Vol. III

No. 1

AT

T present one of the most popular themes of discussion in journals of every kind is the triumphs of the last century over Nature, and their relative importance as compared with those made during preceding centuries. The general verdict appears to be that in every department of human effort and thought no other century is in any manner comparable with the nineteenth. Indeed, the consensus of opinion is that nothing short of a millennium of preceding time can come anywhere near showing so immense a gain. Some go so far as to hold that it requires the combined gains of all past historic time to match the successes of this one century.

It is a pleasing fact to us that in this swift and certain race for human weal, materia medica and therapeutics, in spite of the pessimistic claims of doubters, have held their own with other departments of modern science along lines of practical research and empiric discovery. So far as generalization and the enunciation of fundamental natural laws are concerned, very little has been done, although even here there has been enough to enable the farseeing to spell out success for the workers of the twentieth century.

Among the grand problems which the pioneers of therapeutic philosophy are con

sidering, the one that holds out the greatest hope comes from chemistry. As yet practically nothing has been done with it by the therapeutist. Perhaps more than a century of research will be required to gather sufficient facts to render it more than a dream. We refer to the attempt being made to discover the connection between molecular structure and the physiological effects of organic bodies. We know that the carboxyl group always produces a sour taste and that the acidity of organic bodies increases in the ratio of the weight of the molecule to the number of carboxyl groups that it carries. It has raised the question as to whether or not the physiological and therapeutic qualities of every substance are not functions of structure and weight. Mendeleeff's law is the expression of this principle for inorganic matter.

Spurred on by what is already known in this direction, a host of chemists are at work on this problem because of the promise of fame and fortune which it holds out to them. They are trying to discover what is the structural cause of variations in color, variations in taste, and variations in other properties, in order to know how to command the production of such substances as possess a given set of valuable properties. Recent discoveries in the laws of solubili

ties are helping in the solution of this problem by showing how many properties are due to what are known as ions, or free atoms and free compound radicals, charged with opposite qualities of electricity. This discovery has taught us that salt does not owe its physiological properties to molecules of sodium chloride, but to free atoms of chlorine and free atoms of sodium charged respectively with positive and negative electricity. The ions, therefore, have to be looked to in future to give up the secrets of quality in accordance with the periodic law.

A century ago Dr. Benjamin Smith Barton, Professor of Materia Medica in the University of Pennsylvania, wrote in his "Collection for an Essay Towards a Materia Medica of the United States" (Bulletin of the Lloyd Library of Botany, Pharmacy, and Materia Medica, No. 1, 1900; Reproduction Series, No. 1, xi): “I am not ignorant that there are some persons who consider the science of medicine as a science of extreme simplicity; who believe, or affect to believe, that in the treatment of diseases, we have arrived at something like the ultimatum of perfection. We are already, say these persons, in possession of all the means that are necessary for the alleviation, or for the cure, of our diseases. It is needless then to ransack nature any further."

Suppose the men who held such views one hundred years ago should now be resurrected and enabled to realize fully the extent and quality of our medical supplies, what would they be likely to think of them? Let them have placed before them chloroform, ether, cocaine, and the various external and internal antiseptics now at our command, and have them see how we rationally use them. Would it not be a great revelation to them and a complete rebuke to their old-time conceit? Although we have barely made a start along the road of therapeutic progress, there are still many medical men who act as if inwardly convinced of the truth of the fallacy so neatly challenged by Prof. Barton. So numerous and so startling have been the accessions of the past few years that no one now dares

for very shame openly to avow this doctrine. The conduct of these doubters, however, confirms this interpretation of their methods and silence. If pressed to explain their true position, some of the more knowing ones would no doubt confess their skepticism, and, in justification, refer to the apparent fact that most gains now being made in materia medica are within the limits of a few distinct classes of remedies. We have been discovering hypnotics, analgesics, antiseptics, and antipyretics by wholesale and every eye is fixed chiefly upon these. The men who believe that we are at the end of useful discovery ask us what we are getting beside these. To superficial thinkers this question is difficult to answer, but after a little consideration it is discovered to be pointless. Are we not also getting coughrelieving remedies, substances that stimulate digestion and secretion of digestive fluids, bodies that check hemorrhage through the nervous system without the production of a clot, local anesthetics, tasteless antiperiodics, substances that act antiseptically after reaching the bladder and that relieve the victims of uric-acid poisoning, serums that act as specific destroyers of diphtheria, and last, but not least, glandular secretions, like those of the thyroid gland, that supply deficiencies of the normal constituents of the blood, the absence of which perverts metabolism. Surely these belie the claims of those who hold that discovery is being confined to but a few classes of remedies, however numerous they may be individually.

It is probable that the discovery of new classes of drugs will go on until they become as embarrassing in their numbers as the special new remedies already are. There will not, however, be any reasonable cause for rebellion against such progress. The more there are the more will be the opportunities for natural selection to get in its good work and give us a decided survival of the fittest. A proper censorship, to act as a directing agent protecting the profession from deception, is all that is needed to put everything appertaining to material medica on a perfectly sound basis. May this censorship be quickly established!

[Written for MERCK'S ARCHIVES] THE RATIONAL TREATMENT OF PULMONARY HEMORRHAGE

By William J. Robinson, Ph.G., M.D., New York

IN no class of cases is the raison d'être of the medical profession so apparent, in no class of cases is the presence of a tactful and competent physician so welcomed and appreciated as in emergency cases, and no other class of cases presents in equal measure the opportunities for the making and the unmaking of a physician's reputation; because it is in those sudden, life-threatening accidents that he is enabled to demonstrate, more than anywhere else, what his skill and knowledge can do over and above the vis medicatrix naturæ. It therefore follows that however uncertain and vacillating a physician may be in his treatment of ordinary diseases, he must have clearcut ideas and a well thought-out plan of treatment when he is called to an emergency case. And the young physician who is always on the alert and is always found well prepared to treat such cases is likely to become a successful practitioner-successful financially and successful in saving many human lives.

Among emergency cases, hemorrhages from the various organs occupy a prominent place, and in this paper we will take up the treatment of one of the commonest forms of hemorrhage-hemorrhage from the lungs. Throughout this article we use the term pulmonary hemorrhage as distinct from hemoptysis; the expectoration of slight amounts of blood, or a blood-tinged sputum requires very little treatment, aside from that of the causative disease, which-in nine cases out of every ten-is tuberculosis.

To enter into a discussion of the etiology and diagnosis of pulmonary hemorrhage is superfluous; no subject is better known; its differential diagnosis from hematemesis is more difficult on paper than it is in real practice; as a rule, a correct diagnosis is made by the patient before the arrival of the physician.

The important question, then, is: What are we to do when called in to treat a case of hemorrhage from the lungs? The very first thing to do is to allay the anxiety of the patient and that of his friends and relatives. It is well known that the extreme shock in which we sometimes find patients with pulmonary hemorrhage is due not so much to the actual loss of blood as to mental and psychic influences; it is the sight of blood-especially in those with first attacks---and the fear of bleeding to

death that are important factors. A few kind and encouraging words from the physician to the effect that the bleeding will soon stop and that there is no imminent danger, act like balm on the patient and go far toward the actual checking of the hemorrhage. I lay special stress on the last point. The condition of shock the patient is in tends to contract the cutaneous arterioles and capillaries and, by thus forcing the blood towards the visceral vessels, increases the intrapulmonary blood-pressure; the direct and immediate result of this is an aggravation of the hemorrhage, both in duration and in severity. Now, by relieving the mental anxiety of the patient, the cutaneous vessels relax-as is evidenced by the deathly paleness of the face giving way to a natural color-and the amount of blood in the lungs is directly diminished. We thus see that the reassuring words have not only a humanitarian value in that they decrease anxiety and suffering, but exercise a beneficial influence on the hemorrhage itself.

The next thing to do, if it has not been done already, is to unloosen the clothing of the patient and to put him down in a semi-recumbent position. I prefer the semirecumbent to the recumbent position for the following reason chiefly: it facilitates the expectoration of the exuded blood and mucus. While we must do all in our power to prevent further bleeding, there is no object in attempting to retain in the bronchi and alveoli the blood that is already there; in fact, such retention can only have a doubly pernicious effect; first, by its decomposition it is likely to give rise to bronchitis and broncho-pneumonia, sometimes of a particularly pernicious type; second, its presence prolongs an irritation and cough, which are antagonistic to the sealing up of the bleeding vessel. In fact, the possibility of asphyxia being caused by the overfilling of the bronchi with blood cannot be altogether excluded. The second reason for my objection to the recumbent posture is that such a position favors the regurgitation of blood from the diseased lung into the healthy one-a condition which common sense tells us must be prevented at all hazards. A third reason is that in the recumbent position the heart beat is stronger than in the semi-recumbent; and in pulmonary hemorrhage, as in all other hemorrhages, a strong heart-beat is not a desideratum; it is only in condition of extreme collapse that cardiac stimulation may become imperative, as we shall see later on. The patient must remain in the position he is in, as quiet as

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 useful ness 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.

But,

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. 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 a 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.