saturated with ice-water, by the employment of a lead coil through which ice-water slowly flows, and by the use of the ice-bag. The objection to the first method consists of the almost incessant changing of the cloths, to which the nurse must devote practically her entire time. The chest of the patient is constantly exposed throughout the period during which this method is practised. While perhaps of some value at the time of copious hemorrhage, its practical utility is open to serious doubt at a later period. On account of the unceasing active attendance required, and the incidental manipulation of the patient, it is extremely unlikely that this practice possesses any decided superiority over the use of the ice-bag.

The employment of the lead coil is also attended by some disadvantages. Its weight is sometimes quite objectionable, as is also the necessity of frequent attention to the flow of water. Upon the whole, no special advantages are secured to compensate for the added inconvenience. On the contrary, it is probable that for the average case the inferiority of this method is beyond dispute. Its efficiency has been markedly less in my own experience, than has been reported by others. Considerable difficulty is met in maintaining a close apposition of the coil to the chest wall, on account of the rigidity of the leaden tubes. Failure to secure juxtaposition of coil and soft parts is particularly noticeable among emaciated individuals with shrunken rib-spaces. Under these circumstances, the non-flexible tubes are found to rest here and there upon elevated ribs without sufficient coaptation to the skin to secure practical efficiency. Some of the disadvantages incident to the lead coil are obviated by using a coil of rubber tubing.

All these objections are removed by the intelligent employment of the ice-bag. It is not unduly heavy, as it need not be completely filled with ice. Its use is attended by comparatively no inconvenience, and the cold is applied to the skin without the need of unremitting attention, the patient being quite undisturbed by the ice-bag. Necrosis of the soft parts may be prevented by the intervention of protecting gauze between the bag and the skin. It is, of course, essential that the ice be replenished at not infrequent intervals, as the presence of a rubber bag containing water is not conducive to the best results. Further, the position of the ice-bag upon the abdomen where, owing to the carelessness of the nurse, it too often is found, is not in accord with the principles of its employment. In the same way its application over the lung, from which bleeding does not ensue, is unlikely to exert any direct influence against the recurrence of hemorrhage. Erroneous conclusions as to the particular lung from which the loss of blood takes place are far more frequent than might be supposed. In case both lungs are involved, it is not always easy to differentiate by the physical signs, the unilateral origin of the hemorrhage, nor is it wise in general to examine the chest at this time. If one lung is but slightly diseased and the other unaffected, difficulty in determining the precise area of tuberculous infection is sometimes encountered by inexperienced examiners. I have under observation a patient recently sent to Colorado following a series of small hemorrhages, which occurred during a period of two weeks. Throughout this entire time an ice-bag was kept upon the anterior chest wall of the sound lung, the signs at the other apex having been sufficiently obscure to escape detection. The application of the ice-bag over the heart is often of signal

value, particularly in case of marked arterial excitement. In some cases greater importance may be attached to the position of the ice-bag over the cardiac area, than over the supposed site of pulmonary hemorrhage.

Constriction of the chest by means of tight strapping with rubber adhesive plaster constitutes a not uncommon procedure. As usually employed, overlapping strips are drawn tightly from sternum to spine. over the side corresponding to the lung from which the hemorrhage is supposed to take place. The principle invoked is the restriction of respiratory movements as far as possible upon the affected side. This curtailment of function is in part compensated for by the supplemental exaggerated function of the other lung. It is at once apparent that, in addition to the impropriety of subjecting the patient at such a time to a physical exploration of the chest, an error in differentiating the site of hemorrhage must be singularly unfortunate in that the sound lung would become crippled in efficiency, while a greater burden would be imposed upon the damaged lung of the unrestricted side. It is not entirely clear that the important underlying principle should be an effort to minimize the use of the affected lung, but rather to reduce the depth of the respiratory excursion upon both sides. Equally good results seem to be obtained through the constriction of the entire chest by a single broad strip of rubber adhesive plaster, tightly encircling the ribs below the nipple. A very considerable advantage of this simple procedure is the ease with which the constricting band is applied without appreciable disturbance of the patient. In sharp contrast is the difficulty experienced in applying tightly overlapping unilateral straps, as in this event the patient must be turned upon the side and the traction distributed to less advantage. For the same reason, the employment of ingeniously devised traction plasters designed to restrict powerfully the movements of one side, or to compress pulmonary cavities, are not always of practical value in cases of pulmonary hemorrhage, on account of the difficulties of their intelligent application without undue disturbance of the invalid. If the indications are sufficiently urgent to point to the advisability of retarding the respiratory movements at all, the prime desideratum should be the production of restriction in the simplest possible manner. This is secured with perfect ease by the use of a broad incircling strap of rubber adhesive plaster.

Ligation of the extremities has proved exceedingly effective in the control of alarming pulmonary hemorrhage. While some clinicians have been led to doubt its utility, my own experience has been strongly confirmatory of the claims presented by its early advocates. The method is not to be recommended save in the presence of rather copious hemorrhages, with tendency to frequent recurrence. The ligature should be applied around the limb not far from the trunk, and should be sufficiently tight to compress the veins but not the arterial vessels. The principle involved is the reduction of blood volume in the lung, as a result of preventing the return of the venous circulation in the extremities. Coldness or cyanosis of the hands or feet must, of course, be avoided. In desperate cases it has been my custom to keep the ligature closely applied for much longer periods than usually advisedin some instances for an entire day-without disagreeable result. It is very important that the bandages be removed with the utmost caution, it being urged that they be gently loosened one at a time,

with intervening periods of not less than one-half hour. I recall an illustrative incident, occurring many years ago, when in attendance, throughout an entire night, upon a patient suffering from repeated terrifying hemorrhages during the temporary absence of the attending physician. Ligatures were placed upon all four extremities close to the body and the loss of blood eventually controlled through their influence. The following morning, upon the arrival of the physician in charge, all the ligatures were quickly removed, with an immediate resulting deluge of blood from the mouth of the patient, and instantaneous death.

CHAPTER XCVIII

GENERAL DRUG THERAPY

THE routine administration of drugs to pulmonary invalids, which has been so largely in vogue for many years, has been the immediate cause of an untold amount of harm. The adoption of this pernicious practice in the treatment of all classes, regardless of the character of the remedy or existence of special indications, has been responsible for two conspicuous evils-the directly injurious effect upon the digestive functions, and the enormous loss of time and opportunity suffered by consumptives in seeking hygienic, dietetic, and climatic advantages. No words of condemnation concerning the indiscriminate and ignorant employment of drugs can too strongly stamp the disapproval of the profession. There can be no dissenting opinion that the general practitioner should be encouraged to utilize to a far greater extent the facilities for recovery offered by superalimentation, rest, outdoor living, and climate. Furthermore, he should be urged to discard the conventional exhibition of cough syrups, tonics, hypophosphites, malt preparations, and emulsions with which the market is surfeited. Upon the other hand, there should be condemned with equal emphasis the prevailing tendency to decry the administration of any drug whatever, irrespective of its nature and the exigency of the demand. Some specialists in tuberculosis have denied in toto the value of medication for almost any aspect of the disease. The former tendency toward the administration of drugs to the exclusion of rational measures has given way to such a reversal of sentiment that the use of important remedies to meet urgent symptomatic indications is often met with strenuous objections. To such an extent have the susceptibilities of general practitioners and patients been played upon regarding the supposed disadvantages of all medicine for the consumptive, that an unreasoning prejudice against its employment has become a popular fad. Thus, unnecessary embarrassment is occasioned to the resourceful physician, who seeks to utilize the beneficial effects of judicious medication, in order to control untoward symptoms.

Without desire to condone the ignorance responsible for indiscriminate dosage, the conviction is sustained by practical experience, that an intelligent exhibition of a few remedies to meet the varying needs and requirements of tuberculous invalids is eminently proper,

It

and constitutes a valuable adjuvant to more important measures. would seem that quite as much evil may be expected from allegiance to the principles of medicinal nihilism, as from persistent adherence to the old-fashioned doctrine of overmedication. Protest, therefore, ist offered against the inculcation, in the popular mind, of delusions concerning the non-utility of all drugs for the pulmonary invalid. To deny their occasional favorable influence in the practice of discerning, discriminating, and resourceful clinicians is as idle as to repudiate the known advantages of hygienic measures and climate.

In the management of special symptoms, it has been insisted that the treatment should be conducted along the lines of hygienic methods, but that due recognition should be accorded to the intrinsic merit of judicious drug therapy. The suppression of hemorrhage, the restoration of disordered digestion, and the alleviation of various disturbed. functions are often wondrously facilitated by the employment of appropriate medication. It cannot be asserted that equally beneficial results. are obtained by the employment of drugs for their general effect. In fact, the indications for general drug therapy are exceedingly few and relatively unimportant. In selected cases, however, some value may be attached to the administration of strychnin, arsenic, creasote, and preparations of emulsified fats.

Strychnin is often of advantage through its influence as a general stimulant. In physiologic doses it is supposed to exert an effect upon all body functions. By virtue of its stimulation of the nervous system the activity of the vital processes of cell nutrition are correspondingly promoted. It is thought, with increased functional activity, added defense is acquired against the tuberculous infection. It has been claimed by some that the maximum benefit from the exhibition of this drug, may occur only when the dose is progressively increased to the limit of physiologic toleration. The amounts reported to have been administered without toxic effect by enthusiastic advocates of strychnin therapy for consumptives, almost surpass understanding, in some instances a grain of the drug having been given daily for prolonged periods without unpleasant effects. While it may be accepted as capable of clinical demonstration, that the best effects follow its employment in considerably larger doses than have formerly been given, its routine administration in increasing doses should not be encouraged. It is possible that unusual conditions may exist suggesting the expediency of the maximum physiologic dosage, but the employment of the drug at other times, save to a judicious extent, should be deprecated. Generally speaking, in the absence of special contraindications, good results may be expected among pulmonary invalids by the administration of grain three or four times daily. Under its influence the appetite and general functional activities are often advantageously stimulated.

It has been my custom for many years to combine the administration of arsenic with that of strychnin, although never as a routine procedure. Through the employment of Fowler's solution, which is perhaps the best form for administration, the promotion of appetite is sometimes pronounced. On account of the narrow margin between the therapeutic and toxic doses it is essential that extreme care be exercised in its employment. It should be given in beginning doses of one minim three times a day, which may be cautiously increased to five minims. The remedy

should not be taken in less than one-half glass of water after each meal, and should be promptly suspended upon the appearance of nausea or other disagreeable symptoms. As a rule, it is unwise to persist continuously in the use of this preparation for a longer period than two months, when there may be substituted to advantage agreeable preparations of iron. In the event of dry, spasmodic cough the syrup of hydriodic acid may often be administered with gratifying results.

Unfortunately, creosote has been regarded for many years as of essential value by numerous practitioners. For three-quarters of a century, with varying degrees of enthusiasm, the supposed specific action of this drug has been highly vaunted. Its value at first was thought to consist of a certain inhibiting influence upon the growth of tubercle bacilli, and its greatest efficacy was thought to follow its maximum administration by way of the digestive tract. In the majority of cases it was found that in large doses, the entrance of this drug into the stomach was followed by indigestion, disagreeable eructations, repugnance for food, vomiting and diarrhea, with occasional nephritic disturbance. Routine persistence in its employment despite the manifestations of gastric rebellion, has often resulted in incalculable damage, the initial loss of appetite and digestive derangement apparently becoming confirmed. It must be admitted, however, that in exceptional instances, very material benefit has followed its use, notably an improvement of appetite and digestion and disinfection of the intestinal canal, in cases of flatulence and fermentative diarrhea. Other effects have occasionally been noted among patients with excessive, purulent, and heavy expectoration. It is apparent that in the overwhelming majority of cases, creasote must be regarded as an agent capable of producing a definite amount of harm, but among a comparatively few presenting possibilities of some benefit if intelligently and cautiously administered. For general use it cannot be condemned too emphatically, for the unfortunate results far overshadow the isolated instances of improvement. The most that can be said in its behalf is that it has a valid claim for tentative employment among a comparatively few cases. It should be administered, if at all, in small initial doses of not over one or two minims, preferably in capsules, and increased but moderately. Its use should be restricted to intractable cases of gastric and intestinal fermentation, with impaired appetite, chronic bronchitis, or bronchiectasis complicating tuberculosis, and pulmonary excavation attended by profuse purulent expectoration. Furthermore, it should be promptly discontinued as soon as it becomes apparent that the appetite and digestion are impaired by the drug. But little confidence may be reposed in its practical utility for the purposes of inhalation. The many derivatives of creasote have been found less advantageous than the crude article.

Several preparations of cod-liver oil and easily digested fats must be accepted as possessing certain advantages for a class of pulmonary invalids. The only benefit represented by the administration of such agents, is reflected in the ingestion of a generous amount of easily digested fat. Much discrimination should be exercised in the employment of these preparations on account of their frequent effect in retarding digestion. Obviously, they should not be given to patients with fever and pronounced gastric derangement. In general, they are borne much better in the winter than during the hot summer months. Their special