possible; he must make no movement of any kind. Should he become tired of the one position, he should be laid temporarily flat on his back, or he should be turned on the affected side. Never allow the patient to lie on the healthy side, for two reasons: first, the healthy lung is the one which almost alone carries on the function of respiration, and naturally it must remain as free as possible; second, lying on the healthy side would favor the regurgitation of blood from the diseased into the healthy lung a thing which, as mentioned above, must be avoided.

We now come to the medicinal treatment. For pulmonary hemorrhage there is no drug in the entire materia medica equal or even comparable to morphine. And a hypodermatic injection of morphine should immediately be administered, as soon as the patient has been put in the proper position. I usually administer 4 grn. of morphine sulphate combined with1/120 grn. of atropine sulphate. Some physicians give the atropine as high as 1/40 or even 1/30 of a grain, but I have never employed such high doses and do not consider them necessary. The effect of the morphine in this condition is wonderful: it exceeds by far anything one would expect from knowledge of the drug's physiological effects only. Undoubtedly, besides exercising a beneficial effect on the turbulent heart and circulation, and on the respiratory movements of the lung, it does material good by allaying anxiety and diminishing cerebral activity. The usefulness of atropine, which acts as a stimulant to the respiratory center, has been disputed by some; but there can hardly be any doubt that slight stimulation, to overcome the depressing effect of the morphine on the poorly working lungs, is desirable. While it should be our endeavor to diminish pulmonary activity as much as possible, we must not go outside of the limits of safety. It must be remembered that the danger of asphyxia in this condition is not altogether problematical. The atropine has another beneficial effect: it relaxes the cutaneous vessels, increasing the amount of blood in them and thus diminishing the amount of blood in the lungs.

There are two other substances which I occasionally use as adjuvants to the morphine-atropine: sodium chloride (or common salt) and aromatic sulphuric acid. The hemostatic value of those two substances is, in my opinion, based upon personal experience, established beyond doubt. The sodium chloride I give in teaspoonful doses, dry on the tongue; the dose of the elixir of vitriol ranges from 20 minims to a

teaspoonful, diluted with one or two tablespoonfuls of water and repeated if necessary. I also order a large thin ice-bag (bladder), partially filled with finely chopped ice, to be put over the region of the heart or over the affected lung; the icebag is enveloped in a towel or laid over the shirt; it should never be put on the bare skin.

I confess that the rationale of the favorable action of the ice-bag is not quite clear-to my mind at least. In fact, were we to base its use upon theoretical considerations alone, it would appear unjustified; for, contracting the cutaneous capillaries it must tend to increase the flow of blood toward the deeper vessels. But, first of all, it is possible that by reflex action a deeper effect is produced and that the vascular system of the entire lung undergoes a sort of contraction; second, the ice has a distinctly favorable effect in soothing and regulating the action of the heart-this fact is established beyond any doubt; and, third, the patients claim that they feel subjectively better and they think the ice does them good. It is not advisable, though, to keep on the ice-bag uninterruptedly, for fear of chilling or even freezing the skin. I have seen several instances where the skin-possessing apparently a very low resisting power-became actually frozen and mortified. I generally order the ice kept on for an hour at a time, every hour or two. The intervals give the skin chance to regain its normal vitality and resistance. The treatment as above outlined is the one I pursue in almost all cases; there are but few cases of pulmonary hemorrhage which will resist this treatment. In those rare cases where the blood comes in gushes and where we may fear extreme exsanguination and immediate death, there is another expedient which has proved extremely valuable. I refer to tying or cording of the extremities. Tying a cord around the legs only may be sufficient, but in some cases the arms must also be included. The tying must be done close to the trunk; the material is rubber tubing or strips of linen; the degree of tightness must not be such as to interfere materially with the arterial circulation; it must be sufficient to prevent the return of the venous blood. This expedient sometimesthough unfortunately not always-works like magic: the bleeding stops instantly. The running continuous stream of blood being interrupted at several points, the vis a tergo is almost entirely lost, and the blood in the pulmonary system is at a comparative standstill.

I now come to a consideration of a number of other drugs which, from time immemorial, have been recommended in hemoptysis and pulmonary hemorrhage, and which are still recommended in every routine text-book on medicine and therapeutics. These drugs are: ergot, hydrastis and hydrastinine, gallic and tannic acids, lead acetate, silver nitrate, ferrous and ferric salts, and alum. I am so thoroughly convinced not only of the uselessness, but of the positive and serious harmfulness of most of the above-mentioned drugs that the subject of how not to treat a pulmonary hemorrhage becomes of paramount importance and must claim our serious attention. And one of the motives in writing this paper was clearly and strongly to point out how not to treat, how not to injure patients with bleeding lungs.

How purely local astringents, like iron salts, lead acetate, silver nitrate, alum, gallic and tannic acid, could have any effect on an ulcerated artery or ruptured aneurism in the lungs, when put into the stomach, is beyond all comprehension. The above-referred-to drugs may be indicated in hemorrhage from the stomach and intestines, because there they come in direct contact with the bleeding surface; they may even be useful in renal and vesical hemorrhage, because some of them are excreted by the kidneys, and the urine thus acquires an astringent property. If we brought them in direct contact with the lung tissue, they would also prove beneficial, especially in mild cases. For instance, in cases of hemoptysis I found positive benefit from deep spraying with a solution of alum or a solution of ferric subsulphate (10 to 30 drops of Monsel's solution to an ounce of water). But to put local astringents in the stomach with the expectation that they would stop up the bleeding vessels in the lung-well, no greater therapeutic absurdity has ever been committed! It is simply another sad commentary on the crude empiricism of some of our older-and also newer-practitioners. But it is not the mere uselessness of those drugs; it is their positive injuriousness, which may sometimes help towards or accelerate a fatal termination, as I have had occasion to convince myself by personal experience, which compels me to condemn them with all the emphasis at my command. I was recently called in to see a patient, who for the last four to five days had been suffering with frequently repeated hemorrhages. His physician had treated him with gallic acid; 15 grains of gallic acid were administered every three

hours, day and night. Each time the powder was administered-from a few minutes to half an hour afterward—the patient would be taken with nausea and retching; frequently there would be vomiting and invariably afterwards there would be a hemorrhage, of varying duration and intensity. After the first two days the hemorrhage recurred only after taking the powder. Here we can plainly see how Nature's strenuous attempt at forming a thrombus was being disturbed and frustrated by an ill-advised therapy. I stopped the gallic acid, ordered small doses of morphine in bitter-almond water, and while the sputum was streaked with blood for several days more, there was no further recurrence of the hemorrhage. And it is herein that the danger lurks in the abovementioned drugs-in their ruinous effect on the digestion and the consequent lowering of nutrition (which in the poor consumptive is at a low ebb, anyway), and in the nausea, retching, and vomiting which they cause; the latter by-effects are, of course, direct exciting causes of further hemorrhages.

Ergot is of such extended-we might say universal-use in pulmonary hemorrhage, that the subject deserves special and separate consideration. While it is not exceptional, nowadays, to hear a voice raised. against the use of local astringents, the opponents of ergot in hemoptysis are so far very rare; it is still recommended in nine out of every ten text-books on medicine and therapeutics. I therefore consider it my duty to analyze the contraindications to ergot in detail.

We physicians look down with contempt upon the layman for the illogical reasoning and false deductions he indulges in the matter of diseases and their cure; we laugh at him for his comparison of non-comparable affections, and pity him for his false hopes and childish expectations. Because a mixture cured a cough due to a bronchitis he feels disappointed if it fails to do the same thing in a cough due to pulmonary tuberculosis. Because an innocent lipoma has been excised and has never returned, he is indignant at our inability to do the same thing with a malignant epithelioma; and so on. But are we not doing the same thing every day? Do we not jump at conclusions which are absolute non-sequiturs and which have no justifiability, either in theory or in fact? Do we not only too frequently mistake post hoc for propter hoc? Do not many of our hypotheses, when subjected to cool, sober analysis, appear like mere childish fancies? Because ergot will

stop a hemorrhage from the uterus, we jump at the conclusion that it will do the same thing with a hemorrhage from the lung. But is there a rational basis for such a belief? Are the two organs-their structure, their blood supply, and their nervous control-similar to one another? If a gravid or puerperal uterus contain a partly detached ovum or some débris following a miscarriage or natural labor, and we administer ergot, the ergot will have a most decided and unmistakable effect. It will initiate or strengthen uterine contractions and will cause the uterus to expel the foreign body. Would it, therefore, be reasonable to expect that a foreign body-let us say a cork-swallowed into the bronchus would be expelled by the administration of ergot? Absurd, you say? No more absurd -not much more, at any rate-than to expect that ergot will stop hemorrhage from the lungs, just because it stops hemorrhage from the uterus. Here in the uterus we have a great number of bleeding vessels, imbedded in an enormous mass of hypertrophied muscular tissue. A special center in the lumbar region presides over that mass of muscular tissue. Stimulated by ergot, the center sends its command to the uterus— and the uterus contracts! And in this contraction there is the whole secret of uterine hemostasis, so far as ergot is concerned. As in a vise, the contracted muscular tissue keeps each bleeding vessel, until a little thrombus has been formed and its mouth has been effectually sealed up. is not on account of any specific action of the ergot on the blood or on the bloodvessels; it is on account of its specific power to produce uterine contractions. It is superfluous to add that no such condition of affairs exists in the lungs; that the lung cannot be made to contract over its bleeding vessels. But has ergot no effect on the arterioles themselves? Yes, it has, but in the case of pulmonary hemorrhage the effect reacts injuriously. Whether the ergot acts directly upon the walls of the arterioles or through the vaso-motor center in the medulla, is of no great consequence; the latter theory is the one which is most generally accepted at the present time. But whichever it may be, the fact is admitted that ergot increases the blood pressure; and increasing the blood pressure means driving the blood with greater force toward the open mouths of the ruptured vessels; it means greater resistance to the formation of a thrombus. Bradford and Dean have demonstrated that ergot causes a rise of pressure in the pulmonary circuit as well as in the aortic, and that this must have a

It

disastrous effect on the course of the hemorrhage there can be no doubt.

In my opinion, failure to discriminate between the essentially different conditions of hyperemia and hemorrhage is responsible to a great extent for the improper use of ergot. In congestion and low types of hyperemia, ergot, by increasing the blood pressure, does good; the circulation is stimulated and the congestion is relieved. All the bloodvessels being under equal tension, no damage can accrue. But if there be one leak in that circuit, the blood will simply ooze out through that leak with all the more readiness, in obedience to the law of the path of least resistance.

We are confronted with a similar condition in the brain. Ergot is positively useful in cerebral congestion, but there are few physicians so ignorant as to administer it in apoplexy. As Wood says, "Ergot is still much used for the relief of chronic cerebral and spinal congestion. When there is a rupture of the vessels, as in apoplexy, by increasing the blood pressure it tends to do harm rather than good.

As regards hydrastis and hydrastinine, the drugs appear to be more useful in hemoptysis than in hemorrhage; in the latter condition the results have not been striking. Still, I prefer not to be dogmatic, because my experience with these drugs may not have been sufficient to justify definite conclusions. I know some physicians who claim good results even in pulmonary hemorrhage.

There is one substance, though, which I feel should not be left unnoticed, as I think it has a very promising future. I refer to gelatin. Though as a cure for aneurism it has not justified expectations, its blood-coagulating properties are well established, and so many reports have appeared as to its usefulness in various forms of hemorrhage, even when given internally, that I decided to give it a trial at the first opportunity. In the one case in which I used it, the effects seemed to me remarkably good; hemorrhages did not recur in three months, though previously the patient had them every two to three weeks; and I shall not hesitate to use it in every case that presents itself. The patient took about. four ounces of gelatin, added to soups, broths, etc., in the course of twenty-four hours, for four weeks in succession. No gastric disturbance occurred; on the contrary, the bowels seemed to become more regular than they ever were. Twice or even three times as much gelatin may be given per day.

Concerning the other details of the treat

ment, little need be said. The room should be large, airy, well ventilated, and of a uniform temperature, 65° to 70° F. Rest, both physical and mental, should be absolute. The patient should not go to the closet to attend to the needs of nature. The food should be scanty, chiefly fluid, highly concentrated, and nutritious. Only small quantities should be taken at a time. Ice cream is both grateful and useful. Food that may be difficult to digest or may generate gas should be withheld absolutely. Constipation, which on account of the morphine administered, is the rule, should be treated. The best thing for this purpose is magnesium sulphate in dram doses, dissolved in not more than an ounce of water, frequently repeated. If the stomach is too irritable, injections of glycerin, or glycerin suppositories (freshly prepared), or enemata of soap and water will have to be resorted to.

There is one point that we must consider before concluding this paper: What are we to do in case of collapse brought on by the excessive loss of blood? This is a condition which we have not infrequently to deal with. Both the loss of blood, which is sometimes so profuse as to be in itself a sufficient factor, and the intense mental shock are the causes of it. If the collapse is moderate, and if, in the physician's opinion, a fatal issue is not to be apprehended, then it should be left alone, for a time at least. As has been pointed out many times before, collapse is Nature's best means to stop a hemorrhage, by favoring coagulation. Under what conditions will blood coagulate so rapidly as when it is practically at a standstill? Still there are conditions where interfere we must. We have, all of us, seen collapse following a pulmonary hemorrhage, where the patient's surface is cold. and clammy, the nose pinched, the eyes sunken, etc.,-in short, where death seems imminent. Should we not interfere in such condition and should death supervene, we could justly be held guilty of negligence. The most irrational drug to give in this condition would be digitalis. Not only does it powerfully increase the strength of the heart-beat-an undesirable thing-but it also contracts the arterioles and thus drives the blood to the locus resistentiæ minoris the gaping artery or aneurism. Alcohol is not very satisfactory. Caffeine is better than digitalis, but it is also objectionable because it excites the brain and prevents sleep, a condition we wish to avoid. In this condition the brain is to be kept as inactive as possible. There are two drugs which are the remedies par excel

lence in this condition-camphor and nitroglycerin. I know of no drug which will so quickly and so surely start a heart which has come to a temporary standstill as camphor will. And I may say, en passant, that this drug is not sufficiently known and appreciated in this country as a cardiac stimulant. The camphor, of course, is to be administered hypodermically; the best way to give it is dissolved in oil: I part of camphor dissolved in 4 parts of warm (sterilized) olive oil or expressed almond oil; of this solution I to 2 Cc. (16 to 32 minims) may be injected, and repeated if necessary. The nitroglycerin, preferably in solution, may be placed on the tongue, where it acts almost as rapidly as if injected hypodermically. The nitroglycerin exerts a very beneficial effect: it dilates the cutaneous capillaries and diminishes the arterial pressure. As it may be of great service in acute apoplexy-by removing the blood pressure in the cerebral vessels-so it is of service in this condition, by removing the blood pressure in the pulmonary vessels. Strychnine may also be administered hypodermically, but as an adjuvant; it cannot replace the other two drugs in this condition of extreme collapse. Another important and useful measure is the application of numerous hot-water bottles or bags to the lower extremities. In the great majority of cases of the severest form of collapse-say, 90 per cent-these measures will suffice to bring about the desired result. Where they fail, we resort to enteroclysis of large amounts of saline solution (6 parts to 1000, or about 43 grn. to a pint), 4 to 12 pints may be injected and retained. The absorption of the fluid takes place very rapidly. There are some cases so desperate that it may be considered necessary to inject the saline solution subcutaneously or even intravenously; but personally I have had no experience with the latter method. In my hands, the camphor and nitroglycerin, together with hot-water bags and occasionally enteroclysis, have always sufficed to bring the patient out from the deepest collapse.

This paper on the treatment of pulmonary hemorrhages may be summarized as follows:

I. Relieve the patient's intense anxiety by a few kind and encouraging words; unloosen or remove his clothing, and put him in a semi-recumbent position.

2. Inject a quarter to a third of a grain of morphine combined with 1/120 to 1/60 grain of atropine.

3. You may also give a teaspoonful of

common salt, dry on the tongue, or 20 to 60 minims of aromatic sulphuric acid, diluted with a small quantity of water.

4. Order an ice-bag on the chest.

5. If the above measures fail to check the hemorrhage within a short time-half an hour or so you must cord the extremities; not too tight, but sufficient to prevent the return of the venous blood.

6. Do not under any circumstances give ergot, or alum, gallic and tannic acids, or any other local astringents. The first has no effect as an hemostatic except indirectly in uterine hemorrhage, and by raising the blood pressure in the pulmonary circuit hinders thrombosis. The local astringents put into the stomach can have no effect on the bleeding vessels in the lung, and are injurious by irritating the stomach, causing nausea and vomiting and inducing constipation.

7. Insist upon absolute mental and physical rest, upon a scanty, nutritious and chiefly fluid diet, and relieve constipation either by epsom salts or by enemata.

8. As a prophylactic against further hemorrhages, make the patient consume large amounts of gelatin, prepared in various forms.

9. Mild degrees of collapse are to be left alone; in severe collapse, administer camphor (hypodermically) and nitroglycerin; also strychnine (do not give digitalis). Besides, several hot-water bottles are to be applied to the lower extremities.

10. It sometimes becomes necessary to resort to enteroclysis of large amounts of saline solution; or the latter may have to be injected subcutaneously or intravenously. 119 E. 128th street.

[Written for MERCK'S ARChives] THERAPEUTIC MANAGEMENT OF TYPHOID FEVER

By Aurele Nadeau, St. Joseph De Beauce, Prov. Quebec I. METHOD OF INTESTINAL ANTI

SEPSIS

EXCEPTING perhaps the treatment of pneumonia, few subjects have so engrossed medical attention as the therapeutics of typhoid fever. The disease occurs under nearly all latitudes, in all seasons, among all nations, and, we may say, at all ages. To the greater glory of our art, be it said, this frightful scourge is, day by day, becoming more amenable to our control, and its mortality is everywhere decreasing. Statistics taken in 1866, both in France and Germany, give a percentage of 18 and 20 deaths, while our actual average varies

from 7 per cent. to 8 per cent., inclusive of hospital practice.

Three systems of treatment, in general practice, seem to have superseded all other methods at the present time: (1) Symptom Therapeutics; (2) Hydrotherapy; (3) Intestinal Antisepsis. Partisans of the two latter methods have recourse occasionally to the treatment of some predominant symptom, should such occur; but that practice which seeks the symptoms solely, to the exclusion of all other methods of antisepsis or hydrotherapy, has passed its usefulness and very properly so.

Brand's baths have proven their value, and are increasing in popularity throughout the medical world, especially the hospital world. Their frequent use, either as general or local agents, by enthusiastic and numerous hydrotherapists, has certainly much to do with the gratifying results of late years.

This method still counts some detractors among eminent practitioners on both sides of the Atlantic. I suppose in this, as in many other things, many have not strictly drawn the line between use and abuse, or have become exclusive and forgetful of other adjuvants. It has been lauded as a specific; in reality, it can only take rank as one of the many agents in the therapeutics of a disease that is necessarily prolix.

We now come to the last of the accepted treatments of typhoid fever, intestinal antisepsis, a much more simple method, one within reach of all, equally applicable to the city as to the country invalids, to the laborer as to the hospital patient surrounded by all conveniences. If, to those advantages, we can add that intestinal antisepsis frequently checks the disease, that in all cases it will destroy its malignancy, and thus render superfluous the Brand method, then we have a means of the greatest power. The purpose of this paper is to demonstrate this fact especially.

Before entering in medias res I must say that this method also has its opponents, who deny its raison d'être on the principle that typhoid fever is primarily an infectious-generalized-disease; and accepting for typical cases certain "aberrant and unusual forms"-as Hare calls them-they generalize from exceptions, saying: Where is the need of intestinal antisepsis, since the bacillus is everywhere? But is the bacillus everywhere? We think not; at least such is not the prevailing theory accepted today.

The great majority of authorities call typhoid a progressive intestinal toxemia.