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A FURTHER CONTRIBUTION TO THE LOCAL TREAT

MENT OF PULMONARY CAVITIES.

BY WILLIAM PEPPER, A.M., M.D.,
Professor of Clinical Medicine in the University of Pennsylvania.

I HAVE two objects in offering this brief summary of my recent experience in the local treatment of pulmonary cavities. It is, in the first place, desirable that each observer engaged in such an important work as the attempt to effect a radical improvement in any part of our treatment of pulmonary phthisis, should publish fully and promptly the favorable or unfavorable results obtained. Moreover, I promised my highly-esteemed friend Dr. H. H. Smith, Chairman of the Section of Surgery and Anatomy of this Association in 1878, that I would, at that meeting, present this summary of results, in connection with a brief allusion to the local treatment of pulmonary cavities contained in his able address' before his Section. Circumstances prevented this, but I have felt as though it were my duty to offer these results to the appropriate Section of the Association at the earliest convenient opportunity.

I may say in advance that, after pursuing the use of intrapulmonary injections assiduously, until their entire harmlessness was demonstrated, and until it seemed to me that the range of their applicability was fairly determined, the attempt bas been made to medicate the interior of pulmonary cavities by other means. It is of course well known that frequent efforts have been made to do this successfully. Indeed, considering that it is an established clinical fact that pulmonary cavities do, in a small proportion of cases, result in recovery by contraction and cicatrization; while, on the other hand, the dangers and inconveniences resulting from their presence are so very serious; it is but natural that continuous efforts should be made to learn the most efficient mode of treating them.

The chief indications

* Trans. Amer. Med. Association, vol. xxix., 1878, p. 205.

that are presented for such treatment are: the disinfection of the contents of the cavity; the modification of the lining surface of the cavity so as to lessen the amount of expectoration and of irritating and exhausting cough; and the modification of the morbid action in the layer of tissues immediately surrounding the cavity. In attempting to secure these results, medicated liquids have been injected down the larynx and bronchi; brushes or probangs containing some medicated liquid have been passed through the glottis and carried down into the bronchus of the affected side; all forms of inhalation have been used; and, finally, direct operative treatment by incision or puncture has been tried.

The first two of these methods—the introduction of liquids through the larynx and bronchi into the cavity, either by injection or by probang-have apparently been entirely abandoned. Ordinary inhalations, either by an atomizer or by the more simple inhaling tubes or bottles, do not seem capable of producing any positive or lasting effect. There is, however, one form of inhalation, more recently brought into use, that would appear to promise more favorably. I refer to methods of continuous inhalation, by which the patient is enabled to respire continually, by day and by night, an atmosphere charged quite strongly with alterative or disinfectant vapors. Two or three years ago, Dr. W. Roberts, of Manchester, England, described a simple portable “respirator inhaler," in the form of a metal box perforated in front and behind, and filled loosely with layers of tow on which the inhalation liquid was poured. This inhaler fits over the mouth, and is fixed over the ears like an ordinary respirator. A much more convenient form of apparatus for continuous inhalation has been devised and extensively employed by Dr. II. Curschmann, now of Hamburg. He has used it with great success in cases of putrid expectoration due to chronic bronchitis, and also where there has been destructive disease of the lung accompanied with offensive sputa. In at least one of his two most remarkable cases, I think, however, the physical signs are open to an interpretation different from that which he assigns, and one which renders the recovery of the patient less extraordinary.

I quote the following report of one of these cases: A man aged 53, who had been ill some months with symptoms of phthisis, was admitted under Dr. Curschmann's care in Nov. 1878, with

dulness, bronchial breathing, and medium-sized moist râles over the lower half of the right lung posteriorly. At one point percussion was tympanitic, and auscultation revealed signs of a cavity, which was proved to be such by tapping and drawing off some of its fetid contents. The patient expectorated about a litre of most intolerably putrid secretion in twenty-four hours. His evening temperature was 39° C., his pulse 112, and he suffered from night-sweats. He was treated throughout with almost continuous inbalations, first of oil of turpentine, and then of pure carbolic acid. In three weeks the sputa were quite free from smell, fever and night-sweats had left him, and be only spat up about one-third of the amount he had done on admission. As in the other case referred to above, there was ultimately extraordinary disappearance of the abnormal physical signs, and the patient gained twenty pounds in weight during his scarcely six months' stay in the hospital. Except a little morphia for the cough at the first, he took no medicine internally-no hypophosphites, no iron, no cod-liver oil. In both cases the successful result can be attributed to nothing except to antiseptic treatment-for such it is—by inhalation.

Since obtaining a supply of Curschmann's respirators from Berlin,' I have used continuous inhalation in a certain number of cases. There can be no doubt of its efficacy in destroying the putrid odor of the sputa in some cases of dilated bronchi or pulmonary cavity. It certainly exerts a modifying effect on the bronchial mucous membrane, and may be of material service in the treatment of obstinate bronchitis. I have seen unmistakable benefit from its use in cases of empyema discharging putrid puis through a pulmonary fistula. In cases of extensively diffused chronic catarrhal pneumonia, I have some interesting evidence pointing to the benefit that may possibly be derived from the continuous inhalation of suitable vapors. In cases of true pulmonary cavities, however, apart from the disinfection of their contents, it seems to be unsettled yet how far the condition of the walls can be modified even by this method of inhalation. It appears to be a subject deserving of thorough and prolonged investigation, and I am now engaged in carrying out observations on a number of suitable cases. The mode of using these respirators is very simple. The space between the wire disks

1 This respirator is figured in the Berliner Klinische Wochenschr. No. 27, 1879, fig. 430 ; and can be obtained from H. Dunzelt, 22 Schaaren-Strasse, Berlin.

through which the air is respired, is filled with fragments of sponge on which the substances used for inhalation are poured. Those which have so far yielded the most satisfactory results are carbolic acid, creasote, oil of turpentine, a mixture of tincture of iodive and compound tincture of benzoin, and thymol. If care be taken to apply a little cosmoline to the skin where the rim of the inhaler touches the face, and to wipe the rim frequently, no local soreness will be produced. The vapors of these substances, even when dropped on the sponge undiluted, are tolerated with remarkable ease. Some patients become impatient of the constraint of wearing such a mask continuously, but as a rule, a clear explanation of the object in view, and the permission to leave off the respirator for a few hours each day, will overcome all such difficulties.

Admitting, therefore, that as yet, I know of no satisfactory evidence that the healing of pulmonary cavities can be positively favored by any method of inhalation, I will ask your attention to the results of treating such cavities by the direct injection of medicated liquids by means of a small syringe and delicate canulated needle.

In an article that appeared in the American Journal of the Medical Sciences for October, 1874, all of the questions connected with this subject were discussed by me at such length that it is now unnecessary to do more tiian refer briefly to a few points of interest.

In the first place, although the idea of opening lung cavities by an incision through the chest-walls is almost as old as Baglivi (possibly much older); still, owing to the very imperfect character of the early clinical records of thoracic diseases, it is difficult to show that such an operation was actually performed before the last century (Barry), or more probably the present one (IIastings and Storks).

Secondly. The idea of conducting continuous treatment of such cavities by local applications made directly through the chest-walls, has been seriously entertained only within the past

few years.

Thirdly. That the possibility of penetrating the lung in a state of health with delicate needles without injury, was demonstrated in a few instances by the advocates of acupuncture; and more recently, in the lower animals, by Koch and others. I have myself repeated the experiment a number of times; and before

I ventured to inject iodine into the lung-tissue of the human subject, I made numerous injections of this substance into the lungs of healthy rabbits, which were killed at varying intervals afterwards, so that I was able to satisfy myself that not the least trace of irritation remained.

Fourthly. The operations of Storks and Mosler have shown that lung cavities are very tolerant of external interference, and that they may be cut down upon and opened, canulæ introduced and retained, and various medicinal agents injected in solution or spray (Mosler).

Fifthly. That the observations reported in full in my paper above referred to, have shown that the continuous treatment of lung cavities by repeated injections by means of delicate canulæ (a mode of treatment that bad never been suggested until I practised it in February, 1874), may be conducted without severe pain, hemorrhage, traumatic irritation, or interference with internal medication and hygienic measures.

I proceed now to report in brief all of the cases in which this mode of treatment bas been employed, in order to establish certain conclusions that would appear to follow.

CASE I. (No. II. in former communication.) John Wilson. Chronic phthisis; cavity at left apex, with disease of the lower lobe; seven injections of iodine into the cavity; temporary improvement in cough and expectoration; pneumonia of right lung from exposure, followed by caseation and softening; death. At the autopsy the left lung was much contracted, with dense pleural adhesions. On careful examination of the area through which the punctures had been made, it was impossible to detect any trace of the passage of the needle. A large anfractuous cavity existed in the upper lobe, divided into sacs by several imperfect septa. The various injections had entered the largest and most anterior of these sacs, the lining membrane of which was smooth, shining, and whitish.

Case II. (No. III. in former communication.) Thomas Peyton. Chronic phthisis, with large circumscribed cavity at the right apex; two injections of iodine, without any unpleasant result, but treatment discontinued on account of nervousness of patient.

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