CASE 5. A young married lady, highly neurotic and migraineous, had an attack of muscular rheumatism, affecting the muscles on one side of her neck and extending down on her chest posteriorly on the same side. I prescribed salol for her without giving relief. During the night her husband telephoned me her suffering had become well-nigh unbearable, and asked for some remedy. A dose of morphine. with bromide of potassium was given. This gave temporary relief. I called next morning, and found her suffering not only from the same muscular pain, but had a headache in addition, which latter I suppose came from the dose of morphine. A ten-grain dose of antifebrin gave relief and produced sleep.

CASE 6. A young bride, apparently strong and healthy, living in the same house with the last (her sister-in-law), had, a day or two afterward, an attack of headache that I suppose was migraine. She took one ten-grain dose of antifebrin with an effect she pronounced to be heavenly.

CASE 7. A young wife, pregnant for some three months, had an unusually severe migraine. I ordered ten-grain doses of the drug every two hours. She took three doses, but was not relieved in the least degree. I regret that I did not examine the specimen of the medicine gotten for her, as I have some reason to doubt the honesty of the druggist from whom it came.

CASE 8. A delicate, highly neurotic young lady, a victim of frequent headaches and many other nervous disturbances, had an attack of tonsillitis, and suffered at the same time from headache and general muscular pain. She had taken half a grain of morphine the night before, which had relieved pain but had failed to put her to sleep. Two doses of antifebrin, two hours apart, gave relief and caused her to sleep.

CASE 9. A lady somewhat over forty, for many years a sufferer from severe migraine, occurring at her menstrual occasions. For several years she has called me at these times to give her morphine hypodermically. This I consented under protest to do, and only on the condition she would not ask me for this service during the menstrual intervals. She had tried anti

febrin without effect. I gave her antifebrin in my usual way, but it failed to give relief.

CASE 10. A lady somewhat under fifty, and past the climacteric, has, during the past few days, been suffering from neuralgia about the left eye. One or two ten-grain doses of antifebrin given at night gave relief and caused sleep.

CASE 11. A gentleman of sixty, large and plethoric, a hearty meat-eater, and the subject of lithemia, has been under my treatment for sciatica characterized by the occurrence of severe paroxysms at night. Antifebrin, given in ten-grain doses hourly till thirty grains had been taken, simply lessened his nervousness, and enabled him a little better to bear the pain.

CASE 12. A married lady, somewhat over thirty, is usually troubled with severe headache on the approach of menstruation. I asked her to try antifebrin. One dose of ten grains relieved this headache at her last menstruation and caused her to sleep.

CASE 13. A lady of forty-four years, who is the subject of an old metritis that has left her womb considerably enlarged and retroverted, is now manifesting symptoms of her near approach to the menopause. She suffers from frequent and severe migrainous headaches. In one of them ten grains of antifebrin gave relief. A few days afterward in another attack the same dose failed to relieve.

CASE 14. A married lady, who has been under my treatment for uterine inflammation, and is subject to frequent attacks of migraine, after a tiresome and wakeful night spent with a sick child, had an attack the following morning. I had given her a prescription a day or two before for some six-grain powders of antifebrin. Two of these powders at half-hour intervals gave relief. The after-effect was a sense of languor.

CASE 15. A young married lady was treated at the office yesterday at noon for endometritis. The endometrium was painted with carbolic acid and an iodoform pencil introduced. She walked home (about half a mile) without discomfort, but last night very severe paroxysmal pains came on, evidently due to uterine contraction, excited, perhaps, by the iodoform introduced. I prescribed three five-grain doses

of antifebrin, one to be taken every half hour. They were taken and complete relief afforded.

Dr. M. H. Chouppe calls attention, in the British Medical Journal for December 17, 1887, to the value of antifebrin as a uterine sedative. He thinks it relieves the pain of uterine contraction caused by ergot without relaxing the contraction. Opium had been given in large doses in one case to give relief to the pain caused by ergot administered to check hemorrhage. Pain was relieved, but contraction was relaxed, and hemorrhage recurred. Antipyrin relieved pain without the recurrence of hemorrhage; hence Chouppe's conclusion. The parallelism of the action of antipyrin and antifebrin would lead us to expect the same sort of result from the latter drug.

These cases are, of course, entirely too few to justify any other conclusion than that antifebrin is an agent of considerable value for the relief of pain, and especially for headaches. I hope other members will report their experience in a sufficient number of cases to form the basis of a collective investigation, from which some sort of classification may be made. In the paper read by Dr. Brandeis the important point was made that in fever antifebrin is a toxic agent of sufficient power to be an unsafe remedy; and I will say, incidentally, in several cases that have come under my care lately, in which fever was present, I prescribed antipyrin as a analgesic and obtained the same sort of results as those that followed the use of antifebrin, with the addition, of course, of temperature depression.

Several questions occur to me as important to be considered with respect to this agent: (1) Is it an analgesic of wide, perhaps general applicability, in the same sense that opium is? (2) Does it modify cell action of the brain as opium appears to do, irrespective of the blood-supply. For example, does it relieve both nervo-hyperemic and nervo-anemic headache? (3) Does it relieve pain by modifying the cell action of the parts affected? In painful rheumatic joint, for instance, does it modify the abnormal local action that causes pain? (4) Does danger attend its more or less prolonged use, as is especially the case with chloral? (5) Does it lose its power to control

a

pain after more or less prolonged use? (6) What is the best method of administration? One of the most important aims in medical science is to discover a safe and efficient analgesic, and these questions, I think, are worthy more thoughtful attention.

One fact that we know with regard to the causation of pain-namely, that it is usually associated with a loss of equilibrium between anabolic and catabolic processes, in which the latter become dominant-gives us some insight, perhaps, into the mode of action of antifebrin. We are all acquainted, no doubt, with striking examples of the relief of pain by a well-digested meal. Both antifebrin and antipyrin are known to exercise a marked control over disintegration of tissue, especially richly nitrogenous tissue. Depression of temperature would of itself suggest this fact, but the considerable elimination of urinary waste products is a demonstration. May not antifebrin relieve pain then by the control it exerts over the breaking down of tissue? This is a mere suggestion. As it is so often our duty to relieve pain in the presence of fever, it comes properly in the discussion of this subject to consider the question of the safety of any antipyretic whose effect comes through depression of chemical activities in the organism. It has always seemed to me reasonable to consider fever as a conservative reaction against the presence of some materies morbi, in some way connected with nature's effort to eliminate it. Is it well to put out a fire that burns for a good purpose? If the heat is a source of danger, should it not be controlled by other measures-conduction, for instance? It should not be forgotten, moreover, that thorough oxidation does not constitute the whole of chemical activity during fever, it is a very important part, and is obviously a salutary process, having directly to do with the effectual elimination of waste matter. Antipyrin is known to increase uric acid at the expense of urea, and it does so by interference with oxidation, thus substituting for an easily soluble and easily eliminable waste product one that is with great difficulty dissolved and eliminated. The same is true with other waste products. One of the principal sources of danger in fever lies in the difficulty

of throwing off waste matter. A crippled kidney is always a bad complication. The higher the fever the greater the waste, and at the same time. the stronger the temptation to use an antipyretic which lowers the temperature but interferes with elimination.

It may be objected that tissue-disintegration is a normal process always going on, and since it is bad in a less degree to interfere with the elimination of waste matter in the absence of fever, the analgesics antipyrin and antifebrin should not be used at all. It may be replied that all analgesics, and possibly most other medicines, do some injury to the organism, and they must be employed as the choice of the less of two evils. The injury done by the pain, if left alone, must be greater than that done by the analgesic, if it is proper to administer the latter; and it is a point of much practical importance that the physician, when he prescribes a remedy, should see well to it that he has certainly chosen the less of two evils.

LOUISVILLE.

THE BERGEON OR GASEOUS METHOD OF TREATING PULMONARY

TUBERCULOSIS.*

BY T. B. GREENLEY, M. D.

As I have not noticed, in all that has been written on this subject, a satisfactory explanation of its rationale, I propose to offer some objections both to the plan and its possible therapeutic virtues. In the first place it is, to say the least, an unpleasant, not to say disgusting, mode of exhibiting a remedial agent, especially so to a sensitive female. At the outset she is likely to be alarmed at the great display of the necessary paraphernalia in the way of apparatus, and, if a young woman, her modesty is pretty sorely tested. In using this display of apparatus the operator is very particularly cautioned to roll the air-bag closely,

in order to exclude every particle of atmospheric air, for fear that if any remains and is injected with the carbonic acid and sulphureted hydrogen it will cause colic. Now this is something I have not been able to comprehend: why atmospheric air should cause pain

*Read before the Hardin County Medical Society, December 1, 1887.

in the colon when the other two gases do not. It is certainly not because it is more irritating than those gases to the mucous membrane, and, a priori, could not be from distension; therefore the question still remains in statu quo.

It is claimed by advocates of the gaseous treatment that the gases are absorbed and carried by the venous circulation to the lungs, and there eliminated by means of exosmose through the pulmonary alveoli, and thus act as a disinfectant or alterative on the ulcerated surface.

In order that the gas may reach the lungs, it has to be absorbed by the mesenteric veins, carried to the vena porta, thence traverse the liver, passing through its capillaries into the radicles of the hepatic veins, thence to the vena cava inferior, whence it reaches the right side of the heart, thence through the pulmonary arteries to the parenchyma of the lungs. Thus it is seen that in order to reach the alveoli of the lungs it has quite a circuitous route, besides passing through the capillary systems of two organs.

The question here arises, In what form does this gas circulate with the blood? Is it in the form of a gas or a fluid? It can not be in the form of a fluid, as it requires a pressure of more than twenty-seven atmospheres to convert carbonic acid into a fluid, and seventeen atmospheres to reduce sulphureted hydrogen. Of course no such pressure can be brought to bear on these gases, admitting they enter the circulation. Now, after they are taken up by the mesenteric veins of the colon, if we presume that hypothesis to be true, are hey sufficiently condensed to pass through the capillary circulation of the liver and lungs? This would seem to be very doubtful, especially in such large volumes, when it is known. that atmospheric air in very minute quantities circulation. On this account great care has so quickly destroys life if admitted into the to be observed in operations about the neck, as life has been frequently lost by air entering the veins. The difference in this respect no doubt, to some extent, is due to the differnitrogen not being so soluble as some other ence in the solubility of gases in the blood,

gases.

On the supposition that the combined gases, or either of them, have traced the circulation from the mesenteric veins of the colon to the capillaries of the lungs, and are now eliminated by exosmose, as Bergeon and his followers claim, how can they produce any salutary effect on the ulcerated surfaces affected by tubercles? The alveoli here are destroyed, and of course it would be impossible for these cavernous or ulcerated surfaces to admit the passage of the gas through them; and if it is essential that the gas should come in contact with the diseased surfaces in order to produce a salutary effect, which seems reasonable, how does it reach them? Of course, as soon as any gas is eliminated through the alveoli it is expelled by expiration, and does not nor can not come in contact with the diseased surfaces.

It is not claimed that the gas acts as a germicide, but that it merely holds the bacilli in abeyance, thus giving the patient resting time, so that improvement may take place.

Now, admitting the hypothesis that sulphureted hydrogen can reach the lungs from the bowels and thereby ameliorate the symptoms of tuberculosis, would it not be a much more rational way of using the remedy by inhalation in a diluted form than to employ the disgusting mode of injecting it into the bowels? This gas can be inhaled very readily in a diluted form. Some say it can not be inhaled with safety, as, if it enters the arterial circulation, it acts as a poison. No doubt it would in large quantities, but we only need it in small quantities in the lungs. If it is not a germicide, in what way can it do good? Some claim for it antiseptic properties, thus preventing septicemia, which is regarded by some authors as being of greater importance to combat than the destruction of the bacilli. Dr. Davenburg says the bacillus is nothing, but septicemia is every thing. Now, can sulphureted hydrogen be properly regarded as an antiseptic? This is a doubtful question in any case, and doubly so in the present instance.

Judging from the known functions of the liver, to wit, the elimination from the blood of many impurities, together with the manufacture of bile products, one would a priori infer that, if three quarts or a gallon of nox

ious gases were thrown upon it daily or twice a day for an indefinite time, its duties would not only be greatly increased, but its functional capacity overburdened or crippled.

It is said by some physicians that the patients under this plan of treatment noticed the smell of sulphureted hydrogen on exhalation. I think this may be imaginary, or, if they did smell the gas, it escaped from the apparatus during its administration. I have only talked with one or two physicians who practiced this treatment and with but one patient on the subject, and they did not notice any odor of the gas from the lungs.

I may here state that personally I have very little experience in the Bergeon method, one case only having come under my observation. This was a young lady in the second stage of tuberculosis, and the gas treatment was commenced before the diarrheic stage had set in. The gas seemed to irritate the bowels, causing pain, and in a short time persistent diarrhea supervened and continued unabated to the last. The gas treatment was practiced only about three weeks, but apparently the patient grew worse all the time. I have noticed in the reports of several writers that the treatment in their hands had greatly improved some of their patients, reduced the temperature, checked the night-sweats, diminished the expectoration and improved their appetite. Now, may not these cases have improved as well without the s? It is well known to the profession that there frequently occurs in the course of chronic tuberculosis periods of amelioration. And again, consumption is a very hopeful disease, and when any new plan of treatment is instituted, with the assurance to the patient that it promises him relief, he is cheered up and his faith greatly inspired. As a rule, during the gas treatment other remedies are also used, and the apparent improvement may be and no doubt is due more to them than to the gas.

gas

It is unfortunately too common among medical men to have hobbies, and in many instances to allow their judgment to be warped too far in their favor.

"The history of medicine is a recapitulation of individual vacillation, of selfish egotism and

unstable doctrines. The theories of yesterday are the superstitions of the morrow, and the practices based upon such theories become the shuttle-cock of each doctor's battle door."*

We have had in the management of this disease in a short period of time the inhalation treatment, the pneumatic-cabinet treatment, the injecting of antiseptics into the cavities through the chest wall treatment, the Bergeon method, and now comes the hot air charged with medicated vapor treatment, which I believe promises good results, for in this plan we make local application of the remedies.

In inhaling atomized fluids or vapors condensation takes place before the remedy reaches the diseased locality and is lost in the bronchia. The pneumatic-cabinet plan seems to be a disappointment. The injecting plan through the chest wall of disinfectants and germicides is too formidable and uncertain to become popular, even if it promised success.

The gaseous

plan will soon become obsolete. All these plans have had their enthusiastic supporters.

The last plan, just coming into vogue, is somewhat inconvenient as well as expensive, but I think promises to accomplish more than any that has preceded it. The inhalation of hot air is the only way by which medicated vapor can reach the diseased part of the lungs. Cool air can carry no vapor, therefore it is essential the air should be hot-not less than 140° F.

Dr. McCaskey, of Fort Wayne, Ind., published a very able paper on this subject in the July 23d No. of the Journal of the American Medical Association. He gives an illustration of the necessary apparatus.

But I am diverging from my subject. If sulphureted hydrogen injected into the bowels acts as remedy for consumption, then nobody should be troubled with that disease, as it is formed incidentally in the stomach and bowels in quantities, or at least, by the use of certain kinds of diet, may be so formed. By feeding the patients on eggs and allowing them to drink sulphur-water we would have the gas selfmanufactured in due quantities. A facetious writer suggests the free use of baked beans with the bowels plugged. But, burlesque aside,

*Conservative Gynecology, by Dr. Bigelow.

every body knows that certain kinds of diet tend to the generation of gas in the bowels, and that instead of its being so readily absorbed by the mesenteric veins, as claimed by Bergeon's followers, it frequently becomes inconvenient to retain, causing colic if it is not permitted to pass from the bowels through the anus. Query May not a greater part of the combined gases injected in the Bergeon plan of treatment be disposed of in the same way?

WEST POINT, KY.

Societies.

BERLIN MEDICAL SOCIETY. Prof. Virchow, at the meeting December 14th, discussed the subject of Emphysema Pulmonum, and made demonstrations of preparations. Prof. Virchow from his investigations is lead to accept the explanation of the founder of this teaching, Laennec. Laennec described two kinds of emphysema, the vesicular and the interlobular. He also knew that in the first form a gradual loss of lung tissue occurred; that an atrophy of the septum followed, and that in this manner larger spaces occurred, which under favorable circumstances could develop into cavities. Laennec proposed the explanation that this shrinking of the lung substance was on the one hand the cause of the dyspnea and on the other the cause of the disturbance of the circulation. This expresses itself in the increase of the dilatation of the veins and the gradually augmenting cyanosis.

If one now contemplates the preparation of an emphysematous lung which has been expanded, dried, and then cut through, he sees large cavities instead of the smaller cavities which are made by the alveoli of the lungs. This condition always develops in isolated places, while we see normal tissues in the immediate vicinity. On closer inspection these cavities show they are not only dilated alveoli, but that they always represent a number of alveoli which are collected together in a single cavity. If the process advances the cavity becomes larger, and the entire lobule goes over gradually into a similar condition.