[From The Medical News, July 30, 1887.] 
LOCAL TREATMENT OF DISEASES OF THE 
BRONCHIAL TUBES AND LUNGSd 
BY BENJAMIN F. WESTBROOK, M.D., 
PHYSICIAN IN CHIEF TO THE DEPARTMENT OF THROAT AND CHEST 
DISEASES, ST. MARY’S HOSPITAL, BROOKLYN ; PRESIDENT OF 
THE BROOKLYN PATHOLOGICAL SOCIETY. 
The object of this paper is to describe some of 
the methods which I have employed in the local 
treatment of chronic bronchitis, chronic interstitial 
pneumonia with bronchiectasis, and phthisis pul- 
monalis, and to give the results which have been 
obtained. 
This disease has been treated by three principal 
methods : First, by the direct introduction of coarse 
spray into the air-passages by means of Sass’ spray 
apparatus; second, by the inhaling apparatus of 
Dr. George A. Evans; and third, by the pneumatic 
cabinet. 
In the use of the direct spray, the principal indi- 
cations watched for have been the amount and vio- 
lence of the cough, the amount and character of 
the expectoration, and the presence or absence of 
emphysema and asthma. When the cough is severe 
and spasmodic, the treatment is usually begun by 
CHRONIC BRONCHITIS. 
1 Read at the meeting of the American Climatological Society, 
Baltimore, May 31, 1887. 2 
WESTBROOK, 
the use of sedative substances, particularly carbolic 
acid and the fluid extract of hyoscyamus. In using 
the carbolic acid our custom is first to spray the air- 
passages with a solution equivalent to that of Dr. 
Dobell, the formula is : 
R.—Acid, carbol. cryst. . . . ti\,xx. 
Sodii bibor. ..... 3iij. 
Sodii phosph. . . . . 3'j- 
Glycerini . . . . . %i. 
Aquae 3vj-—M. 
After first cleansing the nasal passages by the use 
of this spray, the patient is directed to draw out the 
tongue and take a deep inspiration, during which 
the spray is thrown into the pharynx, or directly 
into the larynx by a bent tube, during two or three 
successive inhalations. A fi ty per cent, solution of 
carbolic acid in glycerine is then added to the fluid 
in the flask until the point of tolerance of the patient 
is reached, and, when as strong a solution as can be 
borne is obtained, the air-passages are sprayed with 
this five or six times, the patient always inhaling as 
deeply as possible. If the necessity for it exists, the 
nasal catarrh is then treated by such application as 
seems to be indicated. This method of treatment is 
repeated every day or every other day, as often as 
is convenient for the patient, no home treatment 
being employed, though usually some remedies in 
the way of tonics or alteratives are used internally at 
the same time. 
By this thorough cleansing and disinfecting of 
the air-passages, combined with the anaesthetic effect 
of the carbolic acid, the irritation is usually very 
markedly allayed, so that for twenty-four hours, at 
least, after the treatment, the cough is diminished in 
frequency and violence. The method is not always DISEASES OF BRONCHIAL TUBES, ETC. 
3 
efficacious. It is sometimes necessary to rely, to a 
great extent, upon sedative drugs, particularly at the 
outset of the treatment, where the spasmodic char- 
acter is very well marked. 
If the treatment by carbolic acid is inefficient, or 
if the results come about slowly, fluid extract of 
hyoscyamus may be either added to or substituted for 
it, the passages being first cleansed and disinfected 
by means of the alkaline and carbolic acid solution. 
A spray of hyoscyamus of the strength of about half 
a drachm to the ounce is introduced, the application 
being repeated half a dozen times at each sitting. 
This solution is particularly efficacious where a ten- 
dency to asthma exists. 
When there is a very copious secretion of muco- 
purulent matter, stronger astringents have to be em- 
ployed. The principal of these are tannic acid, the 
iron salts, and the fluid extract of pinus canadensis. 
For the use of tannic acid a standard solution is used 
as the basis. 
R.—Acidi carbol. cryst. . . . n\,xv. 
Glyceriti tan. .... ,fijss. 
Aquae menth. pip. . . . S;vss.—M. 
After the preliminary step of cleansing and dis- 
infecting, this solution is sprayed directly into 
the air-passages. When the patient has become 
accustomed to its effects by one or two inhalations, 
glycerite of tannin is added to it until it is as thick 
as it can be and be capable of producing a spray.1 
1 The addition of only a very small amount of water is necessary 
to render the glycerite of tannin sufficiently fluid to produce a 
spray with a pressure of forty to fifty pounds. Five or six drops 
of water to a fluid-drachm give a good spray, and ten drops to 
a drachm make it capable of being sprayed at quite a low 
pressure—i. e., fifteen or twenty pounds. 4 
WESTB ROOK, 
This spray is then inhaled five or six times. Its 
effects are often very salutary, the amount of ex- 
pectoration decreasing perceptibly after each sitting, 
though the treatment is immediately followed by an 
increased expectoration, which lasts for from one to 
three or four hours. 
Of the iron salts, I have most frequently employed 
the chloride, using a mixture of equal parts of the 
tincture of chloride of iron and glycerine. This is 
diluted to about twenty-five percent, and used in the 
same way as the tannin. Where great relaxation 
and an anaemic condition of the mucous membrane 
exist, it acts better than the tannin solution. A 
solution of iron alum of the strength of fifteen grains 
to the ounce may also be used. Pinus canadensis is 
of service in about the same class of cases as are 
benefited by tannin, though it has rather more seda- 
tive effect than the latter. The preparation usually 
employed is a mixture of equal parts of Kennedy’s 
white fluid extract and glycerine. The liquid is 
very heavy and can only be sprayed with a high 
pressure. To use any of these substances most 
effectually, it is necessary to have a pressure of from 
forty to fifty pounds to the square inch. This is ob- 
tained by the use of the Crown Gas Engine, manu- 
factured by the National Meter Co., 252 Broadway, 
New York. 
A large tank is connected with the gas engine, 
which has, by a special contrivance, been converted 
from a water into an air pump, and the compressed 
air from the larger reservoir is drawn off into an 
ordinary office receiver at the convenience of the 
operator. I usually have a pressure of from fifty to 
sixty pounds to the square inch in the larger reser- 
voir, and, by means of stopcocks, can regulate the 
pressure in the small office receiver to which the gas DISEASES OF BRONCHIAL TUBES, ETC. 
5 
is attached, according to the requirements of the 
case under treatment. Where the nasal passages are 
very much inflamed and tender, and particularly 
where there is stenosis, which increases the friction 
to a high degree, it is better not to go beyond thirty 
pounds at the beginning of the treatment; but when 
the swelling of the turbinated bodies and septum 
has been sufficiently reduced to admit of the free 
access of air or spray, the passages can be much 
more thoroughly cleansed and disinfected if we use 
a pressure of from forty to fifty pounds. 
I think it possible that one cause of the avowed 
failure of certain gentlemen who have recently 
written upon this subject, to treat successfully nasal 
catarrhs with the spray, is to be found in the low 
pressure which they have employed in the introduc- 
tion of the spray into the nostrils. The degree of 
pressure required in a given case can be determined 
in two ways. In the first place, by the amount of 
resistance which the spray encounters in passing 
through the nose. This is quickly shown by the 
regurgitation of the fluid through the nostril into 
which it is introduced, and its failure to pass through 
and out at the opposite side. The second are the 
sensations of the patient, though the latter gener- 
ally depend upon the former. 
Where the nostrils are sufficiently patulous to ad- 
mit the spray readily, so that there is little tendency 
to friction or the development of high pressure in 
particular localities of the nose, the pain is usually 
very slight, and a high pressure may be advan- 
tageously employed. But where the stenosis is well 
marked, and the friction consequently very great, 
there is a tendency for the fluid to accumulate or to 
be forced violently into the chamber of the antrum, 
and the pain is sometimes very severe. Under such 6 
WESTBROOK, 
circumstances the preliminary spraying must be 
done with a very moderate pressure, and if, even 
then, the spray does not pass readily through the 
nostrils, it is better to dilate them by the introduc- 
tion of cocaine, when no further difficulty of the 
kind will be experienced. I suspect, however, that 
the cocaine may to some extent interfere with the 
therapeutic action of the medicinal agents employed, 
though it does not, of course, lessen the value of the 
disinfectants. 
In the spraying of the larynx and trachea it is al- 
ways better to use a very high pressure, and the rea- 
sons for this are twofold. In the first place, with 
the high pressure a very large volume of fluid is in- 
troduced in a short space of time, so that in a few 
seconds an ordinary flask, such as is used in these 
manipulations, may have its contents half exhausted. 
And in the second place, the forcible impact against 
the walls of the mouth and pharynx nebulizes it to 
such an extent that it is more widely diffused in the 
respiratory passages. Occasionally a drop of the 
fluid will form upon the end of the spray tube and 
fall into the trachea, producing a violent fit of 
coughing; but, with the high pressure, the time oc- 
cupied in each introduction of the spray may be so 
shortened that there is very little danger of this 
accident. 
The advantages to be obtained by this method of 
treatment over the others to be described later on, 
are that it occupies very much less time, in conse- 
quence of the far larger amount of fluid that can be 
sprayed into the throat during one or two inhala- 
tions, and its better cleansing properties. The for- 
cible introduction of the spray directly into the 
larynx and trachea gives a much more thorough DISEASES OF BRONCHIAL TUBES, ETC. 
7 
washing than can be accomplished by the slower 
methods to be described hereafter. 
The treatment of chronic bronchitis by means of 
the pneumatic cabinet has also been very successful 
in my hands, as it has in the hands of other gen- 
tlemen who have ■ reported their experience with 
this instrument. The patient is confined in the 
cabinet under a negative pressure of from two-tenths 
to five-tenths of an inch. The sitting usually lasts 
ten minutes, though it may, after the patient has be- 
come accustomed to its use, be prolonged to fifteen 
or twenty minutes. The pneumatic differentiation 
is accompanied by the inhalation of the spray, for 
which purpose we employ the “Evans inhaler.” 
The solutions most frequently employed by me are, 
a twenty per cent, solution of carbolic acid, with 
borax and glycerine, a solution of the fluid extract 
of pine needles with iodine, and a combination or 
mixture of the two solutions in equal parts. When 
asthmatic breathing is present, the solution of hyos- 
cyamus already referred to is of great value. If 
much emphysema exists, the cabinet is not indi- 
cated. I have never seen any benefit derived from 
its use in these cases, though I have tried both rare- 
faction and condensation. The inhalation of the 
hyoscyamus may relieve the asthmatic breathing, but 
this may be accomplished just as readily outside the 
cabinet as in it. In one case a sitting of five min- 
utes in the cabinet developed in a very emphysema- 
ious subject, whose breathing was fairly good when 
he entered the cabinet, a most terrible attack of 
asthma. The moral effect upon the patient was 
such that he could never be induced to reenter the 
box, and promptly transferred himself to the care 
of another physician. I have frequently seen it in- 
crease the asthmatic breathing temporarily in such 8 
WESTBROOK, 
subjects, though in others it has produced temporary 
relief. 
The cabinet is particularly valuable in very chronic 
and intractable cases where the relaxed vessels of 
the bronchial mucous membrane, though for a time 
contracted by the action of stimulant applications, 
soon resume their previous condition of ddatation. 
The cabinet undoubtedly acts in a twofold manner 
in these cases: First, as has been pointed out by 
Dr. Isaac Hull Platt, in a paper read before this As- 
sociation at its last meeting, by the compression of 
the bronchial surfaces, and by some alterative effect 
due, probably, to a combination of the compression 
with the tonic action upon the vasomotor system of 
the lungs; secondly, by the action of the spray in- 
troduced during treatment. The disadvantage is 
that, with the spray introduced in this way through 
the long tube, we do not get the same cleansing 
effect as can be obtained in the direct method pre- 
viously described. To obviate this difficulty, I have 
adopted the practice of first thoroughly cleansing 
the upper air-passages with the Siss’ apparatus 
before the introduction of the patient into the 
cabinet. 
The apparatus which Dr. George A. Evans intro- 
duced to the profession about two years ago has 
been used in a number of cases with generally satis- 
factory results. It consists of an ordinary “Wolff” 
bottle with a glass globe on top, into one side of 
which is introduced the point of an ordinary spray 
tube, while from the other emerges a tube for the 
collection of pulverized spray. It is a modifica- 
tion of the idea of Sales-Giron, and depends upon 
the principle that when a coarse spray is forcibly 
thrown against a surface it will be broken up into 
minute panicles and form a fine nebula which will DISEASES OF BRONCHIAL TUBES, ETC. 
9 
float in the atmosphere several minutes before being 
precipitated or evaporated. The grosser part of the 
spray remains in the globe and falls through a tube, 
back into the “Wolff” bottle, while the more finely 
nebulized portion is carried off through the tube of 
exit, from which it is inhaled by the patient. The 
mouth-piece consists of a hard rubber tube with an 
opening on one side, the tube held in the mouth of 
the patient, and the opening on its side covered by 
his forefinger during inspiration; during expiration 
the finger is removed so as to allow the breath and 
spray to pass out through the side opening. The 
patient is instructed to make deep and slow inspira- 
tions, with the idea of securing, as far as possible, 
voluntary expansion of the chest. The solutions 
employed have been about the same as those used in 
the Sass’ spray and the pneumatic cabinet. 
The advantages claimed by Dr. Evans for his 
method are that, first, the patient is compelled to 
make voluntary efforts at deep inspiration during a 
space of time ranging from half an hour to an hour. 
By this means a valuable system of pulmonary gym- 
nastics is put into operation. Second, the spray, 
very finely nebulized, and introduced directly into 
the air-passages, in great volumes, has a better op- 
portunity of diffusing itself in the residual air, and 
so reaching deeper into the lungs, than it could do 
under any other circumstances. Third, by means 
of the fine nebulization much stronger solutions may 
be employed than with the ordinary coarse spray. 
For instance, we have frequently employed a thirty 
per cent, solution of carbolic acid, a strength which 
could not be tolerated if applied to the air-passages 
in a liquid form, but which is easily inhaled by any 
one who is not extraordinarily sensitive. 
The first few inhalations of these strong solutions 10 
WESTBROOK, 
occasion some cough, but this soon passes away, and 
the patient will continue to inhale for a long time 
without any further disturbance. At the termina- 
tion of the sitting, the mouth, pharynx, and larynx, 
are pretty thoroughly anaesthetized, so that a feeling 
of numbness exists which lasts for an hour or more. 
Though the volume of spray as it issues from the 
tube seems very large, hanging as a cloud in the 
atmosphere of the room for a long time, still very 
little of the fluid is used up in its formation, and not 
enough is carried into the respiratory passages to 
have ever produced any symptoms of carbolic acid 
poisoning in the patients upon whom we have used 
it. As the precipitation of the coarse globules of 
spray has been thoroughly accomplished before it is 
introduced into the mouth, no fluid is deposited upon 
the mucous membranes, but they are simply subject 
to the mild action of the vapor or spray during the 
time of the sitting, and the spray itself is all thrown 
out through the mouth and nose. This method of 
treatment is particularly useful in cases in which the 
mucous membranes are extremely sensitive, in those 
accompanied by violent spasmodic cough, and where 
the disease is of very long standing, and a prolonged 
application of the medicinal agent is desirable. Its 
disadvantage is that, as the spray is introduced by no 
power except the inspiratory suction, it does not 
come with sufficient force to the mucous membranes 
to cleanse them thoroughly. But this objection has 
been overcome, as in the case of the cabinet patients, 
by thorough preliminary douching with the spray 
from the Sass’ apparatus. By inhaling through the 
moutn, and exhaling through the nostrils, medication 
of the nasal as well as the lower air-passages is ob- 
tained. 
To get the most satisfactory results by this method DISEASES OF BRONCHIAL TUBES, ETC. 
11 
it is necessary to employ a high pressure of air. I 
commonly use a pressure of from fifty to sixty pounds 
to the square inch. But Dr. Evans, who has a more 
elaborate apparatus for the compression of air, em- 
ploys a pressure of seventy to eighty pounds. The 
advantage consists in the greater volume of spray 
produced. The inspired air is loaded with it, and 
during the exhalation it pours from the nostrils in a 
cloud such as is seen to issue from the nostrils of a 
horse on a very cold and damp day. Where the 
membranes are very irritable, and the stronger solu- 
tions of carbolic acid are not well borne, a mixture 
of fluid extract of pine needles with iodine is very 
serviceable, and, as in the case of the Sass’s apparatus, 
it is frequently combined with an equal portion of a 
ten or fifteen per cent, solution of carbolic acid. I 
have also used solutions of tannin with the Evans’ 
inhaler, but the spray is exceedingly disagreeable to 
the patient, and apt to produce nausea. 1 have not 
employed any other astringents with this apparatus. 
CHRONIC INTERSTITIAL PNEUMONIA AND 
BRONCHIECTASIS. 
By the local treatment of this affection, three ob- 
jects are to be accomplished. First, the healing of 
the bronchial catarrh ; second, disinfection of the 
dilated bronchi; and, third, the restoration of the 
breathing capacity of such portions of the lung as are 
not hopelessly degenerated. 
The first two objects are best accomplished by the 
use of the coarse spray or the Evans’ inhaler. Each 
has its advantages, but so far as I am able to judge 
from my personal experience, the coarse spray is 
more serviceable. 
The third object is to be accomplished through the 12 
WESTBROOK, 
use of the pneumatic cabinet, or some other appa- 
ratus for the inhalation of compressed air. 
The method of treatment is first to wash thoroughly 
and disinfect the nasal and lower respiratory pas- 
sages with a coarse spray from the Sass’ tube. In 
the treatment of the lower air passages, a high pres- 
sure is necessary, so as to give a large volume of spray, 
and to project it with great force into the respiratory 
passages. This is at first productive of violent 
cough, which clears the secretions from the bronchial 
tubes, after which the spray is deeply inhaled, pene- 
trating, probably, as low as by any other method. 
After this preliminary washing, the patient is put into 
the pneumatic cabinet and subjected to a negative 
pressure of two- or three-tenths of an inch for from 
fifteen to twenty minutes, while a mild spray is intro- 
duced through the tube in order to keep the mucous 
membrane of the pharynx moist during the treat- 
ment. The application of the pneumatic differential 
pressure in these cases should be made with the 
greatest care, as there is danger, if the pressure be 
too great, of producing emphysema of those por- 
tions of the diseased lung which are still accessible 
to air. For this reason, pressures over half an inch 
should not be employed. The sitting is made rather 
longer than in the case of chronic bronchitis, because 
of the necessity for the use of a lower pressure, and 
with low pressures, as with mild applications of 
medicinal agents, a more prolonged use is necessary 
than where the therapeutic agent is of greater power. 
By this combined method of treatment, very bril- 
liant results have been achieved in a number of cases 
which it is not necessary to detail. In some instances, 
where the cabinet has not been well borne, or where 
no manifest results were obtained after a fair trial, 
the Evans inhaler has been substituted for it with DISEASES OF BRONCHIAL TUBES, ETC. 
13 
very gratifying results. In a few cases no benefit 
has resulted from any local treatment. 
PHTHISIS PULMONALIS. 
Aside from the effects of climate, there are no means 
by which we can obtain so much in the treatment of 
phthisis pulmonalis as by the use of agents, either 
physical or chemical, which act directly upon the 
respiratory organs. 
In speaking of these local measures of treatment, 
I shall confine myself to the three which I have 
already discussed, namely, the coarse spray, the 
Evans’ inhaler, and pneumatic cabinet. In the 
selection of a method of treatment for these cases, 
it is necessary to take account of all the conditions 
present, because that which benefits one case may be 
useless or positively injurious in another. 
The best results are obtained either in the early 
stages, when the disease is in its incipient form and 
no extensive excavation exists, or where the process, 
though considerably further advanced, is still limited 
to a comparatively small portion of the lung. The 
use of sprays is beneficial only in so far as we desire 
to treat the coincident bronchitis, or where cavities 
connect with bronchi of the second or third order 
—i. e., where they are near enough to the trachea to 
allow of the introduction of a sufficient quantity of 
the medicinal agent to disinfect them. In deep- 
seated cavities, and cheesy collections in the smaller 
bronchi and alveolar spaces, it is questionable whether 
a sufficient amount of any agent can be introduced 
through the trachea to have any therapeutic effect. 
But in large cavities with a free opening into the 
bronchial tubes, we may, as in the case of bronchi- 
ectasis, expect to obtain a certain amount of disin- 14 
WESTBROOK, 
fection. Where nasopharyngeal catarrhs exist, they 
should always be treated the same as in chronic 
bronchitis. 
In incipient phthisis accompanied by very little 
bronchial catarrh, where the cough is accompanied 
by the expectoration of only a small amount of 
mucus, local treatment with sprays is of but little 
avad, and it is not worth our while to spend much 
time or worry the patient with it. These cases are 
best treated by the use of compressed air or the 
pneumatic cabinet, and in a very large proportion of 
them we may hope to render the disease latent. The 
action of the positively or relatively compressed air 
is to expand the lungs, to favor the expectoration of 
the contents of the smaller tubes and, possibly, of 
the alveoli, and to modify the intrathoracic circula- 
tion, as has been explained by Dr. Platt, and more 
recently, by Dr. Tiegel in an able article in the 
New Yorker Medicinische Presse for April, 1887. 
The sittings should be frequent, every day, or 
every second day, and the pressure, at first slight, 
say two-tenths to three-tenths of an inch of the 
barometer, should be gradually increased to one-half 
or even three quarters of an inch. Ten minutes is 
usually long enough for each sitting, though in some 
instances where it is well borne we have prolonged 
it to twenty and even twenty-five minutes. There 
is a great difference in the ability of patients to bear 
the differential pressure. Some experience no diffi- 
culty in inhaling under a negative pressure of one- 
half or three-quarters of an inch for fifteen or twenty 
minutes, and say that they feel much more benefit 
from the treatment than when it is lighter, but others 
soon become fatigued under the pressure of more 
than one-half an inch, and, on emerging from the 
cabinet, show signs of great exhaustion. I have 
met three or four cases in which the pneumatic treat- DISEASES OF BRONCHIAL TUBES, ETC. 
15 
ment had to be abandoned because of the exhaus- 
tion and thoracic pain following its employment. 
A safe rule to adopt is never to make the pressure so 
high, or the sitting so long, that it is followed by a 
feeling of weariness or exhaustion. Used cautiously 
in this way it is, I believe, the very best method for 
the local treatment of incipient phthisis, or of 
phthisis limited to a small portion of the apex of 
one or both lungs. When much bronchial catarrh 
exists in the earlier stages, the introduction of sprays 
is all important, and the method is precisely the 
same as for the treatment of chronic bronchitis. 
After this preliminary treatment, the pneumatic 
cabinet is used in the way already described. 
So far as the introduction of sprays is concerned, 
the cabinet is not as useful as either of the other 
methods ; for, while the initial expansion of the lung 
secured by the operation of compressed air is con- 
siderable, the subsequent exhalations do not coincide 
with it, so that, while the patient is in the cabinet 
and treated by the diminished pressure, though the 
chest is expanded and the amount of air actually 
contained in the lungs increased, this increase is 
rather in the residual than the tidal air. In some 
experiments conducted by Dr. Platt and myself, we 
found that a very robust man could exhale more air 
after a deep inspiration outside the cabinet than in 
it. While the expansion of the chest was increased 
by the action of the compressed air, the expiratory 
contraction was diminished. Of course, this applies 
only where the rarefaction is continued during the 
entire sitting, and would not hold good if the 
patient were made to inspire under diminished 
pressure and expire under the normal or increased 
pressure. But after a number of trials, I have not 
been able to use the cabinet in this way. Mr. 
Ketchum, the inventor of the cabinet, tells me that 16 
WESTBROOK, 
he can operate it in this manner, but possibly, from 
lack of skill in its manipulation, we have not suc- 
ceeded in doing so. 
With the Evans’ inhaler in the treatment of the 
earlier stages of phthisis, my experience is not so 
great; as the other methods have proved so satis- 
factory that I do not generally resort to it. Where 
it has been used, however, the results have generally 
been very satisfactory. I believe that its efficacy 
depends, first upon the effects of the spray on the 
mucous membrane of the air passages, and, second, 
upon the salutary influence of the prolonged volun- 
tary attempts at deep inspiration on the part of the 
patient. Under its use the cough and expectoration 
are markedly diminished, the patient acquires a 
gradual expansibility of the chest, and the dyspnoea 
on exertion is markedly diminished. As the natural 
result of this, the digestion and appetite improve, the 
sleep is better, and there is a diminution in fever 
and increase in weight. 
The principles involved in the treatment of more 
advanced cases differ in no respect from those which 
we apply in the earlier stages, but certain precautions 
are to be observed, and less is to be expected in the 
way of a cure. It is possible, however, in many 
instances, greatly to improve the general health of 
the patient by diminishing the expectoration, regu- 
lating the pulmonary circulation, and increasing the 
breathing power. Whether anything can be done 
in the way of disinfection beyond what we have 
already alluded to, is very doubtful. It would seem, 
a priori, to be impossible to introduce enough of any 
antiseptic into the lungs to destroy the caseous foci, 
disinfect the infiltrated tissues in the neighborhood 
of the avenues of entrance, and leave enough to 
prevent a reformation of bacilli during the intervals 
between sittings. To my mind, the only way in DISEASES OF BRONCHIAL TUBES, ETC. 
17 
which the progress of the tubercular invasion can be 
arrested is by so improving the nutrition of the tis- 
sues of the lung as to render them immune to the 
disease. We know that in the case of tuberculosis, 
as of other infectious and septic diseases, it is only 
a certain proportion of those who are exposed to the 
infection who contract the malady. Not every 
patient who is operated upon under circumstances 
which expose him to septic infection contracts 
pyaemia or septicaemia, and antiseptic surgery is for 
the benefit of those who are vulnerable. It need 
not be applied in every case if we had the means of 
knowing which were susceptible and which were not. 
So, in the case of tuberculosis, it is only those 
whose tissues are susceptible to the disease who con- 
tract it. And when the disease is present, in the 
absence of any means for thoroughly destroying 
the bacilli which already inhabit the lungs, our only 
resource is to endeavor to render the remainder of 
the pulmonary tissue invulnerable to their attacks. 
In the treatment of advanced cases our first aim 
should be to cure the bronchitis, or so to diminish 
it as to lessen greatly the expectoration and the 
cough. This being done, the pneumatic treatment 
should be carefully applied, in order to get a better 
expansion and improved circulation, and an altera- 
tion of the action of the trophic nerves. The coarse 
spray, of course, accomplishes but one of these sub- 
jects, while the pneumatic cabinet and the Evans' 
inhaler act in both ways. If the cabinet is used, 
the patient should first be treated locally with the 
coarse spray, and, after thorough cleansing, the en- 
tire respiratory tract should be subjected to a mod- 
erate negative pressure, with the introduction of 
some unirritating spray. 
After the employment of a number of different 
formulae, it has seemed tome and my two colleagues* 18 
W ESTBROOK, 
Dr. I. H. Platt and Dr. A. H. Buckmaster, that as 
good results were obtained by the use of a simple 
alkaline and carbolized solution, as with any of the 
others; though, in some instances where great irrita- 
bility is present, a pine needle extract or the fluid 
extract of hyoscyamus has done better. We used, 
for some time, a solution of the bichloride of mer- 
cury in the strength of i to 1000, but it was not as 
pleasant to the patient as were the others mentioned, 
and there was no apparent difference in their thera- 
peutic effects, or, if any, it was in favor of the other 
solutions. Many other formulae have been used and 
advised by other observers, but the active principles 
of all are similar, and as those that we had used 
acted satisfactorily, it was not thought worth while 
to multiply them, as no opinion of any value 
could be formed in regard to the efficacy of any one 
agent, unless it were used for a long time and in a 
large number of cases. 
Though the effects of the cabinet have been very 
satisfactory in cases which were not too far advanced, 
I think that, on the whole, we have been better 
pleased with the Evans inhaler. This apparatus has 
the advantage of being very easily employed. It 
does not alarm the patient, nor does it fatigue him 
as much as the cabinet. Of course, if the patient is 
very ambitious, and exerts himself to inspire as 
deeply as possible for a long time, he may soon be- 
come exhausted. But when the cases are well ad- 
vanced, and the patients greatly debilitated by dis- 
ease, we do not at first urge them to make any great 
effort at expansion, but simply allow them to hold 
the tube in the mouth and breathe comfortably. As 
they become accustomed to its use, they inhale more 
deeply, the respiratory muscles are gradually strength- 
ened by exercise, and they may finally become able 
to make a very effective use of the instrument. We DISEASES OF BRONCHIAL TUBES, ETC. 
19 
have not employed the local treatment alone in any 
cases of advanced phthisis with extensive destruction 
of the lung, hectic fever, and copious night-sweats, 
but have always felt obliged to use other internal 
medication; so that it is impossible to say, in any 
given case, to what extent the improvement which 
has occurred is due to any one of the means em- 
ployed, but it would appear that the use of these 
local measures is a valuable addition to our ordinary 
therapeutic resources. 
It is particularly important, in using the pneumatic 
cabinet on this class of patients, not to make the 
pressure too high, as it appears from our observation 
that, where portions of the lung are contracting, no 
matter how strong a pressure is used, the contraction 
is not overcome, and any dilatation of the chest 
which is accomplished is at the expense of the non- 
infiltrated portions. In one instance the contrac- 
tion of the lung, which was only apparent above the 
third rib on the left side at the beginning of treat- 
ment, extended, in spite of the daily application of 
the cabinet, so that, after the lapse of six weeks, it 
had progressed below the nipple and the anterior 
border had so far retracted that the cardiac pulsa- 
tions could be felt over the entire precordial region, 
from the second intercostal space to the apex. 
Where this contraction goes on in spite of the judi- 
cious use of the cabinet, we may conclude that the 
instrument is doing no good, and it is as well to 
resort to other methods of treatment. 
We have been somewhat surprised to see tabulated 
in some of the reports on the use of the pneumatic 
cabinet, cases of acute phthisis in which cures had 
been effected. It has been our experience that the 
more acute the disease, the more rapid its onset, the 
higher the fever, and the greater and more progres- 
sive the emaciation, the less can be accomplished, 20 
DISEASES OF BRONCHIAL TUBES, ETC. 
not only by this, blit by any other method of treat- 
ment. Indeed, we are unable to report any case 
which we have diagnosticated as acute phthisis, on 
which local treatment has had any effect whatever. 
The patients are generally very weak, feverish, and 
irritable, and the application of these local measures 
simply exhausts them. 
I would say, in closing, that the success of the 
local treatment is largely dependent upon the con- 
stitutional condition of the patient. Some, who 
appeared to have a very trifling amount of local 
disease have gone down very rapidly in spite of all 
that we could do. This has been particularly ob- 
served in alcoholic subjects. In one instance, that 
of a man twenty-eight years old, engaged in the 
retail liquor business, whose pulmonary difficulty 
was limited to the upper half of one upper lobe, and 
consisted largely of solidification without much 
apparent excavation, and where good results were 
confidently expected, treatment was found to be very 
exhausting, and, in spite of the greatest care, the pa- 
tient rapidly declined. I have been told by Dr. Jacob 
Fuhs, through whose courtesy we had the oppor- 
tunity of seeing him, that he subsequently developed 
a myelitis followed by paraplegia and rapid dissolu- 
tion. On the other hand, there have been cases 
where the disease seemed very far advanced, and 
extended over a considerable portion of both lungs, 
which have done well from the start, sometimes very 
much to our surprise. The difference is undoubt- 
edly dependent upon the constitutional resistance of 
the patient, and we desire particularly to call atten- 
tion to this fact, in order to illustrate the principle 
that it is not well either to abandon any case because 
of its apparently desperate nature, or to base too 
hopeful a prognosis upon the slight extent of the 
local lesion. 
274 CaimsxiAS1 Street, Brooklyn, N Y.