used to some extent with quite successful results. Ten to twenty minims of a sterilized 10 per cent. solution in olive oil may be administered for several weeks without especial inconvenience to the patient, and often with evidence of signal improvement. Aromatic spirits of ammonia, and alcohol, in the form of whisky, brandy, or champagne, are especially desirable if the heart weakness is accompanied by fall of temperature. The application of an ice-bag is sometimes of service, particularly in cases of pronounced tachycardia. Light massage with carefully adjusted resistance exercises are occasionally permissible, provided, of course, the nature of the cardiac difficulty is suited to the application of these measures. Obviously, the latter form of therapeusis for the heart, though eminently satisfactory to the requirements of certain individuals exhibiting a coincident slight tuberculous infection, is entirely inappropriate for advanced cases.

CHAPTER XCVII

TREATMENT OF PULMONARY HEMORRHAGE

GENERAL CONSIDERATIONS

THE treatment of this condition is uniquely different from that of hemorrhage occurring in other parts of the body, by virtue of the fact that management is restricted to palliative and expectant measures, to the entire exclusion of surgical procedures. In sharp contrast to the prompt exposure and ligation of bleeding points within the abdomen, loss of blood from ruptured vessels in the thorax must be controlled, if at all, through supplementary aid to the natural agencies productive of spontaneous arrest. Fortunately, the undisturbed forces of nature are much more likely to effect a cessation of hemorrhage from the lungs, than from abdominal organs, the contraction of vessels and thrombus formation often taking place before exsanguination is complete or collapse profound. The inherent tendency of the organism to effect a spontaneous control through reduction of volume, increased coagulability, and diminished rapidity of blood-flow undoubtedly explains the surprising number of recoveries in the presence of divergent and sometimes irrational methods of practice.

The management of no other clinical manifestation calls for an equal display of judgment and acumen on the part of the physician, and demands such implicit obedience from the patient and attendants. The conception of treatment should be preeminently practical, rather than theoretic, and, in fact, may become almost intuitive. No attempt should be made to base the nature of therapeutic management in different cases upon a precise determination of the possible causes. Such differentiation is quite impracticable, and bears no actual relation to the manner of treatment. Not only is it of but slight importance to distinguish between the various anatomic conditions responsible for the production of hemorrhage, but in like manner the recognition of the extent and character of gross pathologic change fails to modify appre

ciably the indications for rational therapeusis. It is frequently impossible to secure perfect familiarity with the physical condition, on account of the inexpediency of conducting a thorough examination until the likelihood of recurrence has subsided. While the information concerning the existence of pulmonary cavities, areas of consolidation, or of fibroid induration does not materially influence the character of therapeutic management, certain features of pathologic import are possessed of great significance, notably the presence of mixed infection, chronic nephritis, and the development of septic pneumonia. The vital consideration is the modification of treatment according to an intelligent interpretation of the clinical manifestations, rather than from a groping assumption as to the exact causative influences. Clinical features of great moment in association with hemorrhage, are elevation of temperature, cyanosis, heightened blood-pressure, the acceleration or feebleness of the pulse, dyspnea, and collapse.

It is of the utmost importance to appreciate the varying indications for treatment which are presented by different people, and often from hour to hour by the same patient. In every case of pulmonary hemorrhage the management should be determined to a large extent, according to the peculiar clinical manifestations exhibited by the individual. Under no other circumstances are the exercise of vigilant observation, attention to detail, and a critical study of cause and effect more necessary. No medical practice can be productive of more harmful results than the employment of routine methods in the treatment of hemoptysis, to the exclusion of a wise discrimination regarding drug therapy and hygienic details. Numerous remedies without regard to their physiologic action, or their suitability for special cases are occasionally administered in a spirit of utter empiricism. In other instances, purely theoretic notions are elaborated as to the effect of certain drugs upon the general and pulmonary circulation, while erroneous conceptions are not infrequently entertained regarding the influence of external hygienic measures. Thus a disproportionate value may be attached to a few time-honored remedies, with neglect to utilize important features of régime. The administration of medicinal preparations, with a few notable exceptions, is attended by directly harmful results, while detailed supervision of the patient and surroundings is remarkably efficacious. In disparaging the employment of general drug therapy for pulmonary hemorrhages, it is important not to include one or two remedies which exert a profound influence upon the entire system, with indirect effects upon the pulmonary circulation. As will be seen presently, their value in judiciously proportioned doses is exceedingly great.

THERAPEUTIC MANAGEMENT

The treatment of pulmonary hemorrhage has been thought to be capable of division into palliative and preventive efforts. It appears quite unnecessary, however, to make this distinction save in extreme cases, as there is no essential difference characterizing the attempt to arrest bleeding, and the endeavor to prevent immediate recurrence. Hemorrhages often take place in serial form, one following another either in comparatively quick succession or after the lapse of a few hours. Occasionally one or two days may intervene between these distressing experiences. In view of the tendency to prompt recurrence and the neces

sity of continuous rigid precautions, the palliative treatment naturally resolves itself into one of prevention. The physician is rarely present at the time of the initial hemorrhage, while the subsequent recurrences form but an incident in the general scheme of systematic management. In view of the many degrees of severity, the manifold phases exhibited, and the variety of therapeutic indications in different instances, it is manifestly impossible to recite in detail methods of treatment properly applicable to hypothetic cases. Broad generalizing statements, however, may be made from which to formulate principles capable of individual application.

Important features of treatment relate (1) To the initial directing influence of the physician; (2) attention to vitally important details. of management and environment; (3) rational employment of selected drugs; (4) application of special methods.

INFLUENCE OF THE PHYSICIAN

Experience has shown that in the very beginning of treatment a firm, controlling influence upon the mental attitude of the patient is of incalculable value. Nothing is more subservient of good results than the possession of a calm, hopeful frame of mind, combined with an earnest desire for obedient coöperation. Such mental status is often exceedingly difficult of inculcation, and is dependent to an enormous extent, upon the personal influence and demeanor of the medical attendant.

Extraordinary differences are exhibited by patients in the mental effect established by the incidence of pulmonary hemorrhage. Many are prone to regard the occurrence as of trifling significance, and affect a seeming indifference. With apparent nonchalance they boast of the number of hemorrhages experienced, and, strangely enough, manifest pride in their previous non-conformity to instructions. To such patients, who are referring continually to their past record, it is with the utmost difficulty that there may be conveyed an adequate appreciation of the importance of the condition, and the necessity of careful supervision. Not infrequently these people, doubting either the sincerity or the soundness of their medical advice, are loath to accept the statement, that recovery from an astonishingly large number of hemorrhages affords no valid excuse for ignoring the possible gravity of recurrences. It is not uncommon in health resorts, to observe among these "old timers" great reluctance in submitting to medical supervision. In some cases, despite the onset of pulmonary hemorrhage, an active out-of-door existence may for a time remain uninterrupted until the patient of necessity is compelled to yield final obedience. Occasionally, a portion of the responsibility for the evil results must be assumed by the medical adviser, to whose laxity and carelessness is attributable the disastrous delay. Let it be asserted with the utmost emphasis that every case of pulmonary hemorrhage should be regarded as of grave import until its complete arrest, prevention of recurrence, and absence of sequelæ have been determined beyond peradventure, as a result of continuous observation. No matter how apparently insignificant the hemorrhage, loss of blood from the lungs is worthy in all instances of judicious supervision. Several times I have been forced to witness the development of septic bronchopneumonia and death, follow

ing the initial expectoration of two or three ounces of blood by individuals refusing to yield conformity to the principles of rest and hygienic management. I recall many instances of sudden death from severe hemorrhage as a result of bicycle-riding, driving, and dancing, despite the warning signals displayed by slight initiatory hemoptyses. Small repeated hemorrhages, though not in themselves necessary elements of danger, yet if persistently ignored, represent, like the red flag waved before the approaching train, the existence of possible sources of destruction. An appeal, therefore, is made for at least the tentative enforcement of precautionary measures in all cases of hemoptysis, even if the loss of blood is quite inconsiderable. Among people of this class, in order to secure implicit obedience, the attitude of the physician should often be that of peremptory command, indomitable patience, and consummate tact.

The effect of hemorrhage upon another group of patients is quite the reverse of the preceding, there sometimes being produced the greatest possible amount of consternation and dismay. The fears of the invalid may be so exaggerated as to take the form of an almost hopeless and unspeakable terror. This unfortunate mental state is accentuated in many cases by the excitability of relatives. Under such circumstances. prompt and emphatic reassurance not only represents a prime obligation upon the medical attendant, but constitutes as well a most important feature of treatment. It is eminently good practice to calm the perturbed feelings and restore equanimity of temperament as quickly and fully as possible. A judicious endeavor to assuage the fears of the patient is usually successful in inspiring hope, the establishment of confidence often minimizing to a degree the likelihood of recurrence. It is impossible to overestimate the beneficial effect produced by the kindly encouraging words of the physician at a time of such critical moment. Optimistic cheer should be extended no less in the midst of desperate conditions, than in the presence of smaller hemorrhages. Physicians who, upon words of encouragement, have noted the relieved countenance of the invalid in place of an overshadowing expression of fear and demoralization, will accord hearty support to the wisdom of ever-ready reassurance to patients of this class.

REGARD FOR DETAIL

Attention to infinite detail represents a feature of management of the very greatest importance. It should be remembered that hemorrhagic patients are extremely susceptible to nervous influences, the tendency to bleed being aggravated enormously by slight annoyances and minor physical indiscretions. Thus it is incumbent upon the physician to exercise a strict supervisory control over all that pertains to the invalid and the environment.

It is essential that no person should be allowed in the sick-room besides the nurse, as to whose selection considerable discrimination should be exercised. In addition to perfect familiarity with similar conditions, the nurse must display primarily a ready adaptability to the individual requirements, in order that the sensibilities of the patient be not disturbed by virtue of peculiar idiosyncrasies. Her predominant characteristics should be cheerfulness but firmness of disposition, reticence but courage at times of emergency, scrupulous devotion to detail, and vigilance of observation. If the patient is consigned to the

care of relatives, a painstaking effort should be made in the selection and instruction of the attendant, to the end that a soothing and restful influence surround the invalid at all times. Conversation in the room should be strictly enjoined, the patient being addressed only when necessary and always in words of encouragement. The invalid should not be permitted to reply save in the whispered voice, assent being made whenever possible by a mere nod of the head, as loud talking is often conducive to a recurrence.

The room should be kept at an even, cool temperature, with an abundance of air, but without exposure of the patient to direct drafts. The temperature should rarely exceed 60° F. in the bed-chamber, which should be isolated as much as practicable from other portions of the house. Frequent opening and closing of windows or doors should be prohibited, in order that the element of noise be eliminated to the greatest possible extent. For the same reason the jarring of tables, moving of beds, or rocking of chairs should be restricted.

The patient should remain at all times in the recumbent position, upon a moderately hard mattress, with the head but slightly elevated. In exceptional instances the head and shoulders may be raised slightly, this being justified by severe dyspnea, but permitted for no other reason. The contention is made by some clinicians that the semirecumbent position is more advantageous on account of the added facilities afforded for easy expectoration. With the invalid in the complete recumbent posture, the expectoration may be received into a towel or piece of gauze held by the nurse, with the head of the patient turned slightly to one side. Other physicians advise placing the patient upon the affected side, in order to prevent the return passage of blood into the bronchi of the sound lung, but these conclusions appear more theoretic than practical. As a rule, invalids are able to remain squarely upon the back for prolonged periods, but this is not the case if resting upon either side. The act of turning, even with the assistance of the nurse, is often sufficient to induce cough, accelerate respiration, elevate blood-pressure, excite nervous apprehension, and produce hemorrhage. It is difficult to understand why regurgitation of blood into the bronchi of the sound lung is more to be feared than into the bronchial tract of the affected side. In fact, it would seem that the tendency to bronchopneumonia might be increased by the inspiration of blood in those. bronchioles exhibiting previous pathologic change.

A cardinal principle of management should be the absolute maintenance of the patient in a fixed position. The arms should remain in a comfortable position by the side, at no time being raised to the head. The knees should not be elevated save during the use of the bedpan. The bed-clothing should be light and consist merely of a sheet and one or two blankets, according to the season. The food should be simple, and consist entirely of cold liquids or semiliquids during the period of greater emergency. Milk, beef-juice, gelatinous preparations, and ice-cream may be given, provided but small quantities are allowed at a time. No articles of diet should be permitted requiring mastication. It is unwise to administer medicine by mouth, for fear of inducing vomiting, with the attendant strong probability of exciting recurring hemorrhages. No remedy save an occasional cathartic is indicated that cannot be administered to greater advantage hypodermatically, by inhalation, or by the rectum. In taking nourishment the head should not be raised