.) " " "

252

PRINCIPLES OF M E D I C A L

S Y M B O L S

A N D

W E I G H T S

TREATMENT

A B B R E V I A T I O N S A N D

METRIC

FOR

M E A S U R E S

WEIGHT

O n e K i l o g r a m * ( K g . ) equals in w e i g h t one liter of distilled w a t e r a t m a x i m u m density; i.e., a t 4 ° C . and 760 m m . pressure. I Kg. I.о Gm. 0.1 " o.or " 0.001 Gm.

equals " " " "

icxra Grams Gram (Gm.) Decigram (dg.) Centigram (eg.) Milligram (mg.)

METRIC FLUID

equals

I L I.о

cc.

O.I

"

MEASURE

I liter of 1000 cubic centimeters I cubic centimeter I/10 of a cubic centimeter

U . S . APOTHECARIES' OR T R O Y

I I I I

lb. 5 5 gr.

equals " " "

i I I I

WEIGHT

pound of 12 Troyounces Т г о у о ш с е of 8 drachms drachm of 60 Troy grains grain (0.065 Gm.)

BRITISH WEIGHTS AND

MEASURES

Metric

Imperial Measure I I I I

pint of 20 fluidounces fluidounce of 8 fluidrachms fluidrachm of 60 minims minim

Avoirdupois Weight I pound of 16 ovmces I ounce of 16 drachms I drachm, 27.34375 Troy grs.

equals " " "

567.93

cc.

28.39 3.54

" "

O.OS9

"

Metric equals

1 One avoirdupois pound equals 0.453592 K r . One Kilogram equals 2.204622 pounds.

453.59 Gm. 28.35

"

1.77

"

INDEX Abdominal distention, 4 4 , 1 9 4 . Acidosis, 160. Addison's Disease, 177. Adrenal cortex, 177. Adrenal glands, 177. Adrenalin, 1 7 7 , 178, 243. Agar, 125, 236. Alcoholic beverages, 242. A m y l n i t r i t e , 226. Analgesics, 238. Anaphylactic shock, 72. Anemia, 145, 187; diet, 147; blood transfusion, 149; splene c t o m y , 153. Angina pectoris, 11. Antipyretics, 238. Antiseptics, 247. Arsenic, 148. Arsphenamine, 10, 1 3 2 , 206. Arteriosclerosis, 174. Arteriosclerotic renal degenerat i o n , 33. Arthritis, 45, S7· Aspirin, 232. A s t h m a , 107. Bacterial extracts, 249. B a t h s , 28, 43. Bichloridol, 1.38. B i s m u t h , 136, 138, 237. Black wash, 214. B l a u d ' s pills, 239. Blood pressure, 19. Blood transfusion, 19, 23, 149, 244. B r a n d y , 8, 16, 242. Bromides, 245. Bronchiectasis, 79. Bronchitis, 77. Broncho-pneumonia, 6 j , 65, 77.

Calomel, 2 1 3 , 228. Calomel o i n t m e n t , 1 3 2 , 137. Calomel powder, 130. Cardiac disease, 3, s , 9, 184. Cascara sagrada, 235. Castor oil, 227. C a t h a r t i c s , 235. Cervical adenitis, 57. Chicken pox. See Varicella. Childhood, a c u t e infections of 49. "Chronic tubes," 71. Circulatory system, disorders of, 3, 19, 43· Cod liver oil, 242. C o m a , 160. Compound jalap powder, 227. Conjunctivitis, 62. Constipation, 44, 1 2 1 . Convalescence, 195. C. O. T . pills, 238. CoφUS l u t e u m e x t r a c t , 178. Coryza, 83. Croton oil, 227. D e h y d r a t i o n , 25. Diaphoretics, 235. Diabetes, 155, 186; coma, 160; complications, 1 6 1 ; diet, 157, 1 6 3 , 1 6 5 ; in childhood, 1 6 1 ; insulin, ISS. IS7. 158, 160, 163, 164; renal, 162. D i a r r h e a , 44, 1 1 9 , 120. Dick t e s t , 50. D i e t : in cardiac insufficiency, 8; in anemia, 147; in a s t h m a , m ; in constipation, 1 2 3 ; in diabetes, 1 5 7 , 1 6 3 , 1 6 5 ; i n g a s t r o intestinal disorders, 1 1 3 ; in lead poisoning, 142; in nephri-

254

INDEX

tis, 29; in typhoid, 39; Kareil, 8; Lenhartz, 117; Postoperative, 193. Digitalis, 6, 7, 10, II, 13, 14, 17, 148, 219. Diphtheria, 67; complications, 70. Diptheria Antitoxin, 69, 216. Diuresis, 6. Diuretics, 233, 234. Dobell's solution, 247. Dover's powder, 238. Drug lists, 206, 233. Dusting powder, 248. Edema, 24. Elaterin, 227. Emetics, 247. Endocarditis, 9, 45, 47, S8, 202. Endocrine disorders, 167. Enemata, 125, 191, 194. Enterocolitis, 62. Epinephrine, 243. Epsom Salts, 226. Fowler's solution, 149, 240. Gargles, 247. Gastric indigestion, acute, 116. Gastro-intestinal disorders, 113. Gaultheria, oil of, 232. Glomerulo-nephritis, 27. Glucose solution, 244. Goitre, 167. Gray powder, 138. Heart-block, 17. Hypertension, 14, 16, 31, 185. Hypnotics, 239. Hypodermoclysis, 192. Hypof unction, 172. Hyposulphite of Soda. See Sodium thiosulphate. Incubation periods: Diphtheria, 67; Measles, S9< Pertussis, 62; Scarlet fever, so; Syphilis, 127; Varicella, 66.

Indigestion, 116. Infectious Diseases, 37. Influenza, 85, 87. Insulin, i s s , 157. iS8, 160, 163, 164, 233. Intestinal astringents, 237. Iodides, 78, 136, 214. Iodine, 168, 174. Iron, 148. Jalap powder, 227. Kaolin, 147. Karell diet, 8. Kidney, passive congestion of, 34· Laryngitis, 61, 84. Laxatives, 235. Lead poisoning, 141. Leeching, 7. Lenhartz diet, 117. Lobar Pneumonia, 75. Lugol's solution, 170. Magnesium sulphate, 226. Mastoiditis, 56. Measles, 59. Medication, 205. Mercurials, 136, 211. Methenamine, 246. Morphine, 6, 8, 14, 45, 189, 217 Neoarsphenamine, 136, 210. Nephritis, 27, 58, 185. Nitrites, 225. Nitroglycerin, 225. Noma, 62. Normal saline solution, 244 Ointments, 248. Opium, 183, 217. Otitis media, 56. Ouabain, 224. Ovarian extract, 178. Ovarian residue, 178. Ovaries, 178.

INDEX Pericarditis, 1 7 , 5 8 . Peristalsis, 4 5 , 1 2 1 . Pertussis, 6 2 , 2 0 4 . Pharyngitis, 8 2 . Phenacetin, 4 4 , 2 3 8 . Pilocarpine, 2 3 5 . Pituitary extracts, 175. Pituitary gland, 1 7 4 . Pituitrin, 1 7 6 , iQS, 2 4 3 . Pneumonia; lobar, 7 5 ; broncho, 77Postoperative diet, 193. Postoperative medical treatment, 189. Potassium Iodide, 1 6 8 . Preoperative Medical Treatment, 182. Prophylactic Inmiunization, 1 9 9 . Pulmonary edema, 1 6 , 2 4 . Pulmonary tuberculosis, 8 9 . Purgatives, 2 2 6 . Quinidine sulphate, 7 , 2 2 4 . Quinine, 2 2 8 . Renal Diabetes, 1 6 2 . Renal irritation, acute, 3 3 . Respiratory Infections, 1 8 8 . Respiratory tract, acute infections of, 75Respiratory tract, upper, acute inflammation of, 8 0 ; complications, 8r. Rheumatic fever, 4 5 . Rhinitis, 6 1 . Russian oil, 2 3 6 . Salicin, 2 3 2 . Salicylates, 2 3 0 . Saline solution, 2 3 , 2 4 4 . Scarlet fever, 4 9 . Scarlet fever antitoxin, 5 3 . Schick test, 68. Sedatives, 2 4 s · Senna, 1 2 5 , 2 3 5 . Smallpox vaccine, 2 4 9 . Sodium iodide, 1 6 8 .

2SS

Sodium nitrite, 2 2 6 . Sodium thiosulphate, 1 3 4 , 2 0 9 , 210, 211, 242. Splenectomy, tS3. Stimulants, 2 4 3 . Stomatitis, 6 2 . Strophanthin, 2 2 4 . Strophanthus, 2 2 3 . Sweating, 2 8 , 3 S . Syphilis, 1 0 , 1 2 7 , 1 8 8 ; congenital, 1 3 г . Syphilitic angina, 1 2 . Syphilitic nephritis, 3 2 . Tapping, 7· Testes, 1 8 0 . Theobromine, 2 3 3 . Theophylline, 2 3 4 . Thyroid extract, 1 6 8 , 1 7 3 , 174, 233· Thyroid gland, 1 6 7 . Thyrotoxicosis, 1 6 9 . Thyroxin, 1 6 8 , 1 7 3 , 2 3 3 . Tonics, 2 3 9 . Tonsillitis, 8 3 . Toxemia: in diphtheria, 6 9 ; in measles, 6 1 ; in scarlet fever, 5 4 ; in typhoid fever, 4 2 ; in varicella, 6 6 ; in thyrotoxicosis, 1 7 2 . Toxemic edema, 2 4 . Toxemic shock, 2 2 . Toxic nephritides, 3 2 . Tracheitis, 6 1 , 8 4 . Transfusion, 1 9 , 2 3 , 1 4 9 , 2 4 4 . Trianol, 2 3 9 . Tuberculosis: complications, go; in children, 1 0 3 ; non-pulmonary, 1 0 4 ; pulmonary, 8 9 ; treatment, 9 3 . Typhoid fever, 3 7 . Urinary antiseptic, 2 4 6 . Uremia, 3 4 . Vaccines, 2 4 9 . Vaccine therapy, 1 9 9 ; in asthma, 1 1 2 , 2 0 4 ; in boils and car-

256

INDEX

hundes, 202; in acne, 203; in chronic bronchitis, 203; in chronic diseases of the respiratory tract, 203, 204; in common colds, 201; in endocarditis, 202; in lung abscess, 203; in osteomyelitis, 204; in pertussis 64, 201, 204; in pyelitis, 204; in smallprax, 24g; in typhoid fever, 199 249; prophylactic immunization, 19g. Vascular relaxation 22. Varicella 65. Venesection, 6, 24, 36.

Veronal, 239. Viruses, 249. Washes, 248. Weights and Measures, 251. Whisky, 16, 242. Whooping Cough. See Pertussis. Wintergreen, oil of, 232. X - r a y Treatment : in Asthma, 112; in Anemia, 149; in Pertussis, 6s; in Thyrotoxicosis, 170.