Compliments of 
DR. PEPPER. [Extracted from the American Journal of the Medical Sciences for October, 1874.] 
ON THE 
LOCAL TREATMENT OF PULMONARY CAVITIES BY 
INJECTIONS THROUGH THE CHEST-WALL. 
By WILLIAM PEPPER, M.D., 
<k £kr\ < : 
CLINICAL PROFESSOR OF UN*1 VQP.RSITY OF PENNSYLVANIA. 
V ■■ f r . jn ’ 
It is not difficult to explain the recent revival of interest in the attempt 
to employ direct local applications in the treatment of phthisical cavities 
in the lungs. Undoubtedly it may be partly traced to the increasing 
familiarity and confidence in the use of delicate trocars and exploring 
needles in puncturing different tissues for purposes of diagnosis or for the 
removal of morbid effusions. But even more largely is it to be traced to 
the recent modification of medical opinion as to the nature and prognosis of 
certain cases of pulmonary phthisis. As far back as our knowledge goes, 
there have been occasional reports of recovery of cases of reputed phthisis, 
and many of the older authors freely admitted the possibility of such an 
occurrence. It is difficult for us to determine at the present time how 
far this belief was unfounded, or how far it was justified by the actual 
results of their practice. Our greatest difficulty in appreciating the value 
of such opinions lies in the simple fact that all clinical histories of thoracic 
disease, published before the introduction of percussion and mediate auscul- 
tation, and where the diagnosis is not verified by post-mortem examination, 
are hopelessly vitiated. No one, even at the present day, when the know- 
ledge of aetiology and symptomatology is so precise, would pretend to 
diagnose, without the aid of auscultation and percussion, between empyema 
with or without pulmonary fistula, chronic pneumonia, bronchiectasis with 
copious purulent secretion, and pulmonary phthisis. All who have criti- 
cally studied such essentially diverse conditions as these—and their number 
might readily be increased—must be aware how deceptively similar the 
general symptoms are in certain cases, and how entirely we fall back upon 
the aid furnished by physical diagnosis. Yet it is in the face of this 
uncertainty as to the precise morbid condition present, that we are obliged 2 
to accept the conclusions of medical authors before the days of Avenbrugger 
and Laennec, drawn from their treatment of cases of chronic thoracic 
disease. I call particular attention to this point now, because it will be 
seen later that the historical discussion of the local treatment of pulmonary 
cavities has been confused by the introduction of much of this defective and 
unreliable evidence. 
Following the more precise study of the signs and lesions of pulmQiiary 
diseases inaugurated by Laennec, and the diffusion of his brilliant but too 
exclusive theories upon tuberculosis of the lungs, the most despairing 
views were adopted as to the prognosis and curability of pulmonary phthisis, 
under the idea that all cases where cheesy deposits and yellow granula- 
tions occurred were to be regarded as essentially tuberculous and incurable. 
It would be presumptuous as well as out of place at present, to speak 
decidedly as to the nature of certain apparently distinct lesions frequently 
met with in the lungs. The results of modern investigation have carried 
medical opinion on this subject first in one direction, then in another, and 
the remarkable discussion upon tuberculosis held at the sessions of the 
London Pathological Society, during the past winter, may be taken as 
proof of the difficulty of definitely formulating our present knowledge of 
the nature and relations of the various lesions known as true miliary 
tuberculosis, cheesy infiltration, and fibroid degeneration. But though it is 
probable that Niemeyer and his immediate followers were extravagant in 
their views of the essentially non-tuberculous character of many cases of 
pulmonary phthisis, the clinical fact remains that in different cases of 
phthisis the morbid process presents vast differences, both in its vital 
tendencies and gross anatomical characters ; in its rapidity of development, 
tendency to extension and diffusion, and influence upon the general health. 
The attempted classification of phthisis has also been derided on account 
of the signal want of success of any of the plans of treatment which were 
introduced in consequence of the modified theory of the nature of the 
disease. Undoubtedly no specific has been discovered, nor is it possible 
that one ever should be. Unfortunately, also, no new remedies or new modes 
of using old ones have been introduced which have sufficed to very materially 
change the former well recognized course of pulmonary phthisis. But 
still it would be most short-sighted to deny that the whole discussion has 
been highly serviceable to the treatment of this complex condition. It 
reawakened an interest and enthusiasm in the attempts to cure phthisis, 
which is already bearing fruit in a more judicious adaptation of remedies 
to special cases ; and in a more extended study of the influence of diet, and 
especially of climate, upon the different forms of the disease. 
The recognition of the importance of inflammation as a cause of many 
of the lesions met with in phthisical lungs, and the fact of some cases 
depending in the early stage, if not throughout, upon an unhealthy low 3 
grade of inflammation of the lung tissue, led me, so far back as 1867, to 
begin the consideration of the possibility of applying directly to the seat 
of the disease some of the alterative agents which prove so effectual in 
the treatment of analogous inflammatory states of external tissues. 
After passing in review the various modes by which this might be 
accomplished, I concluded that it could be most safely and satisfactorily 
done by passing a very delicate canulated-needle through the intercostal 
tissues into the diseased area, and injecting suitable fluids directly into 
the affected tissue. I began this mode of treatment of cases of pulmonary 
vomicae in February, 1874 (Phila. Med. Times, March 14, 1874), and a 
few weeks afterwards received the number of the Berliner Klinische Woch- 
enschrifl, October 27, 1873, containing an account by Prof. W. Mosler, 
of Griefswald, of several cases treated in a somewhat analogous manner. 
1 have already spoken of a recent revival of interest in this question, 
but in reality the local treatment of vomicae in the sense in which the term 
is here employed and in the manner which will be fully detailed, has never 
been attempted, so far as I am aware, until very recently. As this question 
has, however, given rise to some discussion, it may not be without interest 
to consider the following points :— 
1st. The history of the direct local treatment of pulmonary cavities by 
thoracentesis. 
2d. The indications it is designed to meet. 
3d. The more recent methods proposed. 
4th. The dangers and disadvantages of such treatment. 
5th. The clinical results of this mode of treatment. 
It is extremely difficult either to confirm or disprove the statements 
made that Hippocrates recommended puncturing pulmonary cavities. In 
very many places in the Hippocratic writings (both in those which are 
undoubtedly genuine, as well as in those which are plausibly attributed to 
some writers of the Cnidian school) we find mention made of empyema, 
of its diagnosis, terminations, and mode of treatment, in which paracen- 
tesis thoracis always has a place. In some instances the language used 
in describing the cases of so-called empyema is such as to have led the 
eminent scholar Littre (OEuvres Completes d1 Hippocrate, tom. ii. p. 97) 
and Francis Adams, the editor of the Sydenham Society edition of the 
genuine works of Hippocrates, to doubt whether this term was not some- 
times used to denote phthisical cavities. The conclusion to which I have 
myself been led is that the cases of paracentesis referred to by Euryphon 
of Cnidos, by Hippocrates, Galen, Aetius, Avicenna and Avenzoar, and 
by Rhazes, were performed for the relief of empyema. Owing, however, 
to the absence of any reliable diagnostic symptoms, it may be that in 
some instances pneumonic abscesses or even tuberculous cavities were 
punctured. It appears unlikely, however, that this latter lesion is intended 4 
in their descriptions, since, as a rule, the operation is directed for the 
evacuation of a collection of pus, and very frequent mention is made of 
the external appearances which indicate the approach of the pus to the 
surface by ulceration of the intercostal tissues. So far as an analysis is 
permitted of the clinical histories of such cases they would seem to refer 
rather to the development of pyothorax than of pulmonary phthisis. It 
may at least be safely concluded that none of the older physicians de- 
signedly recommended or practised thoracentesis in cases of phthisical 
cavities in the lungs. 
Still less can we determine from the writings of authors during the 
middle ages that this operation was ever performed at that time. Para- 
centesis, even for clearly recognized pyothorax, was almost abandoned : it 
being scarcely admitted, according to Trousseau ( Clinical Medicine, Syd. 
Soc. Ed., vol. iii. p. 207), that there were any cases, except those of sur- 
gical lesions, in which the operation ought to be performed. Ullersperger, 
in his treatise on the curability of phthisis {Die Frage u. d. Heilbarkeit 
der Lungenphthisen, Wurzburg, 1867, p. 234), affects to regard the punc- 
turing of tuberculous cavities as a mere form of paracentesis for empyema, 
and quotes without hesitation, but without any proof, a list of nearly- 
forgotten writers as having performed it. So far, however, as can be 
inferred from their imperfect descriptions, there seems little doubt that the 
operations were performed for the relief of ordinary cases of empyema. 
Coming to more recent times, when thoracentesis had regained favour 
and was made the subject of numerous treatises, we find Baglivi, in 1696, 
using the following language :— 
“A phthisick arising from an ulcer is commonly branded as incurable, upon 
the plea that the ulcer is internal and occult, and cannot be cleaned like other 
external ulcers. But why do they not make it their business to find out the 
true situation of the ulcer, and make an incision accordingly, between the 
ribs, to the end that proper remedies may be conveyed to it ? For my part, I 
know no reason why that should be neglected. About seven years ago, when 
1 was at Padua, a man received a wound in the right side of his breast, that 
reached to his lungs, and, employing an able surgeon, had an incision made 
between the ribs to the length of six fingers’ breadth, in order to discover the 
situation of the wound in the lungs, which was perfectly cured in two month’s 
time, with vulneraries applied with tents and with syringes. Now practitioners 
ought to use the same piece of diligence in curing a phthisical ulcer in the 
lungs, lest the scroll of incurable diseases should grow too long, to the infinite 
disgrace of the profession.”—Practice of Physick (English trans.), 2d edition, 
London, 1723, p. 301. 
This is referred to by Ullersperger (loc. cit.), and is quoted in full by 
Hutchinson (Phil a. Med. Times, May 30, 1874, p. 548), in a critique 
upon my former article on this subject, with the following comment: 
“ We have sufficient evidence in the above that the propriety of estab- 
lishing a communication between the lungs and the outer air through the 
walls of the chest, for the purpose of applying remedies directly to the 
seat of disease, in cases of phthisis, was entertained as early as the seven- teenth century.” Unquestionably credit must be given to Baglivi for the 
suggestion that such a procedure should be employed ; but the very terms 
in which he advocates it sufficiently imply that its propriety was not en- 
tertained by physicians, while with himself it appears to have been a mere 
speculative idea, which he never attempted to carry out. As to the case 
which is so briefly narrated by Baglivi, it seems difficult to form any clear 
idea of the condition actually present. It can hardly be credited that an 
incision not less than four inches in extent was made down to the surface 
of the lung soon after a penetrating wound of the thorax. The favour- 
able results often observed in such cases when the wound is quickly 
closed and the case trusted to nature, would render such an operation most 
improper. If pneumothorax did not already exist, it would certainly be 
induced. More probably the case was one of limited pleural abscess or em- 
pyema following a penetrating wound of the thorax. Many cases of this 
kind, treated in the same way and with equal success, are to be found in 
even older writings than those of the learned Baglivi. 
A much more valuable contribution to this subject was made by Barry 
(Treatise on Consumption, 2d edition, London, 1127, p. 267), also 
quoted by Ullersperger and Hutchinson, who describes carefully the ana- 
tomical relations of phthisical cavities, pointing out especially that there 
is generally close adhesion between the pleurae over their seat, so that an 
incision might be made into them without danger or difficulty. In his 
first publication, after discussing the operation with remarkable clearness, 
he says : “ ’Tis most certain that many phthisical persons may by this 
means be preserved, that will otherwise unavoidably perish. If the ope- 
ration be rightly performed, there is great reason to expect success, neither 
if it fails can it be attended with any very great danger, or much con- 
tribute to hasten their fate.” He adds, as another advantage of the ope- 
ration, that “ the ulcer may be more easily cured by deterging and healing 
injections.” In his later publication (Treatise, on the Three Different 
Digestions, etc., London, 1763, p. 360 et seq.), he repeats the same 
reasoning and advice, and gives several cases in which he had the operation 
performed. When we remember, however, that he had no better guide to 
direct him in his diagnosis than “ to open the breast where the most fre- 
quent pain and oppression direct the situation of the ulcer,” it is not 
surprising that it should appear doubtful, after a careful study of these 
cases (although accepted unquestioningly by Hutchinson), whether it 
was really a pulmonary cavity which was opened in a single instance. 
Certainly the clinical symptoms detailed are very unlike those so familiar 
in phthisis, and very similar to the phenomena of some cases of circum- 
scribed empyema, in some instances opening into the lung tissue and partially 
discharging through the bronchi. Mosler refers to Barry’s views as being 
without practical results, but this scarcely assigns to them their proper 
value, since not only did they lead Barry himself to attempt the opera- 6 
tion, but it will be seen that more than a century afterwards they induced 
the performance of operations which anticipated, in many particulars, those 
of Hosier himself. 
In the present century Richter (Bemerk. u. d. Lungensucht, in den 
gelelirten Gotting. Anzeigen 49. Stuck v. 28. Marz., 1805, p. 481) 
recommends incising pulmonary cavities, and reports two supposed cases 
in which he operated successfully. In the first of these, redness, swelling, 
and fluctuation presented themselves in the fourth interspace, and an in- 
cision at this point gave exit to a large amount of pus, followed by re- 
covery. In the second, the patient became phthisical after an attack of 
pneumonia. An incision was made over a spot where there had been 
fixed pain, fluctuation was detected, and pounds of pus evacuated, after 
which the patient gradually recovered. 
These may be taken as illustrations of a number of cases which have 
been published before or since, where it is difficult to doubt that, although 
the operator recommended the operation with the deliberate intent of 
evacuating a phthisical cavity, he had in reality to do with a simple 
empyema, or possibly a true pneumonic abscess, though this latter lesion 
is so rare that it can hardly have existed in any large proportion of the 
cases recorded. Such cases were published by Herff, quoted by Canstatt 
(Spec. Path. u. Ther., von Henoch, 3te. Aufl. 2 Bd. p. 687), but I 
have not been able to get access to the original account. 
Ilamadge (Consumption Curable, London, 1836), who wrote a treatise 
characterized by the most unbounded egotism and ignorance of pathology, 
in support of his method of curing phthisis by forced inhalation, reports 
several cases where thoracentesis was performed. In the first case, called 
by him “supposed consumption cured by paracentesis,” slight swelling 
presented itself two inches beneath the left nipple,.and the heart was dislo- 
cated to the right; an incision through the intercostal tissues gave issue 
to yellow pus with a quantity of air which rushed out with a hissing 
sound. Unquestionably this was a case of pneumothorax following an 
empyema which had partly discharged through the lung. In the second 
case, styled “ Consumption cured by Paracentesis,” the clinical history, the 
description of the operation, and the results of post-mortem examination 
all show that the case was one of chronic plastic pleurisy, with fibroid 
change in the apex of the right lung, and that the operator merely introduced 
a trocar through the fourth intercostal space into comparatively healthy 
lung tissue, without causing any serious results. In his fifth case he de- 
scribes the operation on a patient with phthisis, who had a chronic abscess 
in the apex of the left lung, as follows :— 
“ A trocar was introduced between the second and third ribs, in a line 
nearly perpendicular with the left nipple ; very little matter escaped, as I had 
expected, for my chief object in performing' this operation was to insure the 
emission of the air, and thus effect a diminution of the cavity by the expan- 
sion of the inferior lobe of the left lung. 1 kept the punctured place open for about ten days, by the introduction of a small piece of catgut properly secured 
externally ; when, finding- that the cavity became so contracted, through the en- 
croachment made on it by a general pulmonary expansion, as to preclude all 
further escape of air, I withdrew it. About this time a catarrhal affection of 
the inferior lobe of the punctured side supervened. In less than two months 
my patient was able to go out, and had completely lost his phthisical symp- 
toms. In less than two years after the operation he was in the enjoyment of 
excellent health, the only drawback being the existence of catarrh, to which 
he more immediately owes his recovery.” 
It is evident that in all of these cases the intention was to directly open 
pulmonary cavities, though it may be doubted whether, even in the last 
case, the end was obtained. Certainly the procedure, undertaken with a 
most mistaken object, cannot be regarded as having had the slightest in- 
fluence upon the condition of the patient. In a brief article published 
nine years later, Dr, Herbert, a pupil of Dr. Ramadge, states that 
“ within eighteen months, he has been present at seven such operations 
performed under Dr. Ramadge’s direction, and has in no ca.se seen them 
attended with any inconvenience or followed by disagreeable consequences.” 
(Lancet, 1845, vol. i. p. 15.) Unfortunately, this appears to be the sole 
record of the cases, and although it is evident from this that Ramadge 
continued to puncture chests where he supposed cavities to exist, in order 
to “give exit to the air,” and “ induce expansion of the surrounding lung 
tissue,” it is impossible to determine the real nature of the cases operated 
on or the results of the operation. It is certain that the arguments by 
which he supported his practice very naturally failed to attract attention 
or to induce others to follow his example. 
In the year 1845, Dr. Hastings and Mr. Storks (London Med. Gaz., 
1845, vol. xxxv. p. 378), published an interesting and well-observed case 
of pulmonary phthisis, with a large cavity at the left apex which was 
opened by the latter by an incision in the third interspace. A piece of 
gum-elastic catheter was introduced and worn constantly from the date of 
the operation, November 15, 1844, to December 23, 1844, which is the 
latest detailed report of the case. Pus was discharged through the tube 
from time to time, and it is reported by Dr. Hocken (London Med. Gaz., 
1845, vol. xxxv. p. 481 and 509),1 who conducted the subsequent 
treatment of the case, that the patient’s general symptoms im- 
proved, with a diminution in the cough and amount of purulent secretion. 
A still later report is made by Dr. Hastings (London Med. Gaz., 1845, 
vol. xxxvi. p. 767), who, writing six months after the operation, says: 
“ Although very weak, the patient has latterly been able to get out when 
the weather has been fine. His expectoration for the last two or three 
months has not averaged more than two drachms in the twenty-four 
hours.” 
1 These are the papers referred to by Mosler, under the name of Hooken, with 
statement that he had been unable to discover them. 8 
These authors quote Barry (loc. cit.) as their authority for the operation, 
but do not seem to have ever heard of the publication of Ramadge. 
It is certainly not a little singular that after this time, the subject ap- 
pears to have attracted no attention whatever, and that the remarkable 
cases to which we have above referred, should have induced none of the 
many physicians specially engaged in the study of pulmonary diseases to 
examine into the value of this simple operation. With the exception of 
a courteous, but not convincing critique by Campbell (Lancet, 1845, vol. 
i. p. 675), no discussion appears to have been aroused, and the matter fell 
into entire forgetfulness. 
It is not alluded to by Trousseau in the exhaustive history of Thora- 
centesis in his Clinique Medicate, nor by Walshe, nor Copland, nor even 
by Waldenburg {Die locale Behandlung d, Krankh. d. Athniungsorgane, 
Berlin, 1872). Canstatt observes merely, in referring to the recommenda- 
tions of Herffand Hocken, that they will scarcely find many followers, since, 
apart from the uncertainty of the existence of pleural adhesions, the emp- 
tying of a cavity could have no beneficial influence upon a disease, which 
is usually characterized by the formation of several cavities, and which 
springs from a general diathesis. And Bennett (Reynolds’ Syst. of Me- 
dicine, first ed. vol. iii. p. 589) briefly says : “ pulmonary cavities have 
even been opened from without, and variously treated with the view of 
causing cicatrization, but all such attempts have been, what an intelligent 
consideration of the pathology of the disease might have anticipated, a 
uniform failure.” 
It is difficult to explain the almost entire failure of this operation 
to attract even the criticism of eminent observers. It is true that 
it had been by some recommended for objects which were evidently un- 
attainable, and that the cases which were given in illustration of its 
successful performance were so inaccurately reported as to afford no sound 
basis for its repetition, although neither of these objections can be brought 
against the case reported by Hastings. More probably it was condemned 
by medical pathologists on the ground that it was directed only against a 
local expression of an incurable constitutional disease. And it is also quite 
possible that some unfortunate cases which have not been placed on record 
may have helped to bring it into disrepute. 
Within the past few years we find several observers engaged in the 
study of this subject. Thus in 1873, Dr. Wilhelm Koch published {Langen- 
beck's Archie, f. Klin. Chir., 15te Bd. 3te lift.) the results of experiments 
which showed that injections of dilute solutions of iodine might be made 
with impunity into the lung tissue of dogs ; and suggested, in consequence, 
that this mode of treatment might be applicable to some diseases of the 
lungs in human subjects. This article seems to have attracted no notice, 
and was unknown even to Mosler (Berl. Klin. Wochenschr., No. 45, 9 
November 10, 1873, p. 542), at the time of publication of his article 
referred to below. 
The attention of the profession was more forcibly attracted to this sub- 
ject by Mosler of Griefswald (id. op., October 27, 1873), who appears to 
have been ignorant that the operation had ever been performed, merely 
stating that “such a proposition was made by Barry in 1726, and renewed 
later by Masse, v. Herfif, Hooken (sic), without, however, any practical 
results.” 
In two cases he simply punctured the cavity with a “ tolerably large 
canula” which was permitted to remain. In a third case he operated very 
much after the manner of Storks (loc. cit.), by making a long incision 
(3 ctm.) along the upper border of the 3d rib, and then gradually opening 
the wall of the cavity with a suitable pair of forceps, and introducing a 
pretty large silver drainage tube ; but in addition he conjoined the use of 
medicated injections through the canula directly into the cavity. In the 
first case, one injection of dilute solution of permanganate of potash was 
practised ; in the second, five were employed ; and in the third case, their 
use, as well as that of dilute solution of iodine and carbolic acid, was con- 
tinued for some time. The particulars of this interesting paper (Ameri- 
can Journ. of Med. Sci., July 1874, p. 253), are so fresh in the minds 
of our readers as to render further allusion unnecessary. Suffice it to say 
that in none of the cases did the slightest ill result attend the operation or 
the subsequent injections, and that in the only instance in which the latter 
were employed continuously, there was a positive improvement in the pul- 
monary symptoms, although death occurred three months subsequently from 
albuminoid degeneration of the kidney and spleen, associated with dissemi- 
nated miliary tubercles in the left lung. 
In February of the present year I began to treat pulmonary cavities by 
injecting dilute solutions of iodine through a delicate canula, and have 
continued to do so until the present time with results that will be given 
in detail at the close of this paper. At that time I was unaware that the 
local treatment of phthisical cavities had ever been attempted before, and 
it will be seen that the method which I have used differs in several very 
important respects from any hitherto employed.1 
1 The mere question of priority as to the idea of local treatment of pulmonary 
cavities seems to me very unimportant. In the London Lancet for March 28,1874, 
Dr. Birkard states that he conceived this idea so long ago as 1872, and that 
lately he has injected a weak solution of carbolic acid t hrough the thoracic parietes 
into the lung in a very bad case of phthisis. The injection seems to have been 
performed but once, and to have caused no inconvenience, but no details what- 
ever are furnished. Prof. Mosler has been engaged upon the subject since the 
latter part of 1872. I have already alluded to my determination announced so 
far back as 1867: but Baglivi in 1696, although it is not probable that he ever 
carried it into execution, clearly expressed the suggestion that this local treat- 10 
Before proceeding to speak of the actual results, so far as known, of the 
local treatment of phthisical cavities, it is proper to allude briefly to the 
indications which may be thought to present themselves in favor of this 
method, as well as to the objections which have been advanced against it. 
It is very easy to overstrain the argument which is often drawn from 
the unfavourable nature of a disease in support even of the most unpromis- 
ing plans of treatment. And yet, in the present discussion, it is but fair 
to bear in mind that the treatment proposed is for a condition which is 
universally conceded to be usually a mortal one. It is true that, in the 
earlier stages of phthisis, even after the general symptoms and physical 
signs positively indicate organic disease of the lung tissue, recoveries are 
not rarely observed. But after a cavity of considerable size has formed, 
even though it be single, the remaining lung tissue healthy, and the con- 
stitutional disease inactive, the course of the case is generally downward. 
Pollock, in his masterly memoir on the Elements of Prognosis in 
Consumption, says :— 
“ The cure of cavity in the lung has long been a vexed question. I presume 
there is now no doubt in the minds of the most experienced observers that 
cavities close and heal up. If the cessation of all the physical signs of such a 
lesion, and the perfect restoration of health, be considered evidence sufficient, 
there are cases enough'of this kind on record by good authorities to justify 
the opinion that this form of cure is possible. But all agree that it is not fre- 
quent ; and its infrequency must be apparent from the facts that, out of an 
experience of 4530 cases, most carefully noted at the Hospital for Consumption 
by myself personally, I can only place on record 68 cases of well circumscribed 
cavity, with 13 presenting the characters of ‘ retracted cavity,’ in all 81 in- 
stances in which the patients seemed progressing towards a cure of cavity.” 
It will probably be the experience of most observers that, although 1.8 
per cent, of patients with circumscribed cavities of considerable size may 
for a long time seem progressing towards a cure, a far less proportion 
will actually enjoy entire recovery. 
The dangers which surround a patient with a pulmonary cavity are 
indeed serious. There is, in the first place, the risk of hemorrhage which, 
though rarely directly fatal, is often profuse. Granting also that the 
original disposition to tuberculous deposition has been expended, or that 
the cavity has proceeded from a non-tnberculous ulcerative process, recent 
observations have demonstrated the great danger of secondary constitu- 
tional infection and the development of miliary tuberculosis in cases where 
there are long-standing centres of softening caseous infiltration or of un- 
healthy suppuration. It should also be remembered, that, under the most 
favourable circumstances, patients with lung cavity are constantly in a state 
of feeble vitality, sufferers from harassing cough and dyspnoea on exertion, 
ment was feasible. The only merit in question seems to me to be in connection 
with tlie actual demonstration of the feasibility and clinical value of making local 
applications by thoracentesis to lung cavities, the determination of the best man- 
ner of doing this, and the decision as to which cases are best suited for such treat- 
ment. 11 
and liable to dangerous intercurrent attacks. Unfortunately, in the vast 
majority of cases we also find evidence that the diseased action is invading 
the lung tissue surrounding the cavity, and that the morbid process shows 
little tendency to become circumscribed. 
The objects which have been sought by the ordinary methods of treat- 
ment in such cases, have been to remove the constitutional diathesis, to 
disinfect the discharge from the cavity, to check the paroxysms of cough, 
and to alter by counter-irritants, internal remedies, and inhalations, the 
morbid action in the walls of the cavity. 
So it will be observed that the objects proposed by the authors who 
have recommended opening the cavity, are similar in character. It is true 
that Ramadge (op. cit.) advocated the operation with the curious notion 
that, by insuring the emission of the air, he could effect a diminution of 
the cavity by the expansion of the remaining portion of the lung, bring- 
ing the surfaces of the cavity into contact, so that they would unite and 
cicatrize. But Barry, in 1727 (op. cit.), recommends forming an artificial 
opening into the cavity, in order that the matter may be readily and com- 
pletely discharged, and that, by thus avoiding the necessity for violent par- 
oxysms of cough, the diseased part may be kept more at rest, while, at the 
same time, suitable detergent injections may be employed So, too, 
Hastings and Storks (loc. cit.) performed this operation with the same 
objects in view, and, as has been seen, endeavored to secure them by leav- 
ing a piece of gum catheter in the wound, so as to maintain the direct com- 
munication between the cavity and the external air. One of the results 
obtained, then, by this operation, as performed by Storks and repeated re- 
cently by Mosler, is a certain degree of rest for the walls of the cavity and 
the tissue immediately surrounding. It is of course evident that, as the 
cavity will freely communicate with the air, both by the bronchial tubes 
and by the eanula, its walls will still be subjected to ordinary atmospheric 
pressure which will suffice to prevent any marked collapse of the cavity. 
But, on the other hand, as the air which enters from the bronchi during 
inspiration can immediately and freely escape, it will be found that the 
respiratory movements of the lobe containing the cavity become much di- 
minished. In addition to this, the regular and free discharge of the puru- 
lent secretion of the cavity through the eanula, will, as would be antici- 
pated, and as has been shown by experience, lessen the frequency and seve- 
rity of the cough. In rare cases, the communication of the cavity with 
the bronchi is such that the pus which forms readily passes into the air- 
tubes and is expectorated with ease. But most frequently, the process of 
emptying a cavity by cough is a wearisome, painful, and injurious one; 
and, as the paroxysms are often excited by eating and drinking, it is by 
no means rare to have such frequent vomiting from this cause as to seri- 
ously interfere with nutrition It can scarcely be doubted that the avoid- 
ance or mitigation of this violent cough, and the comparative rest given 12 
to the cavity, would favour cicatrization of its walls and tend to prevent 
its extension. 
The other advantage which is gained by this mode of operating (insert- 
ing a comparatively large canula) is the power of disinfecting the contents 
and walls of the cavity by injections. Although mention is made by some 
of the earlier writers of the use of detergent applications, it cannot be 
shown that such injections into lung cavities were really employed before 
their use by Hosier. It appears to me, however, that this author has at- 
tached undue importance to the mere disinfection of the secretion of the 
cavity as compared with the modification of the morbid action in the wall 
of the cavity itself. The opportunity of endeavouring to bring about such 
a modification is, indeed, to my mind, the greatest advantage derived from 
this operation. It can be effected when a canula has been allowed to re- 
main in the opening by injecting directly into the cavity a suitable amount 
of such dilute solutions as may seem proper. Hosier introduced weak 
solutions of iodine and carbolic acid in one of his cases by atomization, 
but appears to have aimed chiefly at the disinfection of the contents of the 
cavity. Up to this time, I have limited myself in the local treatment of 
phthisical cavities, to the repeated injection, through a delicate canulated 
needle, of small amounts of solutions of iodine of various strengths, the 
canula being introduced into the cavity at the time of each injection and 
immediately withdrawn. As thus performed, of course the operation does 
not affect the relations of the cavity to the external air, nor does it in any 
way facilitate the escape of the secretion. The sole value of such treat- 
ment must then depend upon the question whether we are able to modify 
beneficially the morbid action on the surface of pulmonary cavities and in 
the surrounding diseased lung tissue. Dr. Hutchinson (loc. cit.), in 
speaking of this point, says :— 
“ Moreover, the opinion that injections may be of service in the treatment 
of phthisis rests, we think, upon a mistaken therapeutic basis. In certain con- 
ditions of the serous membranes, they are unquestionably useful by exciting 
inflammation, but a little reflection will convince any one, who has abandoned 
in whole or in part the theory which makes phthisis the result of tubercular 
deposit, that this is the very last thing to be desired in the disease. The ob- 
ject aimed at in the management of phthisis, and especially in those local cases 
in which Dr. Pepper thinks the injections are most likely to be useful, is to 
allay inflammatory action, not to excite it. We therefore are unable to see 
how they can be productive of any good ; on the contrary, if they light up an 
inflammatory process in the walls of the cavity, this will be very likely to ex- 
tend to the circumjacent tissue, and thus the disease, which may have been 
previously held in abeyance, be roused into activity.” 
We must remember, however, that the terms allaying and exciting in- 
flammatory action are purely relative ones, dependent upon the grade of 
morbid activity present. It can hardly be thought desirable, in a case 
where a caseous pneumonia is rapidly degenerating and breaking down in 
the centre, to attempt to allay the morbid action. It is probable that 
our best chance of preventing the ulcerative destruction of the whole af- 13 
fected area would be, if it were possible, to apply a sufficiently powerful 
stimulus to excite a more healthy decree of cell action in the least affected 
parts, so that we might induce the development of fibro-cellular tissue, and 
thus limit the morbid process. We are perfectly familiar with the neces- 
sity and practical rules for graduating the stimulant or sedative characters 
of applications to external ulcers; and know well that there are many 
cases of unhealthy destructive ulceration which are most relieved by pow- 
erful alterative stimulant applications. There is a wide difference in the 
action of such substances when applied to the seat of the disease, and 
when applied to the surrounding healthy tissue; and applications which 
are most useful when made directly to a phagedenic ulcer, might, if made 
to healthy tissue in the neighbourhood, excite destructive ulceration. 
So, too, with regard to circumscribed cavities, which are often lined with 
a layer of granulation-tissue which is constantly the seat of the formation 
of pus—the so-called “ pyogenic membrane”—it is perfectly conceivable 
that some application might be made which would not allay the inflam- 
matory action there, but excite a more healthy action by its alterative 
stimulant effect, and thus lead to a diminution of secretion, and a progres- 
sive contraction and cicatrization of the cavity.1 
It is evident of course that the analogy between ordinary external ulcer- 
ations dependent on local causes, and ulceration of the lung tissue, must 
be drawn with great caution. It is the most hopeless feature of the latter 
that it is so frequently dependent upon a profound alteration of general 
nutrition, and that it is so apt to be associated with the presence of specific 
tuberculous formations in the lungs. Undoubtedly, therefore, in cases 
where the constitutional diathesis is marked, and the cavity is associated 
with diffused disease of the lung tissue, no one would think of undertaking 
a special treatment for the cure of the cavity. But, on the other han'd, we 
meet with many cases where, without raising the question of their relation 
with tuberculosis, the constitutional affection is at a minimum, and the 
pulmonary disease is comparatively circumscribed, consisting of a cavity, 
secreting pus, and surrounded by more or less fibroid induration or cheesy 
infiltration of the lung tissue. We are familiar with the dangers in such cases 
—of gradual exhaustion, of hemorrhage, of progressive extension of ulcer- 
ation, and of secondary infection of the constitution—and I can conceive 
of nothing more desirable in practical medicine than to be able to modify 
1 Dr. Hutchinson alludes to the development of connective tissue, “ the effect 
of which will be to enlarge and keep open the wound made by the aspirator or 
trocar, and thus to allow the escape of the contents of the cavity into the pleural 
sac whenever this is not prevented by close adhesions.” I cannot discover the 
force of this objection. The opening made by a delicate needle is so minute that 
it can scarcely allow the escape of any fluid, and if there are any cases of phthisis 
where pleural adhesions are sure to exist, they are precisely those where there is 
a marked development of fibro-cellular tissue in the lung. 14 
the action of the inner surface of such a cavity, to check the amount of 
purulent discharge, and thus favour its gradual cicatrization and contrac- 
tion. Under the most unfavourable view of the essential nature of such 
lesions, I can conceive of no objection to such an attempt, provided it can 
be made with safety ; and when we are in possession of a method by which 
this can be effected, it seems to call for a patient and extended trial. In 
considering carefully the clinical histories of cases where lung cavities have 
undergone cure, it will be found that so long as active secretion of pus takes 
place from the seat of disease, with violent paroxysms of cough, there is 
little progress towards cure. But as the ulcerated surface heals, there is a 
development of fibro-cellular tissue around the cavity which continually 
tends to contraction. The discharge diminishes and the cavity is less fre- 
quently subjected to the violent distension occasioned by severe coughing. 
The chest-walls over the site become depressed and retracted, the heart is 
displaced towards the affected spot, partly by the traction of the contract- 
ing lung, partly by the pressure of the opposite lung, which undergoes 
compensatory hypertrophy and encroaches more and more upon the me- 
diastinal space. It is thus seen that the phenomena which attend the 
cure of a lung cavity are similar to those with which all are familiar as 
marking the eure of a chronic pleurisy where the lung is so bound down 
by adhesions as to be unable to expand. And it will be noted that, in the 
cases reported in this article, the improvement in the cavity is attended, 
and to a certain extent measured, by the development of these phenomena 
of compensation. 
I have already said that the most important object sought by this local 
treatment of lung cavities seemed to be this very modification of the mor- 
bid action of their lining surface; and it is on this account that the mode 
of treatment suggested in my former paper appears to me preferable 
to the operations of Storks or Mosler, although by these a free escape of 
the discharge from the cavity is secured, and its walls are more immedi- 
ately afforded rest. It enables us to bring any desired amount of an ap- 
propriate solution in contact with the inner surface of the cavity, or with 
any part of its wall; while at the same time it is entirely free from the 
objection of maintaining local mechanical irritation, such as might result 
from the prolonged presence of a canula. In order to show how simple a 
mode of treatment it is, and at the same time how well calculated to fulfil the 
chief indication we have laid down, I will ask attention to a brief description 
of the manner in which 1 have carried it out during the past six months. 
The cavities which have hitherto presented themselves for treatment 
have been in the upper lobe, so that all of the punctures which I have as 
yet made have been in the first, second, or third interspace. The point 
selected has been that at which the physical signs of a superficial cavity 
have been most intense. As a rule, the punctures have been made in the 
line of the nipple, although recently in two cases, owing to the increasing 15 
contraction of the cavity and development of fibroid tissue, it has been 
necessary to select points half an inch inside or outside of the nipple line. 
The apparatus consists simply of a very delicate steel canulated needle, 
like the finest hypodermic needles, but about three inches in length, and 
an ordinary hypodermic syringe capable of holding twenty-five minims. 
In my first experiments I used an aspirator, but as the withdrawal of any 
pus is not contemplated, it is in every way preferable to employ the more 
simple apparatus above mentioned.' 
In order to diminish the pain caused by the puncture, I have always 
employed local anaesthesia by freezing, and with this succeed in effecting 
the treatment without causing a murmur of complaint. Occasionally small 
filaments of nerves have been pricked, and have caused tingling, radiating 
pain, lasting for a few moments. The injections have been given while 
the patients were in a sitting posture, and I have usually directed a full 
breath to be taken before the puncture is made, and to be held during the 
injection. The time occupied by each injection does not exceed thirty 
seconds. The depth to which it will be necessary to introduce the needle 
will vary, of course, in different cases; in the injections which I have 
myself made, I have introduced it from one and a half to two inches. With 
a very little care the ribs can be avoided ; and a reference to the anatomi- 
cal distribution of the nerves and vessels in the thoracic walls will always 
enable the puncture to be made so as to avoid them. The only fluid which 
I have as yet injected into lung cavities, has been dilute liq. iodinii comp 
In the earlier injections, this was used very weak to f3j), but for 
some time past I have increased it to rr^xij in a fluidrachm ; the quantity 
has also been gradually increased from four to twenty-five minims for each 
injection. The entire absence of any signs of irritation assures me that, 
if it were desirable, larger quantities of stronger solutions might be injected. 
The results of injections of iodine have been so satisfactory in the limited 
number of cases in which I have employed this mode of treatment, that I 
have felt indisposed to use any other substance. But it is highly probable 
that other solutions, alterative, astringent, or antiseptic, may be found 
preferable in some cases. Unmistakable evidence of the entrance of the 
iodine into the air-passages has frequently been secured by the immediate 
perception of its pungent peculiar taste by the patients. I need only add 
that hitherto the injections have usually been made once a week on an 
average ; and that, of course, every detail of internal treatment and dietetic 
and hygienic care has been continued, as far as practicable in hospital 
patients. 
It remains, before giving the actual results of this method of treatment, 
to examine briefly what dangers and disadvantages attend it. We trust, 
1 Indeed, I believe that the use of the aspirator is not without danger, as the 
powerful suction brought to bear on the inner surface of the cavity may cause 
hemorrhage. (See Case IV.) 16 
in the first place, that we have succeeded in showing that, if the operation 
itself he free from danger, there are clear indications which demand for 
it a full, fair trial. We are led to say this, by clinical experience and 
theoretical reasoning, even though so careful a thinker as Dr. Hutchinson 
believes “ that it is not likely to result in good to the patient;” or though 
Dr. J. Hughes Bennett thinks the results of all operative treatment in phthisis 
to be “ what an intelligent consideration of the pathology of the disease 
might have anticipated, a uniform failure.” 
Mosler believes that he has demonstrated that “ the local treatment of 
lung cavities can be effected” even by the comparatively serious operative 
method he employed; and I do not see how his statement can be impugned. 
But as there are radical differences between his method and the one which 
I have hitherto employed, I shall limit myself to the objections which 
may be brought against the treatment of lung cavities by repeated injec- 
tions through the chest-walls, effected by a delicate needle. 
And first, with regard to the effects of the puncture itself upon the pul- 
monary tissue through which the needle passes in order to reach the cavity. 
In the cases where this mode of treatment would seem to be indicated, the 
cavity is usually very superficial, and is separated from the pleura only by 
a wall of firm fibroid tissue. It would be almost impossible, I conceive, 
for the mere passage of a delicate needle through this tissue to excite any 
injurious action. At times, however, the cavity is separated from the sur- 
face by a layer of lung tissue in a state of cheesy infiltration. In order to 
determine the influence of a puncture in such a condition, I made the fol- 
lowing observation :— 
Case I. Haemoptysis, followed by Phthisis; Rapid Extension of Dis- 
ease; Repeated Injections of Iodine into a Spot of Caseous Infiltration ; 
Death from Exhaustion ; Autopsy.—John D , ast. 29, a teamster, entered 
the Philadelphia Hospital March lltli, 1814. Has had scrofulous sup- 
puration of cervical glands, and has also had syphilis. In June, 1873, 
had severe haemoptysis, whilst doing some heavy lifting, and this was fol- 
lowed by cough. In December, grew worse, with increased cough, pain 
in left side, and hoarseness. In February of the present year, began to 
lose flesh and strength rapidly. In April, he began to suffer with intense 
hectic fever, exhausting night-sweats, and frequent cough ; his emaciation 
and prostration were extreme, and he was confined to bed. Pulse frequent, 
feeble, and markedly dicrotic. Physical examination showed consolidation 
of left lung throughout, with moist crackling over upper lobe. On right 
side, there was dry crackling at apex. 
May 8. Condition rapidly growing worse. As it seemed impossible to 
arrest the disintegration of the left lung, it was determined to try the local 
effects of injections of iodine upon the lung when in a state of caseous in- 
filtration. Accordingly of dilute Lugol’s solution (1 pt. to 6 of 
water) were injected, the needle being introduced to depth of one and a half 
inch in the second interspace. The puncture caused no symptoms whatever. 
1 Oth. Same injection repeated. 
l\th. Pulse not dicrotic ; he seems slightly stronger. 
Ihth. Same injection repeated. 21s/. Has same injection repeated. Has again begun to sink. 
24//). Disintegration of left lung advancing. Same injection repeated. 
29th. Death occurred from progressive exhaustion. 
At the autopsy, disseminated tuberculosis of the right upper lobe was 
found. The left lung was in a state of caseous infiltration throughout. 
At several spots, puriforrn softening was beginning; this was further ad- 
vanced at posterior part of the apex, where the disease seemed oldest. A 
very careful examination of the points where the injections had been intro- 
duced was made ; but there was no trace left to indicate them. The 
portion of lung into which the needle had been introduced to the depth of 
over an inch was thoroughly consolidated, and remained quite firm. 
There was no staining of this area with iodine. The pleurae were adherent 
over the whole upper lobe. No trace of the passage of the needle through 
the intercostal tissues remained. 
It will be seen, therefore, that in this case five injections of dilute 
Lugol’s solution were made at short intervals into a lung in a state of 
caseous degeneration, and that the iodine introduced was completely ab- 
sorbed by the tissue, while there was not a trace of any mechanical irrita- 
tion from the punctures, either in the intercostal tissues, the pleurae, or 
the lung tissue itself. The results of this case have an important bearing 
upon the possibility of directing local treatment to superficial circumscribed 
indurations or caseous infiltrations of the lung tissue ; but, for our present 
purpose, I would simply call attention to the fact that they agree with our 
reasonable anticipation, and with the results of clinical experience, in show- 
ing that the passage of a delicate needle through a layer of infiltrated 
lung tissue can be effected repeatedly without injurious consequences. 
Finally, it may happen that the cavity is separated from the chest-wall 
by a thin layer of healthy lung tissue. It is frequently possible to decide 
as to the existence of such a stratum of vesicular tissue by careful percus- 
sion and auscultation, and I should be inclined to regard the presence of 
a demonstrable amount of healthy tissue between the cavity and the 
thoracic wall as a contraindication against the operation. Still, it has 
been demonstrated frequently (by Bretonneau, Yelpeau, Koch, myself, and 
others) that puncture of the lungs with a delicate needle may be safely 
performed in the lower animals. Our knowledge of the results of pene- 
trating wounds of the lung would lead us to expect little injury from the 
minute puncture effected by a delicate needle; and finally, it has been 
shown by some of the advocates of acupuncture that fine needles may be 
introduced even to a depth of two inches1 into the healthy human lung, 
without any injurious effect. 
As to the danger of hemorrhage, in the second place, all experience goes to 
show that it is very slight, even if it exists at all. Dr, Hutchinson (loc. cit.) 
states," in one of the cases reported by Dr. Pepper a slight hemorrhage fol- 
1 Memoir on Acupuncturation, by Morand, translated by Franklin Bache, Pliila. 
1825, p. 65. 18 
lowed the introduction of the aspirator ; and the same accident occurred in 
the operations done by Dr. Mosler and Dr. Hastings.” In Dr. Mosler’s case, 
however, the statement is distinctly made in the account of the operation 
that "no hemorrhage occurred.” Ten days subsequently a haemoptysis 
occurred, and was soon checked by astringents blown through the canula. 
As the patient is stated to have already had several similar attacks before 
the operation, the last one can hardly, with fairness, be connected with 
the treatment. In Mr. Storks’s account of the operation on Dr. Has- 
tings’s patient (loc. cit. p. 384), the only mention of hemorrhage is, that 
“ the patient brought up two or three drachms of blood which had escaped 
into the cavity.” It will be remembered that in this operation a long 
incision was made through the skin and muscles, and the wall of the cavity 
itself was opened to the extent of an inch, so that a good deal of blood 
must have flowed. 
The trifling hemorrhage referred to as occurring in one of my own cases, 
took place the very first time I introduced a needle into a lung cavity. I am 
satisfied that it was connected with the effects of aspiration (for I was 
employing a Dieulafoy’s aspirator), since it has never happened to me 
again to have the slightest hemorrhage caused, although I have repeated 
the punctures about twenty-five times upon the same patient, and not less 
than forty times more in various other cases. It will be further remem- 
bered that the puncture only involves the superficial layer of the lung 
where there are no large vessels, and is called for only in conditions of the 
lung-tissue where many of the bloodvessels are obliterated. I feel myself 
justified, therefore, in repeating “ that the danger of serious hemorrhage is 
but slight, if the puncture be carefully performed” (loc. ant. cit.). 
Thirdly. It has been objected that it is impossible to determine whether ad- 
hesion exists between the pleurae over the seat of the cavity, and that conse- 
quently there is danger of allowing the escape of the contents of the cavity 
into the pleural sac, with the development of pleurisy or pneumothorax. 
It is true that in rare instances a lung cavity ruptures and gives rise to 
pyo-pneumothorax; but I believe all authorities will support the state- 
ment that for all practical purposes it may be assumed that there are adhe- 
sions over every chronic circumscribed superficial lung cavity. Not only 
so, but there is every reason to believe that, while the passage of the needle 
itself would, at the most, excite a slight localized plastic pleurisy if the 
membranes were healthy and non-adherent, the minute puncture of the 
lung would not give exit to any amount of air or pus capable of causing 
trouble. 
It must be remembered, in performing this simple operation, that it is 
possible to wound either a vessel or a nerve by failing to regard the ana- 
tomical distribution of these structures. Of course it would be necessary 
in puncturing the chest at any point, just as in ordinary paracentesis, to 
bear in mind the course of vessels or nerves over that particular region. 19 
In the treatment of lung cavities it will be found that the great majority 
of punctures require to be made in front, in the three upper intercostal 
spaces. By keeping as far inward as the nipple-line there is no artery or 
nerve of any importance exposed to injury. If, however, the position of 
the cavity should require the puncture to be made much external to this 
line, it would be desirable to introduce the needle as near the lower border 
of an intercostal space as it is safe to go without risking any injury of the 
intercostal artery. I think it probable that if the needle be advanced 
gradually, a small artery or nerve would be pushed aside and not trans- 
fixed. Certainly no accident of the kind has happened in my own experi- 
ence, extending now over sixty-five punctures. Several times patients have 
complained of tingling pain shooting down the arm on the affected side, 
evidently from pricking of some little nervous filament of one of the tho- 
racic branches of. the nerves of the brachial plexus. But this pain has 
always been slight and very transient. In no case has there been the 
slightest hemorrhage into the tissues of the thoracic wall, or any evidence 
of irritation caused by the repeated punctures. I append the result of this 
treatment in the cases of this character in which I have so far employed it. 
Case II. (Case II. in former communication.) Chronic Phthisis; 
cavity at left apex, with disease of the lower lobe ; repeated injections; 
temporary improvement; extension of disease; diarrhoea; death.—John 
Wilson, set. 35 years, a Finn, came into the Philadelphia Hospital February 
I, 1874. Of a phthisical family, he had had symptoms of lung trouble for 
nearly three years. For the past three months there had been much acute 
pain over the left apex, and his other symptoms had been aggravated. 
He was emaciated and feeble. Physical examination revealed no positive 
disease on the right side. On the left side there was consolidation of the 
apex, with a superficial cavity extending from the first interspace to the 
fourth rib. There were also large and small bubbling rales over the rest 
of the lung anteriorly and laterally, with some weakness of the respiratory 
murmur. Posteriorly, above the spine of the scapula, loud bubbling rales 
were heard ; and below, fine mucous rales. He was placed on use of cod- 
liver oil. 
March 8. A delicate needle, attached to an aspirator, was introduced 
into the cavity to the depth of If inches through the second interspace. 
A few drops of sanious fluid entered the vacuum, and vij of dilute 
LugoPs solution were injected. The operation did not cause cough or 
haemoptysis, and was followed by no pain, acceleration of pulse, or eleva- 
tion of temperature. 
10th. A delicate canulated needle, with an ordinary hypodermic syringe 
attached, was passed into the cavity, and xxvof dilute LugoPs solution 
strength) were injected. The operation caused neither pain nor cough, 
and was followed by no irritation or elevation of temperature. 
15th. Seemed brighter, and stated that he had been feeling better since 
the last injection. The cough certainly had been less troublesome. Again 
injected np xviij of same solution. Careful attention was paid to internal 
treatment and arrangement of diet. 
22c?. Injected xx of same solution. Appeared to be improving. 
A few days after this he felt so much relieved that he insisted upon going 
out of the hospital to attend to some business. While absent, a violent 20 
storm occurred; lie was much exposed, had a slight hemorrhage, severe 
pain at base of left chest, and on his return on April 3 he was much worse, > 
with increase of cough and expectoration, continued pain and friction- 
sound at infero-lateral part of left chest. 
A blister was applied over this spot, and he was placed upon use of 
quinia, digitalis, and opium. 
For a few days there were evidences of some serous elfusion in left pleura ; 
but after this disappeared, coarse friction sound, with signs of rapidly 
developing consolidation of the lung, made their appearance. There was 
high hectic fever, and the loss of flesh and strength, which had before ap- 
peared to be checked, recommenced. Evidences of disease at the right apex 
soon made their appearance, and he began to suffer with diarrhoea, which 
was checked by opium and bismuth. 
May 8. The signs of disintegration of the left lung advancing, another 
injection of dilute Lugol’s solution was made into the cavity. 
15th. He began to have blood-tinged expectoration, and was ordered 
vin. ergotse in fluidrachm doses, and vj of dilute Monsell’s solution 
were injected into the cavity. 
24th. Disintegration of the lower part of the left lung still progressed. 
Injected xx dilute Lugol’s solution into the cavity. Contraction of 
the upper part of left thorax had become more marked, and the heart was 
displaced upwards and to the left. 
30//;. Diarrhoea returned, and proved very difficult to control, causing 
extreme prostration. Soon after the discharges were controlled, increased 
hectic, cough, and expectoration appeared. 
July 30. Since last note the condition of this patient has fluctuated, 
but on the whole has become worse. No further injections have been 
made. The cavity appears to be somewhat contracted, but the disease 
of the remainder of the lung and of the right apex has progressed so 
rapidly as to indicate a speedy termination. 
August 14. He continued to sink, and died to-day, worn out with pro- 
tracted diarrhoea. 
At the post-mortevi the right lung was found enlarged, tightly adherent 
over the upper lobe. On section, the whole of this lobe was in a state of 
cheesy infiltration, with several points of softening. Scattered through 
the middle and lower lobes there were crude yellow granulations. The 
anterior border encroached greatly on the mediastinal space. The left 
lung was much contracted, and throughout tightly adherent by dense white 
fibroid tissue, which formed a complete casing for the lung. On careful 
examination of the area through which the punctures were made, it was 
impossible to detect any trace of the passage of the needle. An incision 
was made into the upper lobe, which was almost entirely occupied by an 
anfractuous cavity. The anterior wall of the cavity was largely composed 
of pure fibrous tissue in places varying from to of an inch in thick- 
ness, with a small amount of lung tissue in a state of fibroid induration. 
The cavity was divided into sacs by various imperfect septa. The largest 
of these sacs lay upon the anterior part of the lobe with a fibroid wall 
not more than inch in thickness, and had been entered by the various 
injections. The lining membrane of this sac throughout was smooth, 
shining, and whitish, and entirely free from any cheesy formation. In 
other parts of the cavity there was a small amount of cheesy matter 
adherent, to the walls. There was very little secretion in the cavity. The 
lower l,obe was in a state of mixed fibroid and cheesy induration, with 21 
here and there small centres of softening. The pericardium was tightly 
adherent to the concave surface of the left lung. The pericardial sac 
contained 8 ounces of turbid serum, but there was no appearance of in- 
flammation. There were a few milky spots on the pericardium. The 
bronchial glands were greatly enlarged and in a state of cheesy degenera- 
tion. There was extensive ulceration of small intestine, and to a less 
extent, of the large intestine. The liver was fatty. 
In this unfortunate case the injections were undertaken rather with the 
negative view of demonstrating their harmlessness than with any definite 
expectation that they would prove serviceable. The symptoms for three 
months before the patient came under observation indicated a rapid pro- 
gress and extension of the disease, and when first examined, it was found 
that the entire left lung was hopelessly involved. Still the repeated attacks 
of pain which had been experienced about the left apex made it almost 
certain that the pleurae were adherent over the seat of the cavity. And in 
fact it resulted that the injections which were practised (seven in all) did 
not cause the slightest irritation nor leave any trace that could be detected 
on post-mortem examination. The course of such cases is altogether 
too irregular to allow the slightest significance to be attributed to the tem- 
porary improvement which followed the first four iodine injections. It is 
true that the portion of the cavity into which the injections were directly 
thrown, presented an unusually favourable appearance, but no distinct 
contraction could be detected. All that can be safely deduced is that 
they were perfectly tolerated, and that they might have been safely continued 
had not the progress of the disease been precipitated by an intercurrent 
attack of pleuro-pneumonia from exposure, and by the supervention of in- 
testinal ulceration. 
The amount of blood in the expectoration, May 15, was too slight to 
allow any conclusions to be drawn as to the effect of the single injection 
of Monsell’s solution. 
Case III. Haemoptysis; Chronic Phthisis with large circumscribed 
cavity at right apex; injections of Iodine.—Thomas Peyton, colored, 
set. 46 years ; admitted to the Philadelphia Hospital May 1874. Enjoyed 
good health until June 1872, when, while working, he had a severe haemop- 
tysis, followed by two others in course of twenty-four hours. This was 
followed by cough and dyspnoea, with abundant purulent expectoration. 
He lost flesh rapidly at first, then recovered somewhat and returned to 
work in the course of two or three months. He had two or three small 
hemorrhages subsequently, but continued to improve until the summer of 
1873, when he was obliged to quit work for a few weeks, after which he 
resumed it and continued until May 1874, when he was obliged by dyspnoea 
to abandon it and enter the hospital. He has usually kept in pretty fair 
condition ; has enjoyed good appetite ; had night-sweats in 1873, and 
again since admission. On admission there were undoubted physical 
signs of a large superficial cavity with thick walls at the right apex, reach- 
ing down to the third interspace. He was placed on use of the following 
mixture : quiniae sulph. gr. xxiv ; acid, sulph. dil. f^ij ; inf. gentianae 
comp, f5 vj ; ft. sol. S.—Tablespoouful thrice daily in water. 22 
20th. A delicate canulated trocar was passed through the second in- 
tercostal space into the cavity, and up xxx of dilute Lugol’s solution (one- 
eighth strength) were injected. No unpleasant symptoms attended 
the operation. 
27//?. The same injection was repeated. The patient was very nervous, 
and said it increased the rheumatic pain in his back ; no further injec- 
tions were practised. 
July 25. The patient has continued in the hospital, and has used 
steadily the prescription given above. He has improved considerably, 
coughing but little, and suffering less from dyspnoea. The physical signs 
remain as before, save that there is increasing contraction at right apex, 
and evidence of very little secretion in the cavity. 
In this case, also, the size, duration, and superficial position of the cavity 
rendered it highly probable that the pleurae were closely adherent over its 
site. The injections did not produce a single unfavourable effect. The 
pulmonary symptoms improved steadily, though slowly ; but it is difficult 
to say how much, if any, influence should be attributed to the intra-pul- 
monary injections which were only twice employed. 
Case IV. Chronic Phthisis, with large circumscribed cavity at right 
apex; Incipient disease at left apex; Repeated injections of Iodine; 
Marked improvement (Case I. in former article).—W. S., aet. 29, has a 
strong hereditary disposition to phthisis, having lost his father, mother, and 
one brother with that disease. He is markedly chicken-breasted, and lame 
from severe coxalgia. He has been a metal-polisher, and was attacked 
with cough in August 1812. In October 1813, he had haemoptysis, after 
which he failed rapidly ; lost flesh and strength ; had marked hectic and 
dyspnoea. There was much pain over the right apex, troublesome cough 
and abundant purulent expectoration. 
There was no recurrence of haemoptysis, but his condition remained 
about the same, with occasional fluctuations, until the early part of the 
present year, when he suffered severely with increased cough and hectic. 
On February 17, 1874, his condition was found to be as follows : He is 
much emaciated, and is very easily fatigued. There are no marked 
digestive symptoms. His breathing is very short, and this is much in- 
creased by exertion, so that it is difficult for him to ascend a single flight 
of stairs. His cough is painful, exciting pain especially on the right side 
of the chest, but is not very severe at present, and is attended with but a 
moderate amount of purulent expectoration. The frequency of the pulse 
is somewhat variable; at present it is 108. 
Upon physical examination there is on the left side some roughness of 
the respiratory murmur, and a few crackling sounds at the apex. 
On the right side there is tympanitic resonance, even on light percussion, 
from the clavicle down to the fifth rib ; the most marked (amphoric) 
tympany is heard at the middle of the second interspace. There is cracked- 
pot sound for two and a half inches to the right of the sternum from the 
second to the fifth rib. Auscultation reveals blowing breathing on inspira- 
tion and expiration over this whole area—the character of the blowing, 
however, varying at different points. Over the seat of cracked-pot sound 
it is very superficial and is rather shrill and high-pitched, and accompanied 
with large, moist, and gurgling rales. Outside of the line of the nipple it 23 
is larger, lower-pitched, and free from r&les. There is intense pectoriloquy 
over this entire area. 
His treatment has been very varied, but without any permanent relief, 
and the course of the case has been gradually downwards. 
On February 24th, the No. 1 needle of Dieulafoy’s aspirator with the 
syringe attached was introduced in the second interspace on a line with 
the right nipple to the depth of 1| inches, and was followed by the escape 
into the vacuum of a few drops of offensive watery pus. About rtpiv of 
a very dilute Lugol’s solution strength) were then injected through 
the canula by a hypodermic syringe. 
The operation was followed by loose, rattling cough, and the expectora- 
tion of about three fluidrachms of fresh, frothy blood. He was immedi- 
ately put to bed, and the cough and hemorrhage soon stopped. His tem- 
perature in the evening and the following morning was only 99° F. 
28th. The injection was repeated in same manner, of iodine solu- 
tion of double former strength being used. There was tingling pain down 
the right arm while the needle was in place, but no other symptoms at- 
tended or followed the operation. 
March. 5. Since the last puncture, he has been feeling very comfortable. 
There has been no hectic ; the cough is less severe, the sputa more scanty 
and whitish. He is bright and cheerful, and states that his dyspnoea is 
greatly relieved. The same needle was introduced to the same depth at a 
point one-eighth of an inch nearer to the sternum. The puncture was 
immediately followed by a rapid flow of fresh, frothy blood into the 
vacuum, about one and a half fluidrachms escaping. The pump was 
detached, and ten minims of iodine solution were injected. He was put to 
bed immediately, but scarcely any cough and no haemoptysis followed. 
8th. The patient is brighter and more cheerful than for months past. 
There is no hectic irritation, the temperature never rising above 99° or 
99.5°. The pulse ranges about 84. His breathing is so much relieved 
that he has walked up three long flights of stairs without much dyspnoea. 
His weight is now 107 pounds. The cough is but little troublesome, and 
only a few white, frothy sputa are raised. Auscultation shows that many 
of the lAles formerly heard over the right apex have disappeared. There 
has also been some increase in flesh. All internal medication was now 
discontinued. 
Before this he had been taking cod-liver oil, a pill of quinia, digitalis 
and opium, and a sedative cough mixture. 
10th. Twenty minims of same solution were injected at a spot a little 
outside of the former puncture. The aspirator no longer used. A strong 
iodine taste was immediately perceived. 
15</i. Fifteen minims of same solution injected. During the past week 
he has had more cough and expectoration, and has felt weak and chilly ; 
partly on account of very low temperature in ward, partly on account of 
the withdrawal of internal medication. 
22d. Twenty minims of same solution injected ; no unpleasant results. 
BOth. Fifteen minims of a stronger solution (Lugol’s solution npx to 
f5j of tepid water) injected. 
April 3. Not feeling so well; increase of cough and expectoration and 
hectic fever. Also suffers from indigestion. Was ordered quiniae sulph. 
gr. iij t. d. also strychniae sulph. gr. ; acid, nitro-muriatie. diluti np x ; 
liq. pepsin f'5j t. d. 
9th. Injected np xxv of Lugol’s solution (one-seventh strength). 24 
10//?. Slept well last night and feels a great deal better ; has had hardly 
any cough. Weight 109 pounds. 
17//?. Injected same solution. Bowels costive; ordered laxa- 
tive pill of colocynth and belladonna. The acid tonic mixture ordered on 
the 3d now stopped ; quinia to be continued ; and mist. ol. morrhuae cum 
calcis lacto-phosphatis fsss t. d. ordered. 
25//?. Injected in same manner. 
May 3. Repeated same injection. Patient improving. Is able to sleep 
well. Has no hectic. Coughs very little, and expectorates purulent matter 
in moderate amount. Is out every day walking over a mile. 
8th. Injection repeated with xxv of Lugol s solution to 
ttl xlviij of warm water). Weight increased to lll£ pounds. 
Same injection repeated May 15th, 24th, and 30th ; and June 5th and 
14th. On introducing needle at usual spot in second interspace, the 
point was evidently imbedded in dense tissue instead of entering cavity. 
This has been growing more and more marked for some weeks past. The 
injection entered with difficulty and only ulxv were introduced. 
June 21st and July 1st of same solution (1 to 5) were injected 
in second interspace, three-quarters of an inch outside of nipple line. 
6//?. Repeated injection, and found difficulty in forcing fluid in, so that 
only irtxij were injected. Continues to improve, although a good deal 
affected by the hot weather. Expectoration very scanty, not more than 
f'3'j daily. 
15th. Still more difficulty experienced and only vij injected. This 
is evidently owing to increased development of fibroid tissue in wall of 
cavity leading to thickening and contraction. 
21s/. Injected xxv in first interspace in the line of the nipple without 
any difficulty ; severe tingling pain coursed down right arm for a few 
moments. 
August 17. No injection since last date, owing to my absence from the 
city. For past three or four days, he has had some catarrhal irritation, in 
consequence of imprudent withdrawal of his underclothing. He has con- 
tinued in fair condition, with very little cough and expectoration. He 
has for several months spent the greater part of every fine day out of 
doors, walking considerably. There has been scarcely any hectic fever, 
as indicated by the thermometer. He has gained flesh slightly ; appetite 
and digestion good. The physical signs indicate no extension of disease 
in left lung. There is increased contraction at right apex. On percus- 
sion, there is marked diminution in the cracked-pot sound; and tympa- 
nitic resonance is less superficial and readily developed. There is still 
marked blowing breathing and pectoriloquy; but respiration is accom- 
panied with much fewer rales than formerly. 
In examining this history, I think it will be granted that it was far from 
being a favourable case for treatment, when we add to the marked family 
tendency to phthisis and the previous scrofulous affection, the advanced 
disease of the right lung, and the incipient trouble at the left apex. 
And yet it is unquestionable that during a period of six months, in 
which time twenty-three injections have been made, there has been a 
progressive improvement both in the general and local conditions. He has 
gained a few pounds of flesh, but has gained vastly more in vigor and power 
of exercise. His spirits and morale have greatly improved. Cough has 25 
almost left him, and the expectoration is very trifling. There has been 
very slight progress in the signs of disease at the left apex, while there 
has been an evident contraction of the large cavity at the right apex, as 
shown by the greater retraction of the ribs, and the increasing displace- 
ment of the heart towards the right side, as well as by the increased re- 
sistance to the introduction of the needle. 
Case Y. (Case III. former article.) Chronic Phthisis of Bight Lung 
with large Cavity at the Apex; repeated injections of Iodine; Improve- 
ment.—James Hill, set. 21, was admitted to my ward in the Philadelphia 
Hospital. His father died of phthisis; he himself enjoyed good health 
until November, 1811, when he had an attack of rheumatism. In April, 
1872, he began to be troubled with cough and pain in the right chest; 
the cough was at first dry, but later has been accompanied with purulent 
sputa. He first spat blood in July, 1872, and since then he has had quite 
frequent small hemorrhages. He has suffered much from pain in various 
parts of the right lung. He has had comparatively little hectic fever, but 
has lost much flesh and strength. 
He was obliged to give up work in November, 1873. His weight on 
admission was 117| pounds. Marked dyspnoea on exertion, pulse 120 
when quiet. 
Physical examination shows contraction and comparative immobility of 
the right side; enlargement of the left side, with slight curvature of the 
dorsal spine, and deviation of the sternum. The left lung is hypertrophous 
and healthy. There are the physical signs of a quite large cavity at the 
right apex, with marked thickening of the pleura and induration of the 
lung below. The apex-beat of the heart is just to the right of the sternum. 
Over the right infra-clavicular space, down to the third interspace there 
is deep-seated tympanitic resonance, which on strong percussion is amphoric 
with slight cracked-pot sound ; cavernous breathing, both in inspiration 
and expiration, with bubbling rales with amphoric echo, and marked pec- 
toriloquy for the spoken and whispered voice. On March 8, the No. 1 
aspirator-needle was introduced in the second right interspace a little out- 
side of line of nipple to the depth of one and seven-eighths inches, and 
evidently entered a cavity. About seven minims of dilute LugoPs solution 
were injected. The operation produced a paroxysm of spasmodic cough, 
but was followed by no haemoptysis or irritation. On the following day 
there was a little blood-stained expectoration, such as he frequently had. 
March 15. Repeated same injection, using n^xv. 
22d. Injected xx of same solution. 
April 9. Injected xxv. 
10//?. Has been taking much subnitrate of bismuth and pepsin for his 
dyspeptic symptoms. Now ordered syr. ferri iodidi gtt. xv t. d. 
17//?, 25th, and May 3. Again injected xxv of dilute LugoPs solu- 
tion (1 pt. to 7 of tepid water). He has gained lbs. since admission. 
May 8, 15, and 24. xxv of stronger solution (1 part to 5 of water) 
were injected. Not the slightest inconvenience has followed any of the 
injections. 
30//?. Injected of this last solution in the third interspace. 
June 5, 14, 21, and 29; July 6, 16, 21, and 28. Repeated same injec- 
tion, but in second interspace as formerly. 
August 17. On my return to the city, I find him in bed with a marked 
attack of purpura. He has been ordered fresh vegetables and fruits freely, 26 
and is getting well of it rapidly. His general condition is favourable. 
There is very little cough or expectoration, and the physical signs indicate 
a tendency to still further contraction of the right chest, especially at the 
apex. The heart’s action is still excited. Until the development of the 
attack of purpura he has been able to exercise freely out of doors. No 
injection since last note. 
In this case, as in the former, the prognosis was rendered unfavourable 
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 re- 
currence of hemorrhage, and the marked emaciation, dyspnoea, and pros- 
tration. On the other hand, the tendency of the disease to assume a 
fibroid form, and the evident attempts at compensation in the retraction of 
the chest, the hypertrophy of the left lung, and the displacement of the heart 
were favourable elements of prognosis. Still it will not, I think, be doubted 
that the progress of the case has been exceptionally favourable ; so that, 
while it is very certain that the local treatment above described was not in 
any way injurious, it is altogether probable that it has been productive of 
good in favouring contraction and cicatrization of the cavity. 
Case VI. Chronic Phthisis; frequent Hemorrhages; large Cavity at 
Right Apex; Repeated Injections of Iodine; Marked Improvement.—W. E., 
set. 43, a tall and heavily-built man, a labourer, of very intemperate habits, was 
admitted to the Philadelphia Hospital 19th March, 1874. His father and 
one of his brothers died of phthisis ; the rest of the family are very healthy. 
He had several attacks of gonorrhoea, and one attack of syphilis, followed 
by very mild and transient secondary symptoms. He was very much ex- 
posed in consequence of his work and intemperate habits, but was not sub- 
ject to catarrh. Had severe attack of typhoid fever in spring of 1870. 
In the fall of that year, cough began with expectoration of muco-purulent 
matter, occasionally containing small proportion of blood. In October 
and November he had frequent large hemorrhages ; dyspnoea became 
marked, and he lost flesh and strength rapidly. He gave up work then 
and has been able to do very little since. Since then his condition has 
fluctuated from time to time. During summer of 1873 he had a good deal 
of purulent expectoration and occasional haemoptysis, but had some periods 
of comparatively good health. At beginning of the fall he lost flesh and 
strength still further, and entered the hospital in October. He went out 
in January and returned in March. At that time, his weight was 149 lbs. 
His dyspnoea was extreme, and he had great difficulty in going up stairs. 
Cough was very troublesome and attended with abundant blood-tinged 
expectoration. 
On physical examination, the thorax is rather narrow with increase of 
antero-posterior diameter. The apex beat of heart is in fifth interspace 
just within left nipple. No clubbing of fingers. Enlargement of capil- 
laries of nose and cheeks. 
At the right apex there is large tubal tympanitic resonance over inner 
two-thirds of infra-clavicular space, and over the outer third dulness on 
percussion. Posteriorly there is dulness down to a little below spine of 
scapula. At left apex the percussion resonance is a little higher-pitched 
than normal. Elsewhere it is normal. 
Auscultation at right apex reveals loud, dry, cavernous breathing down to third rib anteriorly, and, over third interspace, moist crackling with pro- 
longed expiration. Posteriorly there is large blowing breathing over 
apex. Below, respiration is normal anteriorly and posteriorly. There is 
distinct pectoriloquy over the infra-elavicular and supra-spinous spaces. 
At left apex anteriorly, there is feeble respiratory murmur, with dry 
crackling over upper lobe anteriorly. On palpation the vocal fremitus 
diminished all over thorax ; same at right apex. He was ordered cod- 
liver oil and a cough mixture containing cyanide of potassium. 
April 9. His condition appeared stationary. He suffered much from 
dyspnoea, weakness, and cough. An injection of vi dilute Lugol’s 
solution (1 part in 10 of water) was made into the cavity through the 
second interspace in line of nipple. This was followed by a severe spell of 
coughing, lasting an hour, and requiring chlorodyne for its relief. 
1 7/A. Injected of same solution. Has had rather more cough 
than before first injection. 
25/A. Same injection repeated. 
May 3, 8, 15, and 24. Injection repeated, using xv to xx of solution 
varying from 1 part Lugol’s solution to from 9 to 6 parts of warm water. 
His weight increased 11 pounds, to 160. Better in everyway; cough 
greatly relieved ; has had no blood-stained sputa for some time. Is now 
able to walk considerable distances. 
June 5 and 9. Same injection repeated. 
21s/. Injected of Lugol’s solution (1 part to 5). 
June 29 and July 6. Injections caused some pain owing to difficulty in in- 
troducing fluid, apparently owing to increased induration and contraction 
of tissue at point of puncture. 
July 8. Injected same solution in first interspace in line of 
nipple, without slightest difficulty, and with production of no cough or 
pain. The needle was introduced If inches. 
16/A and 21s/. Repeated same injection at same point. 
August 17. Owing to absence from the city no injection has been 
made since last date. For the past two or three months has spent almost 
the entire day in the open air, his strength has been increasing, and he 
now walks as much as five miles a day without fatigue. His breathing 
has become much easier; is able to tarry a bucket of water up to the third 
floor without dyspnoea. For the past eight weeks his cough has been 
rapidly decreasing and during the past month has ceased, and there has 
been no expectoration. There is an entire absence of hectic fever. His 
general appearance is excellent, and his appetite and digestion are good. 
The right apex is motionless during respiration ; there is no increased 
contraction of right apex ; tympanitic resonance is less distinct, it being 
best marked over inner half of first and second interspaces. There is 
large diffuse blowing over outer part of first and second interspaces, 
which toward sternum becomes almost cavernous. There is less dry 
crackling over the left upper lobe with improved respiratory murmur. 
He continues to take cod-liver oil and two ounces of whiskey daily, but 
needs no cough mixture. To-day repeated the same injection through 
first interspace. 
In this case, also, although a more favourable prognosis was justified 
than in the two last ones, it must not be forgotten that the patient’s con- 
dition, when the use of injections was begun, was worse than at any pre- 
vious time, and that evidences of incipient disease of the left apex had 28 
made their appearance. The improvement which has taken place during 
the continuance of the local treatment is very positive and gratifying, and 
shows itself by disappearance of cough and expectoration, by entire cessa- 
tion of haemoptysis, by relief of dyspnoea, and by gain in flesh and strength. 
The momentous importance of determining the actual clinical value of 
any mode of treatment which claims to be of use in pulmonary phthisis, 
forbids any rash conclusions drawn from insufficient data. In March last 
I stated that “ the practical value of this mode of treating pulmonary dis- 
eases is as yet uncertain.” Subsequent experience, although by no means 
sufficient yet to justify a claim of curative powers for it, has certainly 
strengthened its position. In the first place, it is evident from the record 
of cases here published that the injections of iodine reach the lung cavity 
and exercise a decided action upon its lining surface. This is shown by 
the depth to which the needle is introduced, by the strong and unmistak- 
able taste of iodine frequently perceived after the injections; and by the 
paroxysms of cough caused by the first injections in each case. It is evi- 
dent also that this action proves not only to be unirritating, but to tend 
to a diminution of the morbid sensibility of the cavity walls, and to a 
healthy modification of the cell-action there. This is shown by the fact 
that, although the amount and strength of the injections have been con- 
siderably increased, in each case they have ceased to produce any cough. 
It will be remembered that in the earlier injections very small quantities 
to vij) of very weak solutions (Lugol’s solution ij to iv to f3j of 
water) were used, but they have lately been increased to np xxv of a mix- 
ture of 1 part Lugol’s solution and 5 parts of warm water. It may be 
doubted if the small and feeble injections at first employed could produce 
any marked effect upon the lining surface of a large cavity ; but this power 
will scarcely be denied to the much larger and stronger injections lately 
used. Their action further appears to be beneficial, and the modification 
of the cell-action in the walls of the cavity to be in a healthy direction, 
since during the continuance of this treatment there has been in each case 
a marked improvement in the soreness about the cavity, and, even more 
markedly, in the amount of cough and expectoration. I do not think that 
the evidence afforded is yet sufficient to prove that these injections have 
led to partial cicatrization and contraction of the cavities; but the im- 
provement in the physical signs carefully noted above, certainly seems to 
indicate it. If they succeed in effecting this, it will presumably be by so 
modifying the cell-action in the walls of the cavity as to lead to a produc- 
tion of more healthy lymph capable of developing into fibro-cellular tissue, 
limiting the enlargement of the cavity, and ultimately by its organization 
and contraction tending, in conjunction with other agencies, to diminish 
its size. It must be noted that in two cases (IV. and VI.) the increasing 
density of the tissue through which the needle had been passed, and the 
increasing difficulty of effecting the injection at the original spot, would 29 
seem to point to this change in the walls of the cavity. This question 
must, however, be settled by more prolonged observation. 
It is finally evident that, if these injections are capable of disinfecting 
the contents of a lung cavity, and of so modifying the morbid action in its 
walls as to diminish the suppuration, they may be of the greatest value by 
lessening hectic irritation, and further by diminishing one of the greatest 
dangers of chronic phthisis, the liability to constitutional infection, and 
the development of diffuse miliary tuberculosis. It may be maintained in 
opposition to all here advanced that the favorable changes in the three 
cases last reported (IV., V., and VI.), are accidental and temporary, and 
merely such as are seen from time to time in the course of many cases of 
chronic phthisis. I can only vouch for the clinical records as presented ; 
and call attention to the facts that these three cases were doing badly, 
despite careful internal treatment, until the beginning of the use of intra- 
pulmonary injections; that since then their improvement has been such as 
would be rather surprising in a single case, but much more remarkable in 
three unfavourable cases treated simultaneously under rather unfavourable 
circumstances ; that the course has been uniform in all the cases, and 
marked by the same changes; that it has been attended with positive 
improvement in the physical signs; and that this steady gain has seemed 
to the patients themselves, and to all who have watched them, to be 
directly connected with the treatment employed. 
Iu concluding our study of this question the following points appear to 
have been established :— 
1. That the idea of opening lung cavities by an incision through the 
chest-walls is at least as old as Baglivi (probably much older); but that, 
owing to the very imperfect character of early clinical records of thoracic 
diseases, it is difficult to show that such an operation was actually per- 
formed before the last century (Barry), or more probably the present one 
(Hastings and Storks). 
2. That 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. 
3. That the possibility of puncturing 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. 
4. That 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, canul® introduced and retained, and various medi- 
cinal agents injected in solution or spray (Mosler). 
5. That the independent observations reported in full in this paper have 
shown that the continuous treatment of lung cavities by repeated injections 
by means of delicate canulae may be conducted without pain, hemorrhage, 30 
traumatic irritation, or -interference with internal medication and hygienic 
measures. 
6. That the cases which are best adapted for this local treatment are 
those where a single, superficial, and circumscribed non-tuberculous cavity 
exists; but that even when there is implication of the rest of the lung, or 
incipient disease of the opposite lung, some benefit may be expected. 
7. That the mode in which such local treatment does good, is chiefly by 
altering the character of morbid action in the walls of the cavity, dimin- 
ishing the amount of purulent formation, as well as the degree of hectic 
irritation and the danger of constitutional infection. That a certain 
amount of rest for the walls of the cavity is secured by the marked relief 
afforded to the cough. Also that it is indicated, by the progress of the 
cases above reported, that this treatment may favour the cicatrization and 
contraction of such cavities. 
8. That in the cases in which it has been employed (in which over seventy 
injections have been given), it has shown itself free from all danger, and 
of a certain degree of positive clinical value, since, during its use, uniform 
improvement to an exceptional degree has taken place in both the general 
and local conditions of the patients.