"BERGEON'S METHOD OF TREATING CHRONIC DISEASES OF THE LUNGS BY MEDICATED GASEOUS ENEMATA."

W. J. HERDMAN, M. D.,

Ann Arbor.

There is, perhaps, no disease that affects mankind, more universally distributed or more rebellious to treatment than pulmonary consumption. In spite of the rapid advances that have been made in recent years in our knowledge of its etiology and pathology, we have not, as yet, been able to record any very substantial gains in its therapeutics.

In the light of modern pathology, pulmonary tuberculosis is the result of two factors:

1st. A peculiarly susceptible state of the lung tissue, which may be either hereditary or acquired, and,

2d. A peculiar irritant, which, either directly or indirectly, excites an inflammation in the peculiarly disposed tissues-viz., the bacillis tuberculosis.

These causative factors, then, clearly apprehended, determine for us more positively than ever before the mode in which the enemy must be attacked, if our contest would prove successful. And in waging this warfare, we are not to overlook the fact that it is of equal, if not of more, importance that we aim in our treatment, by proper hygiene and by suitable nutrition abundantly introduced into the system, to overcome the peculiarly susceptible state of the lung tissues, and restore them to a healthful physiological action, than to oppose the disease germ by such agents as will at once destroy it, or check its ravages.

It is this primary factor-the impaired state of the lung

tissue and the consequent lowered vitality of the entire organism, which is so dependent upon this important organ—that renders the successful treatment of pulmonary tuberculosis a problem of such difficulty; for, to use the felicitous expression of Oliver Wendell Holmes, "an individual with such a predisposition, in order to be cured, needs to be treated oftentimes, two hundred years before he was born." A word of caution is necessary, then, to those over-sanguine therapeutists who, arraying their forces for attack against the secondary cause alone, the mischief-working bacillus, and neglecting the measures for restoring to healthful action the enfeebled tissues, find in the end that their most skillfully devised methods for destroying the bacillus prove fruitless in permanently arresting the disease, and may even of themselves do serious damage.

The best endeavors, or at least the noisiest efforts of recent therapeutics in phthisis, have aimed at the direct destruction of the specific germ, which has been found to be so intimately associated with the disease, and which is regarded by many as its exciting cause.

With a laudable endeavor to discover what substances the parasite least enjoys, that it may be given plenty of it, both within and without the body, it has been met by all manner of reputed antiseptics and bactericides; and the relentless zeal with which it has been hunted down has only been equaled, in many instances, by the reckless and unreasoning methods that have been devised to reach it. What can be more absurd than an attempt to reach directly a bacteria colony located in the interior of a caseous mass of tuberculized lung surrounded by bronchi and alveoli, plugged with the products of inflammation, by inhalations of gas and medicated sprays? The very morbid changes make it impossible to reach the points where disease is most active; whereas the healthy and permeable lung tissue is furnished with the air thus poisoned in unstinted doses. Or, who is so credulous as to expect much benefit to flow from the hypodermic injections of powerful bactericide solutions through the chest walls into the supposed

location of tuberculous deposits, with the intent of destroying the morbific germs? Even if such injections should reach some spot where such mischief is going on, what shall we say of the possible dangers to healthy tissue thus rudely traversed and wounded?

In order to counteract the growth and multiplication of the bacillus in the lungs, it must be met at every point of assault by influences prejudicial to its development. Indirectly by increasing the natural resistance of the tissues by providing all the means favorable for their healthful nourishment, and directly by the introduction of such therapeutic agents as will oppose the growth of this peculiar parasite, and of such nature and quantity as will least impair the vital forces of the body. When we take into consideration the morbid anatomy of pulmonary tuberculosis, I believe it will appear self-evident to all that, in order to prove most efficient in accomplishing this purpose, such therapeutic agents should be introduced into the blood. Only by this channel can they be brought face to face with the morbid processes at every point, and in the most intimate manner, since the nutrient fluids reach every locality, undergoing vital changes, either normal or abnormal, and when the abnormal processes are most active, there the blood flow is especially directed.

There are additional reasons also at the lungs why the venous blood should be chosen as the channel of introduction of such therapeutic agencies, since the venous capillaries are more abundant, and their function that of elimination rather than absorption.

If, then, in the treatment of pulmonary tuberculosis, a substance can be chosen directly destructive to the growth of the bacillus, and which, in quantity and quality, is not especially deleterious to the vitality of the tissues-if such substance can be readily and conveniently introduced into the venous circulation, and thus conveyed to the lungs, and, still better, if it is of such a nature that the lung surfaces are its natural outlet for elimination, so that its therapeutic work is being accomplished at the very spot where, as a toxic substance, it is finding ready egress

from the system, so that when its beneficent work is done it no longer remains in the system to do harm, we would have in such a substance the most perfect instrument for cure that our present knowledge of the pathology of the disease would seem to require.

This would seem to be the process of reasoning which led M. L. Bergeon, Professor of Medicine, Lyons, France, more than four years ago, to make therapeutical application of the facts discovered by the eminent physiologist, Claude Bernard, more than thirty years before, from experiments made in regard to the action of certain gases upon the animal economy. It was found by Bernard (Archiv. Gen. de Med. Feb., 1857):

1st. That the introduction of H 2 S in quantities insufficient to produce toxic effects upon an animal, no matter in what manner it reached the blood currents, whether by direct injection into the venous or arterial circulation, into the subcutaneous tissue, or by means of the digestive or intestinal tract, that its natural place of elimination was at the lung surfaces, and there it could be detected in the exhaled breath in a longer or shorter time, proportioned to the distance from the lungs at which the gas was introduced.

The most remarkable difference was discovered by Bernard in the action of the gas as a toxic agent upon the animals, when it was confined to the venous blood or found entrance into the arterial blood. Correspondingly large quantities could be introduced by the stomach, the intestines, or by direct intravenous injection, where, by means of its ready elimination at the lungs, it could do no injury to the system; whereas, very minute proportions gaining entrance to the arterial circulation, either at the lung surfaces or elsewhere, were quickly followed by toxic symptoms and death. To quote from Bernard upon this point: "Hydrogen sulphide," he says, "is a virulent poison when introduced into the respiratory passages, since the proportion of 1 to 800 of atmospheric air is sufficient to cause death in a medium-sized dog, and 1 to 200 will kill a horse." Numerous experiments confirmatory of these results have been made from time to time upon several

kinds of lower animals; as frogs, pigeons, rabbits, guinea-pigs, dogs, etc., among which those of Demarquay,* and recently those of Messrs. Brouardel and Loyé,† are, perhaps, the most notable. The experiments of the latter two investigators, made by administering mixtures of various proportions of HS with atmospheric air to tracheotomized dogs, were undertaken with the hope of determining the cause of death in poisoning from sewer gas where HS is oftentimes the supposed toxic agent. From a series of experiments, most elaborately carried out, and recently reported to the French Academy, their conclusions have been drawn in the following words: "We think we are justified in concluding that there are two methods of poisoning from the inhalations of H2S. In the first, the death is sudden, and seems clearly due to the action upon the nerve centres; in the second, death is retarded, and to the nervous symptoms are joined phenomena which seem to be occasioned by asphyxia. It is the proportion of H2S in the air inhaled which regulates the rapidity of the poisoning effect; a dog was killed in two minutes by inhaling five litres of a two per cent. mixture (10 cc.); another dog expired in forty-five minutes after inhaling one hundred litres of a one-half per cent. mixture (50 cc.). It seems to be, therefore, not so much the absolute quantity as the tension in the atmosphere to which the poisoning is due."

From these experiments we see that, in making use of H,S, we are handling a substance which, under certain circumstances, acts as a virulent poison, and, although it is a powerful bactericide, it must needs be handled with caution and in clearly recognized proportions. And this is the most important fact that I wish to bring out in this communication-that, in the employment of H2S as a therapeutic agent, it should be generated and combined in such manner that the dose is not a matter of uncertainty, but of exact determination.

* Recherches Expérimentates sur la Temperature Animale. Paris. 1847. + Comptes Rendus Tom, CIII, pg. 401.