respiratory movements and soon derive real comfort from his
sojourn in the cabinet. The modus operandi of this inhaling from
without and exhaling into the cabinet is as follows : The patient
holds the nose-mask in place with his hand ; he takes his first inspi-
ration while the physician begins to manipulate the lever. Dur-
ing the first expiration the patient removes the nose-mask. The
operator, while continuing with one hand to manipulate the lever,
places the palm of his other hand tightly over the funnel of the faucet
during the patient's expiratory movement, and thus there is an
almost perfect occlusion, and little if any outside air can enter the
cabinet. With a little practice these manipulations enable the
patient to breathe with ease and comfort, and gradually he loses
his distressing symptom to a considerable degree. At first, expira-
tion through the mouth may be permitted, so as to give the patient
rapid relief with the least possible exertion.
Respiratory exercises are also of great value in emphysema of
the lungs. They must, however, be differently executed from those
I have recommended as prophylactic and curative measures in
simple pulmonary tuberculosis. There should be more abdominal
breathing; instead of the inspiratory the expiratory act should be
prolonged, and particular attention should be paid to the second
expiratory effort. During the inspiration a considerable pressure
with the palms of the hands should be exerted over the chest, and
holding the breath after the inspiration should be omitted. Of
course, all such patients must also be especially careful regarding
overexertion. Walks taken with judgment and care on gradated
paths of various inclinations are, however, to be recommended.
Too long and animated conversation should be avoided. The diet
of these patients should be superintended with particular care, and
all such food as beans, peas, cabbage, etc., which tends to distend
the intestines and push up the diaphragm, should be strictly for-
bidden. With emphysematous patients the so-called suralimenta-
tion, or overfeeding, should only be carried on gradually, since, as
a rule, they feel uncomfortable when they gain flesh and adipose
tissue too rapidly. Too voluminous meals are especially contra-
indicated. They often cause veritable distress to the patient. The
266 PULMONARY TUBERCULOSIS,
proper way of feeding this class of pulmonary invalids is in small
but more frequent meals, avoiding taking too much liquid.
Insomnia. Insomnia in tuberculous patients is an important symptom, and
when confronted with it one should not rashly resort to the hyp-
notics of the pharmacopoeia. In phthisical patients insom.nia may be
due to irritating cough, to pyrexia, to digestive trouble, or it may
be a purely nervous manifestation. The therapeutics of fever and
cough have been sufficiently dealt with in the preceding pages,
and, as a dietetic means of preventing insomnia, I only desire to
suggest that the patient's last meal before retiring should be light
and very digestible. Tea and coffee should be strictly forbidden.
As a sleep-inducing dish before retiring, buttermilk is most highly to
be recommended ; kephir and koumiss may take its place. The nerv-
ous insomnia of phthisical patients is less frequent in sanatoria than
anywhere else, for there the open-air treatment is more systematic-
ally carried out. Nothing is more conducive to sleep than remain-
ing out-of-doors. If the patient is able to add a moderate amount
of physical exercise to his rest cure, he will be almost certain of a
good night's rest. Of course, regularity in his hours of retiring
and rising will be essential. Absolute quiet should, as much as
possible, be assured within and in the vicinity of the consumptive's
bedroom. The bed should be comfortable, not too soft, not too
warm, and, of course, the room well ventilated. For the average
patient the temperature of the bedroom in winter should be about
60° F. Whether to sleep on his right or left side, or on his
back, is a matter of choice and habit. The only thing which I rec-
ommend my patients in this respect is to accustom themselves to
sleep with as low a head-rest as possible. Feather-beds as covers
should be banished from the bedroom as unsanitary.
As hydrotherapeutic means to induce sleep we must again men-
tion the wet-pack with or without the shoulder-pieces, as described
on page 254. Bathing the face with cool water or lightly spong-
ing off the whole body is sleep-inducing. Also the vigorous
friction of the feet with a rough towel soaked in cold water, or the
" effleurage," — that is to say, gentle strokes with the palm of the
hand from the neck downward and over the spinal column, — may
produce the desired effect. General massage should only be
applied early in the morning or during the day; the same rule
should hold good with the light gymnastics, which may at times
be permitted in early cases. All these more or less energetic
SYMPTOMATIC TREATMENT OF PULMONARY TUBERCULOSIS. 267
exercises are just as much conducive to sleep, and in fact more so,
when done in the morning or in the afternoon than when done in
the evening; thus, the exciting effect of the exercises will have
passed away by bed-time, and only the desired feeling of fatigue
needed for sleep remains.
Rose,^ in the " Zeitschrift fiir Krankenpflege " of July, 1898,
recommends, as a physical means of producing sleep, energetic and
frequently repeated opening and closing of the eyelids ; but this
seems to be effective only in the very mildest cases of insomnia.
In the following number of the same journal, Buxbaum ^ recom-
mends auto-suggestion in insomnia with all patients inclined to
neurasthenia — in other words, he tells the patient not to fear
insomnia, but to go to bed with the firm determination to sleep.
The medicinal hypnotics, which must be resorted to in extreme
cases, are morphine and chloral. Morphine injected hypoderm-
ically, and chloral by rectum, in the smallest possible doses, will
prevent digestive disturbances apt to arise from the administration
of these drugs by the mouth. While I desire to repeat that sleep-
producing drugs should only be administered in pulmonary tuber-
culosis after all physical means, single or combined, have failed, I
would only apply this rule to cases where a cure or decided
improvement may be looked for with reasonable certainty.
Phthisical patients in the last stages of the disease, suffering from
insomnia or pain, should be made comfortable even at the price of
making them depend, toward the end of their lives, upon the
administration of larger doses of morphine than would be advis-
able under ordinary circumstances,
^ Rose, Arthur, " ijber nicht-medikamentose Schlafmittel," "Zeitschrift fiir Kran-
kenpflege," vol. XX, No. 7.
2 Buxbaum B., " Die Krankenpflege der Sclilaflosigkeit."
CHAPTER XVIII.
Hygiene
and medi-
cal treat-
ment in
laryngeal
tubercu-
losis.
LARYNGEAL TUBERCULOSIS AND INTERCURRENT
DISEASES.
Laryngeal tuberculosis must be treated locally and generally.
The vocal organs should be given absolute rest, and the patient
should avoid all exciting occupations which will make him talk
in spite of his best resolutions, and, of course, he should avoid
strong winds, heavy fogs, sudden temperature changes, and all
places where dust is raised or irritating odors fill the air and cause
coughing spells. For such patients the selection of a warm, moist
climate is recommendable (warm sea-coasts), for they really suffer in
cold and dry regions. As a rule, higher altitudes are less suitable
for them. The throat should be protected so as to keep that
portion moderately warm. Schmidt^ insists that the covering
around the neck should always be loose.
The diet for patients suffering from laryngeal tuberculosis need
not differ materially from that prescribed for the pulmonary
invalid. Of course, hard substances, such as bread-crusts and dry
toast, should be avoided ; also much seasoning, as through their
ingestion irritation and pain may ensue. For painful deglutition,
weak codeine or, better yet, cocaine application before meals should
be made. A tablet of 2^ of a grain of hydrochlorate of cocaine
placed on the back of the tongue is a good way of administering the
cocaine, since the patient can do this himself without any danger.
At times hot inhalation, with the aid of a steam atomizer, gives a
decided relief These steam sprays can be medicated according
to the indication with astringent balsamic, disinfectant, or analgesic
substances. A simple cold spray or the external application of
cold in form of ice-cravats or cold-water compresses seems also
to be beneficial in many cases. Intratracheal injections of guaiacol,
menthol, and olive oil, as described on page 252, for persistent
cough in pulmonary tuberculosis are well adapted to the treatment
of this distressing symptom in laryngeal tuberculosis.
^ Schmidt, M., " Die Krankheiten der oberen Luftwege," Berlin, 1894.
268
LARYNGEAL TUBERCULOSIS AND INTERCURRENT DISEASES. 269
Aerotherapy, of course, must not be neglected in such cases.
Breathing exercises should be instituted in this disease as well as
in pulmonary tuberculosis. They should be taken judiciously,
according to the strength of the patient. The milder the air these
patients breathe, the better they will feel. My modification of the
pneumatic-cabinet treatment, described on page 222, will permit
the sufferer from laryngeal tuberculosis to enjoy the benefit of this
valuable adjuvant in aerotherapeutics just as well as the sufferer
from pulmonary consumption. By breathing through the nose
with the aid of the adjustable mask instead of through the mouth-
tube, the air is warmed sufficiently to cause no irritation whatso-
ever, and the increased air-supply thus entering the respiratory
organs has its beneficial effect.
As a curative measure the lactic-acid application, varying in Lactic
strength from ten to seventy-five per cent., has thus far been most .
universally used. The most frequent way of applying this acid is
directly upon the tubercles or ulcerated surfaces. It may, how-
ever, be also injected under the mucous membrane. At times,
surgical interference is inevitable, and every large institution de- surgical
voted to the treatment of tuberculous patients should not be™^^^""^^^
without its competent laryngologist.
The removal of tuberculous growth in the larynx by means of
curettage seems to be indicated in a certain number of cases.
Gleitsmann,^ in his excellent report to the Section on Laryngology
and Rhinology of the Twelfth International Medical Congress at
Moscow, has promulgated the following indications and contra-
indications of the curette in laryngeal tuberculosis :
Indications :
1. In cases of primary tuberculous affections without pulmonary
complications.
2. In cases with circumscribed ulcerations and infiltrations of
the larynx.
3. In cases with dense, hard infiltrations of the arytenoid region
of the posterior wall, also of the ventricular bands and tubercu-
lous tumors of the epiglottis.
4. In the incipient stage of pulmonary disease with but little
fever and no hectic symptoms.
5. In advanced pulmonary disease with distressing dysphagia
1 Gleitsmann, J. W., "Medical Record," Dec. 4, 1897.
2/0 PULMONARY TUBERCULOSIS.
resulting from infiltration of the arytenoids, as the quickest means
of giving relief.
Contra-indications :
1. Advanced pulmonary disease and hectic.
2. Disseminated tuberculosis of the larynx.
3. Extensive infiltrations producing severe stenosis when trache-
otomy is indicated or laryngotomy can be taken into considera-
tion.
Gieitsmann, as well as Heryng, does not advise the operation in
timid, distrustful patients lacking the necessary nerve-power, and
both prefer to operate on the patient in a hospital, where he is under
absolute control and the after-treatm.ent can be carried out more
satisfactorily.
For the operation of curettage various instruments have been
devised, such as Krause's curettes, Gougenheim's " emporte piece,"
and Heryng's rotary double curette. The last one mentioned is
given the preference by Gieitsmann because it enables the operator
to remove a greater amount of tissue.
Obesity in Occasionally we meet a consumptive with more adipose tissue
patients, than is good for him, and in such cases a fatty degeneration of the
heart is to be feared. Extreme dyspnoea and feeble heart-action are
frequently the alarming symptoms. To attempt to reduce their
fat by such diet as prescribed by Ebstein, Harvey, or Schweninger
would be dangerous. The dieting must be done much more gradu-
ally, and, while it is essential to relieve the heart from its too fatty
environment, such patients should not lose more than about two
pounds in the course of one month. Moderate exercise and mas-
sage will aid in replacing the adipose tissue by muscular tissue.
Bronchitis. Brouchitis must be treated first prophylactically by the aero- and
hydro-therapeutic measures described in the chapter on prophy-
lactic treatment. The inhalation of impure, dusty, or irritating
atmosphere is productive of bronchitis, especially in consumptives
whose point of least resistance lies in the respiratory tract. An
unobstructed nasal breathing is one of the essential conditions to
avoid bronchial catarrhs.
The use of opium is certainly a valuable remedy to abort an
attack of bronchitis. Charbonneau says a full dose of Dover's
powder will frequently abort an attack. Osier is of the same
opinion, saying that no remedy can take its place. English ^
1 "Therapeutic Hints," "Medical Record," Jan. 14, 1899.
LARYNGEAL TUBERCULOSIS AND INTERCURRENT DISEASES. 2/1
explains the therapeutic action of opium in such cases when given
in full doses as follows : " Reaction of irritability, congestion, or
inflammatory activity. Alteration in the character and limitation
of the amount of the secretion. Increase in the general comfort
by relief of pain and soreness, and removal of cough and inci-
dental insomnia."
Counter-irritants, as mustard plasters or dry cupping, are good
local remedies. The inhalation of thymol (one grain to one ounce
of liquid albolene) or other antiseptic or balsamic preparations is
also useful. As antipyretic in an acute bronchitis I give quinine
the preference.
If the cold-pack — that is, cold-water compresses — is applied, it
should be done as described on page 254 for excessive hyperhi-
drosis. Care should be taken in removing the compresses, so as
not to have the patient take a new cold. It is prudent to remove •
the wet-pack under the bed-cover, and rub the chest dry with a
somewhat rough towel, and follow this by a vigorous friction with
alcohol. As a cough-mixture I use one of those given on page
252. Of course, any other expectorant may answer as well.
Pleurisy may manifest itself in a consumptive as a concomitant Pleurisy,
or an intercurrent disease. The acute forms, arising as a new
complication, must, of course, be treated by rest in bed. If there
is a large exudate, absolute quiet before as well as after thoracen-
tesis must be insisted upon. If there is but a small amount of
liquid in the chest, dry cupping and mustard applications often
suffice to aid absorption. Judiciously directed respiratory exercises
are also of value, especially in the subacute and chronic form if
there is no intense pain. To relieve the sometimes acute suffering
from intercostal or pleuritic pains, cold applications are indicated;
if they are not well borne warm poultices may be substituted. Of
medicinal substances opiates are at times indispensable. Diuretics,
such as potassium acetate, digitalis, scillse, etc., may be indicated.
The patient's strength must be kept up by tonics. Of the value
of lateral douches and the respiratory exercises, to aid the absorp-
tion of fibrinous adhesion, the residual of long-standing pleuritic
inflammation, we have already spoken in the respective chapters.
If the pleuritic exudate becomes purulent (empyema), the case
belongs to the domain of surgery. In the speedy and thorough
evacuation of the pus lies the only hope for the recovery of the
patient.
2/2 PULMONARY TUBERCULOSIS.
Pneumonia. Pncumonia, which in consumptives is usually of the lobular kind,
must, when arising in the course of pulmonary phthisis, be treated
as in any other patient. Rest in bed, careful antipyretic medication
(quinine or lukewarm-water baths), and, above all, remedies to keep
up the proper heart-action — digitalis, alcohol, etc. — are essential.
Professor A. Jacobi counsels to give, from the very onset, two drops
every four hours of the fluid extract of digitalis (Squibb's), thus
strengthening the heart, and by its cumulative effect putting the
heart in a condition of defense at the most critical stage of the dis-
ease. Counter-irritation over the whole of the chest renders also
great service. The administration of ammonium carbonate and
ammonium iodide will aid materially in the removal of the in-
flammatory products during the stage of ulceration. Professor E. G.
Janeway's method of putting the pneumonia patient on a milk
diet has rendered me excellent services on various occasions.
In all cases the diet should be in liquid form, not too concen-
trated, and water should be given freely. For severe pains, care-
fully administered doses of morphia (hypodermically over the seat
of pain) are the best analgesic.
Pneumo- Pneumothorax, during the course of pulmonary tuberculosis, is
most frequently the result of some sudden physical overexertion
or traumatism, such as jumping, running, rapid mounting, loud
singing, or a sudden blow against the chest. Again, a violent
coughing spell may be the cause. It is most important to prevent
such accidents. However, patients cannot always control their
coughs, and a pneumothorax may occasionally develop in a con-
sumptive without any apparent traumatic origin. As in pneu-
monia, rest in bed is essential. Liquid diet and stimulants of all
kinds are strongly indicated. Leyden,^ of Berlin, favors "gavage"
in such cases. Locally, the cold-water compresses or ice-bags
often give relief.
Pulmonary Pulmonary gangrene, which is one of the distressing inter-
gangrene. 111 1-1 r ^
current troubles that may appear durmg the course oi pulmonary
tuberculosis, should be treated vigorously by tonics (digitalis,
caffeine, alcohol, etc.). Jaccoud recommends to give the patient
from eight to ten grains of salicylic acid a day. As antiseptic
inhalation a few teaspoonfuls of the essence of turpentine poured
into hot water is to be recommended (Trousseau). The vapor of a
^ Leyden, " Tjber Pneumothorax tuberculosis," " Deutsche medizinische Wochen-
schrift," l888.
LARYNGEAL TUBERCULOSIS AND INTERCURRENT DISEASES. 2/3
five per cent, solution of carbolic acid can also be used for the
same purpose. If there are several foci, medicinal treatment is all
that is possible ; but if the gangrene is circumscribed and this treat-
ment is ineffectual, pneumotomy and drainage are indicated. The
part of the lung involved has been resected in some cases with
satisfactory results.
Pulmonary phthisis complicated by diabetes or diabetes com- Diabetes.
plicated by pulmonary tuberculosis, of course, needs special atten-
tion. Von Noorden, who is to-day considered the greatest authority
on diabetes, having studied the subject perhaps more thoroughly
than anybody else, summarizes in the " Twentieth Century Prac-
tice of Medicine"^ by saying, "This complication should not
cause any relaxation in the carrying out of the suitable dietetic
principles (of diabetes), but rather demands greater strictness and
especially the greatest possible increase in the amount of fatty .
food, with the addition of considerable quantities of alcohol. It is
advisable that the patients should reside in places wherethe climate
is mild, rather than in those lying in high elevations, where the air
is raw, and treatment in a sanatorium is preferable to a stay in
one's own home or in a hotel. Certain hydrotherapeutic measures
of a mild character may be cautiously instituted ; diabetics with
phthisis are individuals demanding the greatest protection against
injurious influences." My only objection to this excellent sum-
mary would be that too considerable quantities of alcohol are not
always well borne by these patients. Whenever I give alcohol, I
prefer to administer it at meal-times, in the form of light white
wines. The main point, in such cases, is to strive to maintain the
strength of the patient by a judicious suralimentation with the
exclusion of sugar, sweetmeats, pastry, preserves, sweet jellies,
macaroni, peas, beans, etc. A small amount of bread and pota-
toes should be occasionally allowed.
While pityriasis versicolor (tinea versicolor, pityriasis of Eich- Pityriasis,
stedt) can hardly, in the light of modern research, be considered
symptomatic of pulmonary phthisis, it is, nevertheless, met with
frequently enough in phthisical patients to merit some considera-
tion here. It is most usually found in patients whose skin has not
received proper hygiene. The disease is due to a vegetable para-
site (microsporon furfur); the eruption is superficial, of yellowish or
1 " Twentieth Century Practice," vol. ii, " Diabetes Meliitus."
i8
2/4 PULMONARY TUBERCULOSIS.
reddish color, and the itching sensation is most intense when the
patient gets overheated. It is usually located over the sternum ;
sometimes, however, scattered over the front of the chest and the
back. The edges of the patches are rounded and somewhat
elevated.
The treatment consists in first removing these patches by warm
baths with soap, preferably sapo viridis, and then applying the
antiparasitic remedy. As an antiparasitic the pure ichthyol has
given me much satisfaction in such cases. After having bathed the
affected parts as above described I apply a good coat of the ichthyol
overnight, removing it in the morning by the aid of a weak solu-
tion of bichloride (i : 5000 to i : 10,000). Other applications, such
as salicylic, carbol, or resorcin salves, will also rarely fail to destroy
the parasite. One precaution must be insisted upon, otherwise the
trouble is sure to recur : that is, the thorough boiling and disinfect-
ing of the patient's underwear.
Miliary Acutc miliary tuberculosis can, in the present state of our knowl-
losis. edge, be treated only symptomatically. A remedy which I have
seen do excellent service, and under which I observed a few appar-
ent recoveries, is tannic acid, administered in large doses of from
ten to fifteen grains three or four times daily.
At times, in a patient suffering from pulmonary tuberculosis,
even in the earlier stages, there will be found manifestations of
Joint-tuber- local tubcrculosis in the joints, testicles, etc. I do not intend here
culosis. -" ' '
to treat the subject from a surgical point of view, but only to indi-
cate the newer methods of treatment applicable to the earlier stages
of joint tuberculosis. Bier's method of treatment by local venous
hyperaemia^ I saw applied for the first time two years ago in the
service of Dr. Torek, at the New York Post-Graduate Clinic, with
most satisfactory results in several cases of tuberculosis of wrist-
and knee-joints. This method consists of ligating the member
above the affected joint by an elastic band of medium width. This
is done several times a day for a period varying from ten minutes
to one hour at the beginning and increasing the duration of time,
according to the patient's susceptibility and power to endure the
pain and tickling sensation produced by the coiistricting band, up
to four or six hours, or even a whole night. The band is applied
1 Bier, " Heilwirkung der Hyperamie," " Miinchener med. Wochenschrift," 1897,
No. .:!2.
LARYNGEAL TUBERCULOSIS AND INTERCURRENT DISEASES. 2/5
only tight enough to impede the venous circulation, and if the pain
becomes too intense the band must be removed. It is essential to
see that the constricting band does not produce anaemia, but hyper-
aemia and swelling. To protect the skin it is advisable to envelop
the part first by a band of linen or other soft material, and also to
change the place for ligation at successive applications. The cura-
tive principle of this method seems to lie in the fact that the locally
increased carbonic-acid gas, and, perhaps, also an increased phago-
cytosis, both attack the micro-organisms. Dr. Torek also had a
case of advanced tuberculous disease of the testicle treated by the