rapid loss of flesh and strength. Examination showed a cavity in upper lobe of right lung, with infiltration of the entire lung, and with signs of breaking down of lower lobe in numerous points; also signs of scattered small centres of disease of left lung. Five injections of dilute Lugol's solution, or of two per cent. sol. carbolic acid were made to depth of one inch into right upper lobe between Oct. 1 and Nov. 1, 1874. After two injections pain was complained of, and on one occasion some sense of oppression. There was some apparent trifling relief to cough, but rapid decline continued, and death occurred Jan. 12, 1875. Post-mortem examination verified the diagnosis of the disease, and showed no trace of the injections.

CASE III. Incipient Catarrhal Phthisis of Left Apex. Three Injections of Iodine.

Charlotte Cummings, æt. 36, with hereditary tendency to phthisis, came under observation Oct. 10, 1877, with history of cough for five months, hæmoptysis, purulent expectoration, hectic fever, loss of flesh and strength. Physical examination showed marked impairment of resonance at left apex from clavicle down to third rib, with prolonged expiration and numerous fine crackling râles. Atropia, quinia, and paregoric were given. Three injections of dilute Lugol's solution of iodine (25 per cent. mx) were made into the first interspace at intervals of about eight days. She complained of some pain, but there was unquestionably relief to the cough, and when she passed from under observation soon after last injection, the râles were not nearly so numerous as previously, and her general condition was greatly improved.

CASE IV. Ellen Morrow, æt. 27, with hereditary tendency to phthisis, has had syphilis, and is of very intemperate habits. She came under observation Sept. 18, 1874, having had cough for two years, and one slight hæmoptysis. She was weak and anæmic, with dyspnoea on exertion. At left apex there were slight depression, lessened mobility, impaired resonance, prolonged expiratory murmur, and numerous crackling râles as far down as third rib. No disease of right lung. During the whole course of her treatment she was in hospital wards, under unfavorable hygienic conditions, and the only medicines administered were cod-liver oil, with occasionally pills of quinia, opium, and

digitalis. Intra-pulmonary injections were begun Oct. 17, 1874, and were continued at intervals of about a week or ten days, for nearly eighteen months. The needle was introduced to a depth of one to one and a half inch at various points in first and second left interspaces. At first ten injections of two per cent. sol. carbolic acid (mx to xxxv) were used; for the remainder of the time dilute Lugol's solution of iodine was used. Fully forty-five or fifty injections were used in all. The case was in every respect an unfavorable one, and presented many fluctuations in its course. There was, however, a steady improvement in the physical signs, and by the end of the period named all evidences of active disease in the left lung had subsided. The retraction of the apex had increased, resonance was still impaired, and respiratory murmur was feeble, with prolonged expiration, but no râles could be heard, even on forced inspiration after coughing. She gained flesh and strength; cough and expectoration almost ceased, and she was able to leave the hospital and return to work. During 1876, 1877, 1878, and 1879, she remained fairly well, although she committed occasional excesses. In the latter year, after a severe exposure, she contracted renewed disease of left apex. Owing to unavoidable circumstances no injections have yet been used, although she has been very anxious to resume the treatment, being convinced of its great value to her formerly. When last seen in May, 1880, her general health was good, and the physical signs showed that the lung-tissue, at the left apex, possesses greater power of action than formerly.

CASE V. Mr. Furrows, æet. 48, had suffered some years from chronic catarrhal phthisis, affecting both lungs, and associated with marked atrophous emphysema. The areas of disease were not large, and were much masked. All kinds of treatment proved unavailing to arrest the disease or to relieve the severe coughing and extreme dyspnoea. At his urgent request, eight intra-pulmonary injections of dilute solution of iodine were made, without any unfavorable or unpleasant effect, but with. entirely negative results. Post-mortem examination about two months after last injection showed no trace whatever of them.

Having thus given a brief record of all the cases in which I have used intra-pulmonary injections, it remains only to state as succinctly as possible the practical conclusions that seem fairly

deducible. It is unnecessary to describe the mode of making the injections, further than to state that the syringe used is like an ordinary hypodermic one, only with a larger barrel, and a longer and even more delicate needle; that the skin at the point of puncture should be chilled by ice, so as to deaden the sensibility; that the amount of liquid to be injected must be determined by the tolerance of the individual case, the first injection being small in amount, say mv to x, and subsequent ones larger, mxx to xxx; and that the depth to which the needle is to be introduced must be governed by the thickness of the chest-walls and the deep or superficial position of the lesion, varying in different cases from three-fourths of an inch to two inches. The only liquids I have used to any extent have been dilute solutions of iodine and of carbolic acid. The strength of the latter was uniformly two per cent.; while for the iodine, Lugol's solution (the liq. iodinii comp.) was used in proportions of one part to from three to twenty parts of water. In a previous communication already referred to, other liquids were suggested as possibly available. Only one of them, dilute Monsell's solution, has been tried, and that but imperfectly in two instances.

It may probably be assumed that the effects of such intrapulmonary injections may be learned from the record of 291 distinct injections, in 17 distinct cases of very varied character.

The dangers that might be feared from their use are: from the effects on the layer of tissue traversed by the needle before reaching the seat of lesion; from the escape of liquid from the lung through the opening made by the needle in the pulmonary pleura; and from hemorrhage from the pulmonary tissue, or from the surface of the cavity. In regard to the first point, it may be stated that, in cases where the cavity is not superficial, no injurious effects whatever have been noticed, whether the intervening layer has been of vesicular structure, of cheesy exudation, or of organized fibro-cellular tissue. In regard to the danger of liquid (blood, pus, softened cheesy exudation) escaping through the minute puncture into the pleural cavity, and exciting inflammation, it may be stated that, while in nearly every case of pulmonary cavity there are adhesions at the point of puncture, all the evidence goes to show that even without such adhesions, not even the most trifling escape of any such liquid actually occurs; or if it does, that it excites only local adhesive inflammation of a rather beneficial and protective character. In regard to the danger of

hemorrhage, I may confidently repeat the opinion formerly expressed after sixty-five injections had been made, that with ordinary care there is no danger of any serious bleeding. In fact, in only a single instance, where the puncture was made with a vacuum (Dieulafoy's aspirating syringe) connected with the canulated needle, has any hemorrhage whatever occurred. Rarely only have the first few sputa expectorated after the puneture been slightly blood-stained. The only unpleasant results that may follow such injections are, paroxysms of cough, and a certain amount of pain, though either of these very rarely occurred to such a degree as to constitute an objection to the mode of treatment. When severe spells of coughing did occur, they yielded to the action of ice held in the mouth, or to a small dose of chlorodyne or deodorized laudanum. The pain caused was, as already stated, rarely bad enough to call for relief; in a few instances where it did, a small dose of morphia hypodermically promptly allayed it.

If it can be shown, then, that such injections are practically free from all danger or serious inconvenience, it remains to be asked what indications present themselves for their use, and to what extent they are capable of meeting these indications.

These questions have, however, been so fully discussed in my previous article on this subject (q. v.), that I shall limit myself here to a bare mention of the different points.

The chief indications that present themselves for treatment in connection with pulmonary cavities, are:

1. The disinfection of their contents.

2. The relief of cough.

3. The diminution of secretion.

4. The modification of the morbid action of the lining surface of the cavity, so as to favor cicatrization and contraction, and the prevention of infection of the constitution.

In addition to these, it would be desirable to secure free and easy escape of the contents, and to afford rest to the cavity by avoiding the necessity of coughing to discharge the secretions; and by relieving tension of the walls, so as to allow partial collapse of the cavity under atmospheric pressure. When a large canula is introduced and allowed to remain permanently in the cavity-as was done by Storks and more recently by Mosler-the latter objects may be secured to some extent; but

it seems that the very serious traumatic effects of such an operation more than cancel this advantage.

In regard to those first mentioned, however, it appears to me, both from general considerations and from the clinical records I have here submitted, that intra-pulmonary injections are capable of affording material aid in suitable cases.

In but a few of the instances where I have used them were the sputa of such an offensive character as to require the special use of disinfectants. But the injection of a dilute solution of carbolic acid was found to exert a prompt influence in removing fetor where it did exist.

As already stated, the entrance of the liquid into the cavity will occasionally excite a paroxysm of cough, rarely of long duration; but in every instance where this mode of treatment has been pursued, very considerable relief has been afforded to the cough, and the amount of expectoration has become notably diminished. In several cases these results followed in a really surprising degree.

I shall not repeat the lengthy consideration into which I have already entered,' as to the possibility of such injectious modifying the morbid action on the surface of and in the tissue immediately surrounding a pulmonary cavity; since my object now is merely to call attention to the results of experience in this direction. It seems, then, that in no instance did the passage of the delicate needle excite any injurious or destructive action in the tissue traversed; that the lining membrane of the cavities into which numerous injections had been thrown, presented a highly favorable appearance, indicative of an arrest of ulceration and a marked tendency to reparative action (see particularly Cases Nos. I., III., IV., VI.); and that in a certain number of cases the conditions of the surrounding lung tissue showed clearly not only an arrest of progressive disease, but a marked tendency to the development of fibro-cellular tissue so as to circumscribe the cavity and tend towards its contraction and cicatrization. (See particularly Cases III., IV., VI.)

Finally, it remains only to consider in what cases such injections are applicable and most likely to be of service.

It will of course be understood that it is not assumed that the positive value of this mode of treatment has been definitely determined by the experiences here narrated. But as they are

1 American Journal of Medical Sciences, October, 1874, p. 324.