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dysentery and died Sept. 1, 1876. During the last two months of his life signs of scattered centres of disease in the left lung were noticed. Post-mortem showed some tuberculous nodules in the left lung. The heart was displaced towards the right, so that the right auricle was above and outside of the right nipple. The apex must have pulsated just at the right edge of the sternum. The right lung was bound down by dense fibrous pleural adhesions, which required to be cut. No trace of the punctures remained. The lung was very greatly contracted in all its dimensions. There were the remains of a huge cavity which had occupied the centre of the upper and middle lobes, but which was evidently much reduced in size by the contraction of the lung tissue; it bad a smooth polished lining, with many trabeculæ and sacculations. The pulmonary structure surrounding it formed a wall half an inch or more in thickness; it was everywhere dense and fibrous, but especially so in the region of the injections where it bad undergone advanced fibrous change. No evidence of fresh action in the right lung. I think it would be safe to say that in this case the relief afforded to distressing symptoms, and the improvement in the general condition during the continuance of the injections were marked; while the progressive change in the physical signs, confirmed later by the post-mortem examination, made it appear that the injections aided in causing contraction of the cavity.
CASE VII. Barney McDade, æt. 46, had been under observation for a number of years with fibroid phthisis of the right lung. This was deeply seated in the upper lobe, with extreme contraction of the side, displacement of the heart, and deviation of the trachea. In 1875, he began to have frequent hemorrhages, marked hectic, etc., and, after failure of usual remedies, two injections of dilute Monsell's solution were made into the right upper lobe. The tissues were found to be so dense, however, that it was difficult to effect the injections, and they were not repeated. At the post-mortem examination, the extremest lesions of fibroid phthisis were found.
CASE VIII. Mary Wiley, æt. 31, a frail, delicate woman, with hereditary tendency to phthisis, and broken down herself by repeated childbirths, came under observation in September, 1877, at the Philadelphia Hospital. Symptoms of phthisis for fourteen
months, several hemorrhages; very troublesome cough, often causing vomiting; fziv purulent sputa daily; pulse 120; respiratious 45 ; weight 85 pounds, having lost 25 pounds of flesh; appetite so poor that little food and vo drugs could be borne. Physical examination showed a very large cavity occupying the upper part of the right lung, with scattered moist râles through the lower part of the lung; left lung apparently healthy. In the hope of relieving paroxysms of cough, injections of dilute Lugol's solution (gtt x to xx; sixteen to twenty-five per cent.) were begun September 30, 1877, and twelve were used before the end of the year. The needle was introduced about one and a half inch; no difficulty whatever was experienced, and no unpleasant symptoms followed in any instance. On the contrary, very positive and decided relief was given. The expectoration diminished, the paroxysms of cough were much relieved, and the pains in the right chest became less severe. About January 1, 1878, she left the hospital to nurse one of her children who had been taken seriously ill. Although too weak to bear any exertion, she devoted herself to the care of her child for almost a month until its death; and then returned to the hospital to resume treatment. She was, however, so utterly exhausted that it was clearly unwise to attempt any such measure, and she sank in the course of a few days. Post-mortem examination showed a very large superficial cavity in the upper part of the right lung, into which the injections bad all entered.
CASE IX. Peter Dowley, æt. 37, admitted to the Philadelphia Hospital June 17, 1874. For nine years has had some cough, dyspnea on exertion, and occasional hæmoptysis, but has worked steadily at his trade as a shoemaker. For the past three years, however, he has been failing, although the symptoms have presented many fluctuations. On admission he looked fairly well, and complained chiefly of the dyspnea on exertion, and the paroxysms of cough: expectoration was quite copious. Cavity from left clavicle down to the third rib, with consolidation of the lung below that as far down as the sixth rib, anteriorly and posteriorly, over which area fine mucous râles were heard. There were also moist crackling râles over the upper lobe of the right lung, with broncho-vesicular breathing. Injections into the cavity were begun August 17th, and eighteen in all were used, between that date and January 4, 1875. He left the hospital very much
improved, and February 2, 1875, he returned to work. The first eight injections were, dilute Lugol's solution (m xx to xxx, twenty to twenty-five per cent.), the others were two per cent. solution of carbolic acid (m xx to xxx). No unpleasant symptoms attended any of the injections; and unquestionably they were serviceable in relieving the cough and in lessening the expectoration.
CASE X. A. B., a German, æt. 45, in the Philadelphia IIospital. Had suffered from an injury which bad caused marked double lateral curvature of the spine, with contraction of the upper part of the right chest. Ile bad presented the symptoms of chronic phthisis for about two years, and on examination a large superficial cavity was found situated in the upper part of the right long. There was very little consolidation of the surrounding lung tissue, and no demonstrable disease of the left lung. He had lost about fifteen pounds of flesh, but still bail a good appetite. The expectoration was very copious (Oss q. (1.) purulent, and quite offensive; the cough was very frequent, and severe paroxysms frequently occurred. Twelve injections into the cavity were used, at first of dilute solution of carbolic acid; later, when the offensive character of the sputa passed away, of dilute solution of iodine. No unpleasant symptoms followed in any instance. Very positive relief was afforded to the cough; the sputa became inoffensive and reduced in amount to one-third or one-quarter of the former quantity; he gained flesh and strength, and was discharged to return to work.
CASE XI. Mr. M., seen in consultation with Dr. T. V. Crandall, æt. 47, with hereditary tendency to phthisis, and always of delicate health. He had catarrhal pneumonia in 1872 and 1874, followed by chronic phthisis of the upper part of right lung. Fistula in avo formed in 1875. His former weight was 160; in 1877 it was only 118. There had been four hemorrhages between April and October, 1877. A circumscribed superticial cavity existed in the right apex; and a few small centres of disease in the lower part of the left lung. His extreme debility, anemia and emaciation, and the long-standing malnutrition rendered the prognosis eminently unfavorable; but the most careful and judicious treatment, including various forms of inhalation, having failed to relieve the terrible paroxysms of cough,
which very frequently caused vomiting, it was decided to attempt to modify the condition of the surface of the cavity by intra-pulmonary injections. Twenty-five injections in all were given in a period of seven months, from Oct. 1877, to May, 1878. Dilute solution of iodine (twenty to thirty per cent. Lugol's solution) m xx to xxx, was used in each instance. The entrance of the iodine into the cavity was often demonstrated by taste, odor of breath, etc. The injections frequently brought on immediately a paroxysm of cough, which could be allayed by fragments of ice and deodorated tincture of opium. All agreed that the treatment was successful in securing the desired result. The expectoration lessened, and the paroxysms of cough diminished greatly in frequency and severity. Progressive contraction of the right apex occurred, with condensation of the wall of the cavity and decrease in the size of the cavity itself. This was shown by the changes in the physical signs, and by the increasing difficulty in effecting the injections. Different spots of puncture had to be chosen, and finally they became so difficult, that it was decided to abandon them, as they appeared to have accomplished all that could be expected. In consequence of the greatly lessened frequency of vomiting his nutrition improved, and there was some gain in flesh and strength. Unfortunately other centres of disease became active, an attack of catarrhal pneumonia occurred in the lower lobe of the left lung, and he declined quite rapidly subsequently, and died towards the close of 1878. Undoubtedly the use of intra-pulmonary injections both prolonged life and greatly increased comfort in this case; while they exerted a beneficial effect on the lesions at the spot to which they were directed. An autopsy could not be secured.
CASE XII. Mrs. J. D., æt. 52, had been a very hard working woman, and had borue many children. Soon after the menopause her health failed, and cough began, and when I first saw her symptoms of chronic phthisis had existed for more than a year. Her general symptoms were very unfavorable, although physical examination showed no disease save at the left apex, where there was a small superficial cavity, with consolidation surrounding and extending as low as the third interspace. Cough was very troublesome, and often induced vomiting, and the expectoration was viscid and muco-purulent. There were marked anæmia, debility, loss of flesh, heetic fever, sweatings, anorexia, and
mental despondency. Careful treatment, including change of climate, having been faithfully tried for many months, without affording relief to the symptoms or checking the progress of the disease, it was decided to use injections into the diseased area. The general symptoms justified a grave prognosis, and especially the fear of constitutional infection and outbreak of the disease in other localities. The result confirmed this apprehension. Fifteen injections were made into the left apex; and the notes of the case record marked relief to the cough, lessening of the expectoration, with evidences of arrested activity of the local disease, and tendency to contraction of the left apex. But ere long tuberculous formation made itself manifest at right apex, and extended rapidly through the lung. Intense cachexia was developed and death occurred. Here, as in Case XI., the local action of the injections was undoubtedly beneficial, but was exerted at too late a stage to secure as much good as might otherwise have been derived.
This comprises all the cases in which I have used injections into pulmonary cavities. Before attempting to sum up the result of the twelve cases, in which a total of 210 injections were made, I will report a few cases where injections were made into areas of partial or complete consolidation, in order to test the applicability of such local treatment to such cases.
Case I. (No. 1 in former communication.) John Dortt: pneumonic phthisis, with caseous infiltration of entire left lung and secondary tuberculous formations in right upper lobe. The symptoms bad lasted only nine months, but patient was sinking very rapidly. Five injections of dilute iodine solution were made in the course of sixteen days into the upper lobe of the consolidated left lung to the depth of one and a half inch. The punctures caused no symptomis whatever. Death occurred five days after last injection. Post-mortem examination showed no trace whatever of passage of needle through the intercostal tissues, nor of the punctures of the lung substance.
CASE II. Charles Johnson, a Swede, æt. 40, was admitted to Philadelphia Hospital Sept. 10, 1874. Symptoms of phthisis had existed for a year; cough, purulent sputa, numerous small bemorrhages: for six months there had been marked dyspnea, and