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CASE III. (No. IV. in former communication.) Chronic phthisis, with large circumscribed cavity at the right apex; incipient disease at the left apex; forty-eight injections of iodine or of carbolic acid in the course of fourteen months.
William Sabin, æt. 29. Lame from coxalgia, and with strong hereditary disposition to phthisis, was attacked with cough in August, 1872, and in October had hæmoptysis; he lost flesh and strength, bad marked hectic and dyspnea, with troublesome cough and abundant purulent expectoration.
On physical examination, some roughness of breathing and a few crackling râles at left apex. On the right side tympanitic resonance from the clavicle down to the fifth rib. Cracked-pot sound existed from the second to the fifth rib; over the whole area, tubular or in places cavernous respiration, perfect pectoriloquy and gurgling râles. Unquestionably a large superficial cavity existed in right upper lobe. His treatment had been varied, but the course of the case bad been downwards. He was in the Philadelphia IIospital, and during the continuance of the new treatment he remained under the same hygienic conditions. Injections into the lung cavity were begun February 21, 1874, and continued at intervals of about a week (with a break during my summer vacation) until April 11, 1875, a period of fourteen months. Forty-eight injections were given in all. The amount injected varied from miv to ml; and the composition from three to twenty-five per cent. of Lugol's solution in water, or from two to three per cent. solution of carbolic acid. An aspirating pump was attached to the canula when the first few punetures were made, and on one occasion, a few drachms of blood flowed into the vacuum; but this never recurred, and the operation never caused any unfavorable symptoms. There were fluctuations in his symptoms, but on the whole his condition improved very decidedly. Ile gained in weight; the hectic fever ceased; cough and expectoration becamecomparatively trifling; dyspnea diminished notably, and he became able to take much more exercise, walking over a mile at a time, and spending the greater part of every fine day out of doors, instead of being confined exclusively to the ward as he had previously been. During this period of fourteen months, marked changes occurred in the physical signs. There was little or no extension of the disease in the left lung. The right side underwent progressive contraction; the heart was
drawn over towards the right; and the signs of cavity grew more and more circumscribed, and less distinct.
Additional proof of the progressive contraction of the right lung and of the closure of the cavity was given by the fact that whereas at first it was perfectly easy to introduce the needle to a depth of two inches, to move its point about freely, and to inject f3j of liquid, it became more and more difficult to make the injections, as the point of the needle became imbedded in dense tissue and the introduction of even a few drops of liquid met with very great resistance. The point of injection was repeatedly varied, so as to make sure that the above change was not the result of mere local thickening. By May, 1875, his cough and expectoration had almost entirely ceased, and he was discharged in an improved state of health to go to a Home for Consumptives in Boston. A few months after arriving there, signs of renal and hepatic disease appeared, and death occurred early in 1876 from ascites. Through the kindness of his physicians I secured the lungs. The left one was emphysematous and enlarged, with a limited amount of inactive disease at the apex. The upper and middle lobes of the right lung were reduced to less than one-third their normal size, and were for the most part converted into tough, non-crepitant, fibro-cellular tissue. On section, a small irregularly-shaped cavity, not more than two-thirds of an inch in its greatest diameter, was found in the anterior part of the lung, involving both the upper and middle lobes. Its surface was trabeculated, and covered with a smooth organized membrane. It was surrounded by a dense, fibrous, darkly-pigmented wall, which presented only a few indistinctly-marked streaks to indicate the lines along which the needle had been so frequently passed. Unquestionably all of the injections had entered the cavity; and it was impossible to avoid the conclusion that they had been instrumental in aiding the remarkable contraction and cicatrization of the large cavity that had occurred. Microscopic examination, conducted by Prof. James Tyson, showed that the condition of the wall surrounding the contracted cavity was one of interstitial inflammation, the alveoli being compressed and for the most part empty. The liver was displaced upwards, encroaching on the right thorax, so as to take the place of the retracted lung; and it, as well as the kidneys, was considerably enlarged. No special examination was made, but probably there was albuminous degeneration.
In this very unfavorable case there can, I think, be no doubt that the pulmonary injections were not only harmless, but positively beneficial.
CASE IV. (No. V. in former communication.) Chronic phthisis of right lung, with large cavity at the apex; smaller cavity in lower lobe behind. Twenty-five injections of iodine. Relief of symptoms, and temporary improvement. Death from acute tuberculosis of left lung. Autopsy.
James Hill, æt. 27, with hereditary tendency to phthisis, began to cough in April, 1872, and first spat blood in following July. Subsequently he lost flesh and strength, had several hemorrhages, and was admitted to the Philadelphia IIospital in November, 1873. Physical examination showed contraction and impaired mobility of the right side of the thorax, with large cav. ity with thick walls at the right apex. Evidently marked pleural thickening over remainder of the lung, with some induration of its tissue. The heart was displaced towards the right. The left lung was bypertrophous and apparently healthy. No improvement showed itself between November and the March following, when the first injection was made. Twenty-five injections of dilute Lugol's solution (7 to 30 minims, 14 to 20 per cent. strength) were made between March 8 and Oct. 26, without the occurrence of even the least unfavorable symptom. Marked improvement in congh and amount of expectoration showed itself; and the physical signs indicated progressive contraction of the cavity at the apex. His general symptoms also improved, and he became able to take more out-door exercise. During the summer he continued in the hospital, and was attacked during my absence on vacation with severe purpura and diarrhea. This was followed by signs of breaking down of lung tissue at the posterior part of right lower lobe, and about the close of October a rapid development of acute tuberculosis with pneumonia of the left lung occurred, and proved quickly fatal. Post-mortem examination showed that the body was still fairly nourished, with a good deal of subcutaneous fat. The right lung was small and contracted, being reduced to about one-half its size. Its tissue was thickened throughout. Over the anterior face of the upper lobe, opposite the second interspace where all the injections had been made, the pleura was greatly thickened, and on cutting into the lung a small cavity was found, with smooth lining membrane, com
municating with a bronchus. The tissue around this cavity was very dense and tough, and undoubtedly marked contraction with diminution in the size of the cavity had occurred since he came under observation. No trace of the punctures remained. The lower lobe presented a small cavity in the posterior part. The left lung contained disseminated tubercles in upper lobe, with recent pleuro-pneumonia of the lower lobe.
In this case, as in the previous one, the prognosis was rendered unfavorable by the large size of the cavity and the implication of the rest of the lung, as well as by the hereditary predisposition of the patient, the frequent recurrence of hemorrhage, and the marked emaciation, dyspnea, and prostration. On the other hand, the tendency of the disease to assume a fibroid form indicated a slow course. Until the severe failure of general health, with purpura and diarrhæa, occurring during the intense heat of midsummer, the course of the case had been for a number of months exceptionally favorable. Subsequently, the dyscrasia of the system showed itself by the breaking down of a new spot of lung tissue, and by the development of acute tubercular formation in the opposite lung. So far as the condition of the original cavity was concerned, it may be confidently stated that the injections not only were harmless while they seenied to afford some relief to the symptoms of irritation, but that they were instrumental in favoring cicatrization and contraction of the cavity.
CASE V. (No. VI. in former communication.) Chronic phthisis: frequent hemorrhage; large cavity at right apex; injections of iodine; marked improvement. The full history of this case is given in my former article,' and as the patient passed from under observation soon after the date at which that was published, it is not necessary to reproduce it here.
The patient was 43 years old, with hereditary tendency to phthisis, and had presented symptoms of serious lung trouble for over three years. There was a large superficial cavity at the right apex, with a healthy state of the lower part of that lung: at left apex, there were signs of slight catarrhal trouble. Sixteen injections of iodine (mxv to xxx; 10 to 20 per cent. Lugol's sol.) were made between April 9th and August 17th; during which time he took also cod. liver oil, and two ounces of whiskey
| Amer. Journ. Med. Sciences, Oct. 1874.
daily. He gained steadily in flesh and strength, and by the lat. ter date was able to walk five miles a day without fatigue. The cough decreased rapidly and finally ceaser), as did also the expectoration. At the time he left the hospital, August 19th, his general appearance was excellent; his appetite and digestion were good; he had gained from twelve to fifteen pounds. The physical signs indicated positive improvement in the condition of the right apex.
CASE VI. Chronic phthisis: large cavity at right apex; disease of the lower portion of the lung ; steady decline under general treatment; thirty injections of iodine ; marked relief and temporary improvement. Subsequently, change of climate, dysentery, rapid decline, and death. Autopsy.
Mr. L. bad presented symptoms of phthisis for eighteen months, and under judicions general treatment had steadily failed, came under my care April 3, 1874. Cough very troublesome; sputa abundant. Physical examination showed a large superficial cavity in upper lobe of right long. There were also patches of consolidation with beginning softening through the lower portion of the same lung. Dyspnæa marked and weakness extreme. He continued to take cod-liver oil and syr. ferri iodidi alternately. Thirty injections of iodine (mx to l of a solution of ten to twenty per cent. Lugol's solution of iodine) were made into the cavity between Sept. 23, 1874, and April 19, 1875. No unpleasant symptoms followed in any single instance. The entrance of the injection was frequently proved by a strong taste of iodine in the mouth. During this time he improved slowly. On March 23, 1875, the following note was taken: much less cough and expectoration; appetite and digestion good; walks three or four miles every fine day ; better than he was one year ayo; no hectic; progressive contraction of the right chest, with drawing of the heart to the right, and evident contraction of the cavity in upper and middle lobes. No further injections were used. IIe went to the country about May 1st, but returned in August, feeling less well, with marked impairment of digestion from improper food. This was corrected with difficulty, and Nov. 1st he started for San Antonio, Texas, in good condition; the physical signs about the same. He was seized with dysentery, however, and never regained what he lost, but returned home in a greatly exhausted condition with chronic