PNEUMATIC DIFFERENTIATION. PROCEEDINGS OF TIIE MEDICAL SOCIETY OF THE COUNTY OF KINGS, Brooklyn, N. Y., February 16 and March 16, 1886. THE THEORY OF THE PNEUMATIC CABINET. By J. Kktchum. SIXTY-NINE CASES TREATED BY THE PNEUMATIC CABINET. By Sidney A. Fox, M. D. PNEUMATIC DIFFERENTIATION. By Benj. F. Westbrook, M. D. THE PRACTICAL APPLICATION OF THE PNEUMATIC CABI- NET. By Isaac II. Platt, M.D. WITH DISCUSSION. REPRINTED FROM tflK Ncru Work mifbical Journal of June 19 and 26, 1886. Rejyrinted from the New York Medical Journal for June 19 and 26, 1886. THE THEORY OF TIIE PNEUMATIC CABINET.* / By JOSEPH KETCH CM, BROOKLYN. The investigation and experiments of which the pneu- matic cabinet is the result have demonstrated a few facts which, thoroughly comprehended, will, to a certain extent, explain the clinical results reported by Dr. Fox and others. It would seem as if the ingenuity of all former investiga- tors had been devoted to the production of sprays, mists, and fogs of varying degrees of tenuity, regardless of the surrounding physical conditions which must be invoked to produce topical application. As well might one inclose a valuable drug in an insoluble capsule and expect results as to introduce a fluid medium in vapor into an intra-pul- raonary space and disregard the physical laws which govern the return to its liquid condition. Let us suppose, for example, that a normal tranquil in- spiration requires twenty cubic inches of air. Now, if the barometer stands at thirty inches and the temperature is, say, 70° F., our twenty cubic inches will contain, by the tables of Professor Guyot and Professor Plantimore, about * Read before the Medical Society of the County of Febru ary 10, 1886. 2 THE THEORY OF THE PNEUMATIC CABINET. six one hundredths of a grain of water. Let us suppose that it is charged to this limit with moisture (and no method of atomization, however ingenious, can exceed this), and thus charged is inspired into the lungs. The agency of temperature asserts itself, and the pulmonary heat is im- parted to the tidal air until it reaches, say, 90° F. Its physical condition has leen changed, and its hygrometric capacity now not only includes the six one hundredths of a grain with which we loaded it, but, in addition, it absorbs eight one hundredths of a grain more from its moist mu- cous environment, and it is expired with fourteen one hun- dredths of a grain into the atmosphere. This excess of moisture in air on expiration over inspiration is demon- strated by the condensation of the excess of moisture on a frosty day, and is estimated by Valentine to be 8,100 grains a day. It may be urged that, in addition to the actual vapor capacity of air, sufficient may be added, in a state of high mechanical subdivision, to effect the purpose, and, to a cer- tain limited extent, this is true; but it has been demon- strated that something more than the inspiratory act is required to introduce this mechanical fog farther than the smaller bronchi. Compressed air was tried by Waldenburg and others; but it was discovered that compression, the very agency used, so reduced the vapor-carrying capacity of the air that condensation took place at the moment of meeting, and condensation on the cell-walls was as far off as ever. Now, with the investigations and experience of old and well- known authorities before us, we find that neither inspira- tion nor pressure will directly introduce artificially moist- ened air into an alveolar space, except through the slow process of diffusion, and aspiration must be resorted to in order to get the saturated air to the locality where we wish to condense it. To produce the latter phenomenon, physics affords but two methods—viz., decrease of temperature and THE THEORY OF THE PNEUMATIC CABINET. 3 increase of pressure. The temperature we can not change, nor would the lungs tolerate any such interference, and, as a last resort, we are compelled to use pressure. We are here aided by anatomical structure and physiological law, for, while in inspiration the glottis is opened to its fullest extent, on forced expiration, such as is produced by the cabinet, it is constricted to less than one half its area, and proportionate force must be employed to expire a given quantity of air in the same time in which inspiration was effected through an aperture of three quarters less capacity than that through which it entered. Recent tests have shown that a pair of lungs of two hundred cubic inches air- capacity, with a normal tidal How of twenty cubic inches, will, when aspirated by a surrounding vacuum equal to one inch of the manometer, inhale at each inspiration one hun- dred cubic inches, or 50 per cent, of their total capacity. This prepares us for the following comparison : Instead of the tidal air of twenty cubic inches robbing the lungs of eight one hundredths of a grain of moisture at every respi- ration, we have one hundred cubic inches of air introduced at 70° F., containing three tenths of a grain of medicine, which is increased by seven tenths of a grain of pulmonary moisture due to its increase in temperature to 90° F., mak- ing our one hundred cubic inches contain one grain of solu- tion. This solution consists of medicament three tenths of a grain, and moisture taken from the bronchial and alveolar surfaces seven tenths of a grain. During the act of respira- tion, and including the moment of rest preceding expira- tion, the atmospheric pressure has not been changed. But the act of expiration begins, and the volume of air about to be expired, weighing one thirtieth of an atmosphere more than the surrounding medium, is compressed by the contraction of the respiratory muscles, and condensation throughout the pulmonary structure is effected exactly as THE THEORY OF THE PNEUMATIC CABINET. 4 the pressure lowers the hygrometric capacity of the tidal column. This, at the difference of one thirtieth of an at- mosphere, or one inch of the manometer, as noted, reduces the physical capacity of our one hundred cubic inches of tidal air to six tenths of a grain, and the excess of four tenths is deposited on the nearest cell-walls. The four tenths of a grain of condensate consists of 30 per cent, of medicine, or twelve hundredths of a grain, at each respiration, and, at eighteen respirations a minute, this would be two and sixteen hundredths grains. Consequent- ly, in a sitting of fifteen minutes, thirty-two and four hun- dredths grains of medicine would be condensed upon the aerating septa of the lungs.* An important condition in effecting condensation is the reversal of the physiological act of respiration. Normal in- spiration is active, while expiration is passive. In the cabi- net the reverse is the case. If a piston pump is kept at the pulmonary temperature, and saturated air at 70° F. is aspirated into it by the active withdrawal of the piston, and it is then allowed to empty it- self by the passive fall of the same, due to its weight, which must only suffice to overcome friction, no condensation is effected, and a weighed quantity of water contained in the pump will lose weight in the proportion previously stated; but let the pump be filled by passive aspiration, and the saturated air expelled by an active fall of the piston, equal to the forced expiration observed in the cabinet, and our weighed quantity of water will increase in weight at a rate that verifies the above-stated equation. Clinical experience and experiment must determine to which of the agents—pulmonary calisthenics, topical medica- * These deductions are calculated for the vapor of water, and must be corrected for density and tension if applied to other fluids or chemi- cal combinations in use. THE THEORY OF THE PNEUMATIC CABINET. 5 tion, stimulated arterial circulation, or thorough ventilation of the blood—are due the results which have been attained. Topical medication was the goal toward which the project- ors devoted their energies, and, that having been accom- plished, it remains for the investigators of the medical profession to determine the range and application of the cabinet as a therapeutic agent. 171 Gates Avenue, Brooklyn. 6 LUNG DISEASE TREATED WITH A REPORT OF SIXTY-NINE CASES OF LUNG DISEASE TREATED WITH THE PNEJJMATIC CABINET* By SIDNEY A. FOX, M. D., BROOKLYN. My purpose is to present this evening a simple record of personal experience with the pneumatic cabinet. The province of this report will not include the physics of pneu- matic differentiation, or any questions of pathology, but merely the results of clinical investigation during a period of thirteen months. I would avoid any misconstruction which might be involved in the title of this paper by say- ing that, in every chronic case, treatment with the cabinet has been supplemented by the course of tonic treatment usually employed, including cod-liver oil and hypophos- phites. Night-sweats have been controlled, as far as pos- sible, by different therapeutic agents, notably quinine, and a combination of the oxide of zinc and the extract of bella- donna. In checking diarrhoea, the different preparations of opium and bismuth, either alone or in combination, have been most effective. I would call the attention of those who may desire to * Read before the Medical Society of the County of Kings, February 16, 1886. THE PNEUMATIC CABINET. 7 further investigate the subject of pneumatic differentiation to the following articles, which represent the published literature to date. II. F. Williams, M. I)., “Antiseptic Treatment of Pul- monary Diseases by Means of Pneumatic Differentiation,” “Medical Record,” January 17, 1885; “Pneumatic Differ- entiation,” “ N. Y. Medical Journal,” October 5, 1885. V. Y. Bowditch, M. I)., “Boston Medical and Surgical Journal,” July 10, 1885, and “Journal of the American Medical Association,” August 1, 1885. A. F. Houghton, M. I)., “Journal of the American Medical Association,” November 7, 1885. Dr. Jensen, same journal and date as Dr. Houghton’s article. Joseph Ketchum, Esq., “The Physics of Pneumatic Differentiation,” “Medical Record,” January 9, 1886. E. Darwin Hudson, Jr., M. D., “Present Status of the Pneumatic Treatment of Respiratory Diseases,” “ Medical Record,” January 9, 1886. Two years ago last January, while convalescing from an attack of acute lobar pneumonitis, one of the physicians at- tending me, my esteemed friend Dr. II. F. Williams, casu- ally remarked that he had an apparatus which promised to mark a new departure in the treatment of lung diseases. That was my first introduction to the pneumatic cabinet. At that time there was no literature on the subject extant, and pneumatic differentiation was practically unknown. Through the kindness of Dr. Williams and Mr. Ketchum, I was permitted to see the patients treated, and to note their progress from time to time. My conviction as to the utility of the cabinet was, in a short time, thoroughly established. Any doubts which may have lingered in my mind have been completely dissipated in the treatment of the sixty- nine cases of lung disease which have come under my care 8 LUNG DISEASE TREATED WITH since February, one year ago. I think I can say, without fear of contradiction, that the results in some of these cases have been remarkable. Following are the results: «W OD O f course, the term recovery, in the sense of a disappear- ance of the physical signs with coincident restoration of the general health, can only be applied to cases that have not advanced beyond what we call an “apical catarrh,” or “ incipient phthisis.” But, where the disease was further advanced and general health has been restored, with disap- pearance of hectic and of all local signs, except some dull- ness and altered respiratory sounds at the apex, it is proper to use the term cared. There may, of course, be a return of the disease at some future time, but that also occurs in the case of many other affections where we feel ourselves justified in speaking of recovery jus having taken place. In some cases the disease may be rendered temporarily latent, and in others, in which, owing to the advanced stage which it has reached, no such result is to be hoped for, life may be prolonged for a few weeks or months. As to the meth- od of treating these cases, particularly those that are far advanced, it has seemed to me that it would he better, if the patient’s muscular strength is greatly reduced, to take off the pressure during the act of expiration, so as to relieve the expiratory muscles of the increased labor resulting from exhalation against a pressure. This would be equivalent to inspiration of compressed and expiration into normal air. Where the pressure is continued throughout both acts, the 28 PNEUMATIC DIFFERENTIATION. fatigue with some patients is very considerable. My friend Dr. Platt does not, however, agree with this opinion, but treats such cases with a very low pressure, so as to avoid fatigue. He thinks that the continuous pressure is particu- larly useful, as it diminishes the pulmonary congestion and lessens the liability to haemoptysis. This is undoubtedly true, but it may be that the resulting fatigue, with very weak patients, more than outweighs this advantage. In addition to the danger of producing undue dilatation of alveoli and bronchiectatic cavities, it is supposed by some that there is also a risk of exciting haemorrhage. I think, however, that the fear is ungrounded if the cabinet is prop- erly used. It has rather a haemostatic effect when used in the ordinary way—that is, by rarefaction of the air in which the patient sits. We have frequently used it for this pur- pose, putting patients whose sputum was bloody into the cabinet under a moderate pressure. When they emerged, the blood would have entirely disappeared from the expec- toration. When cavities exist, however, there may be danger of lacerating vessels which run in their walls. We have had two cases of profuse hemoptysis coming on during a course of pneumatic treatment, but not while the patients were in the cabinet. In neither one can it be alleged that the treatment bore any causative relation to the haemorrhage. The first case was that of a man suffering from extensive fibroid induration of the left lung sequent to an attack of lobu- lar pneumonia of the upper lobe. He suffered greatly from dyspnoea and had periods of febrile movement, sometimes lasting for a month. During one of these periods he was subjected to treatment by a low vacuum, one sixtieth of an atmosphere. After three or four trials, he came around one morning and com- plained of feeling worse. lie was very short of breath and had great constriction and oppression of the chest. Dr. Platt did PNEUMATIC DIFFERENTIATION. 29 not put him into the cabinet. IIo went from tho office to New York, and, while returning on the ferry-boat, began to raise blood. IIo went into a drug-store, and says that ho nearly filled a cuspidor with blood. After resting a few minutes he went out, ran half a block after a horse-car, went home, and had no further trouble. These conservative luemorrhages are of frequent occur- rence in those suffering from pulmonary fibrosis. Had the man entered the cabinet on the morning of the haemorrhage, it might have been said that that was the cause of it. Another caso was that of a man, twenty-eight years old, who, about two years before we saw him, had suffered from some acute pulmonary disease. He had never regained his health, but continued weak and short of breath, with recurring febrile attacks which were terminated, each time, by the sudden ejection of from half a pint to a pint of fuetid pus. The attacks had been gradually becoming less frequent, and the amounts of pus somewhat smaller, but he continued weak and sick. Thero had been several severe hromoptyses. 1 took him into the hospital and tried, with the exploring needle, to learn the situation of tho abscess-cavity, but was un- successful after four deep punctures. The physical signs point- ed toward the axillary and posterior portions of the right lung. As it was not accessible by surgical means, we applied the cabi- net treatment, using a mild vacuum and spray. There was a very marked improvement in his general health, the cough abated considerably, and his spirits were greatly im- proved. On the last day of treatment he appeared in the morning and took the sitting as usual. That night he had a copious 1 Hemorrhage. On the following day there was another. The next day there was no return of it, but on the following afternoon he went out to a restaurant, ate a beefsteak, came home, had another haemoptysis, and was found dead in his room. At the autopsy, at which I)r. Platt was unable to be present, I found an abscess-cavity, of about the size of a hen’s egg, in the posterior part of tho lower lobe, at about its middle and close 30 PNEUMATIC DIFFERENTIATION. to the vertebral bodies—inside the projection of the transverse processes. It communicated freely with a bronchus of medium size. The pulmonary tissue in the vicinity was thickened by interstitial inflammation, and there were numerous tubular and fusiform bronchiectases of small caliber. The cavity, adjacent bronchi, and trachea contained blood. The other lung was normal, with the exception of some emphysema of the upper lobe. There was no sign of tubercle.* There is some question as to whether the hmmorrhagc in this case was induced by the cabinet treatment, but, when we consider that he had had several severe attacks previously, and that this one did not occur until from ten to twelve hours after the last sitting, it seems improbable that the treatment could have been the cause of it. In conclusion, I would say that I regard the cabinet as a valuable addition to our armamentarium. Like every other appliance that is capable of doing good, it is also capable of doing much harm in the hands of ignorant or unskillful persons, and those who control it are certainly under obli- gations to keep it out of the reach of any but competent physicians. * See the report of a meeting of the Brooklyn Pathological Society this Journal, May 29, 1886, p. 620. THE PNEUMATIC CABINET. 31 ON TIIE PRACTICAL APPLICATION OF THE PNEUMATIC? CABINET.* By ISAAC HULL PLATT, M. I)., Brooklyn, ASSOCIATE I'llYSICIAN TO THE DEPARTMENT OP THORACIC DISEASES, ST. MARY'S HOSPITAL, BROOKLYN, ETC., ETC. Any means of treatment which promises relief for such a terrible disease as phthisis is certainly worthy of the fullest attention of the profession. In our fight with this dreadful malady, all we can hope is to gain ground by inches, and the inches gained are well worth the fight they cost. It is with this feeling that we should approach the discussion of the pneumatic cabinet, and not with the expectation of finding a sure and easy cure for consump- tion. If the apparatus before us promises anything in the way of alleviation of the disease, it is well worthy of our careful notice. This cabinet has been in use three or four years, and the results so far reported are, to say the least, extremely encouraging. Of course the general principle of the treatment of dis- eases of the lungs by using air at different pressures is by no means new, the earliest form of appliance being that of the * Remarks made before the Medical Society of the County of Kinps, March 16, 1886. 32 TIIE PRACTICAL APPLICATION OF placed and the air compressed or rarefied at pleasure. I be- lieve it was mainly used for the administration of com- pressed air, and the treatment by this method was said to increase the vital capacity, reduce the frequency of respira- tion, increase the consumption of oxygen, and to exercise a general beneficial effect upon the nutritive processes. After this was introduced the well-known Waldenburg apparatus, on the gasometer principle, by which the patient was ena- bled to breathe from a compressed atmosphere while sur- rounded by air at the normal pressure, expiration being made, as the apparatus was ordinarily used, into the sur- rounding atmosphere. Of course there are modifications of these forms, but all worked upon one or the other principle. It seems to me that the cabinet of Dr. Williams and Mr. Ketchum involves a principle which has never been tried systematically before, if at all. It is this : The atmosphere which the patient breathes—that is, which fills his lungs and exerts its pressure upon the intra-thoracic organs, upon the inner surface of the thoracic walls, and upon the upper sur- face of the diaphragm during such time as the patient is undergoing treatment, and continuously during both inspi- ration and expiration—is of a different tension from that sur- rounding the body. This is well designated by Dr. Will- iams the principle of pneumatic differentiation. It differs from the principle of Tabarie’s apparatus in that the latter subjects the patient to the same atmospheric pressure as that of the air which he breathes, and it differs from Wal- denburg’s apparatus by maintaining the same increased or diminished pressure during both respiratory acts, instead of only one. It is true that this might be accomplished by a combination of two sets of Waldenburg’s apparatus, but probably not very conveniently, and I do not know of the attempt ever having been systematically made. Now, it seems evident that the application of this principle will result THE PNEUMATIC CABINET. 33 pneumatic chamber of Tabarie, which consisted of an air- tight apartment in which a number of patients could be somewhat differently from that of the Waldenburg apparatus, for, while the operation of the latter would be by exerting pressure upon the blood-vessels of the lungs and then sud- denly relaxing it, to increase the How of blood to the lungs, and to increase the active congestion if any existed, the method of Dr. Williams would, if, as I am supposing, the air about the patient be rarefied, exert a steady and uniform pressure upon the vessels of the pulmonary circulation as long as the patient is subjected to the treatment. Now, how will this act ? Such portion of the thoracic cavity as is not occupied by tissue—muscular, glandular, the paren- chyma of the lung, etc.—consists of air-space and blood- space, and it is obvious that the increase in one of these will tend to the diminution of the other. The respiration of air at the normal tension while the body is immersed in a rare- fied atmosphere is in effect the same as the introduction of a compressed atmosphere into the air-space of the lungs; it will increase the air-space and tend to diminish the blood- space, driving a certain portion of the blood from the lungs into the general circulation, which is subjected to a dimin- ished pressure. The pulmonary congestion is diminished in exactly the same way as the congestion of an infiained joint or of an ulcer by bamhiging. Or, to put it another way, the blood is sucked or drawn out from the lungs into the general circulation, as it is sucked into the space beneath a cupping glass. This I believe to be the main action of the cabinet, the reduction of pulmonary congestion, and the theory is practi- cally verified by our experience with regard to blood-spitting and bronchial luemorrhage. Time and again patients have come into the office complaining of the sputa being blood- streaked, and, almost without a single exception, the use of 34 THE PRACTICAL APPLICATION OF the cabinet lias relieved the symptom in the course of a few minutes. In addition to the effect it has upon the pulmonary con- gestion, it undoubtedly acts beneficially in other ways. The thoracic gymnastics afforded by expiration against increased resistance will probably be of benefit to the weak-chested. The increased oxygenation of the blood will doubtless im- prove the nutritive processes. Then the spray, if proper medicaments are used, may be expected to act beneficially upon the accompanying bronchitis. I was not able to fol- low fully Mr. Ketchum’s argument in regard to the conden- sation of the spray in the deeper air-passages. It occurs to me, though, that our difficulty has been not to cause the con- densation of the sprays heretofore used in the medication of the air-passages, but to prevent their condensing too soon. There will be no trouble in making the spray condense if it can once be got where it is wanted; but I have most seri- ous doubts whether it reaches beyond the primary division of the bronchi. Treatment by this method has been spoken of as the antiseptic treatment of phthisis, and by this I sup- pose is meant that the germs of the disease are supposed to be killed by medicament contained in the spray. In this view I have no faith whatever, but regard it as wholly vision- ary, and without the slightest foundation either in reason or in fact. Admitting that the Bacillus tuberculosis is the one and only cause of the disease, which is not proved; that its destruction will cure the disease, which is still further from being proved; that a small portion of the spray is carried into the alveoli, which is not probable—we are still very far from proving even the possibility of reaching the germs in this manner, for the bacilli, incased as they are in tubercu- lar and caseous masses and in thick mucus, are well protected from even the very minute amount of our disinfectant which we may imagine ourselves able to carry into the deeper air- THE PNEUMATIC CABINET. 35 passages. The pneumatic cabinet is undoubtedly a most valuable addition to our armamentarium for the treatment of thoracic diseases, but it is too much to expect it to go to the root of the evil, and it must be regarded as an adjunct to, and not as a substitute for, such other means of enabling the patient to fight off the disease as we have at our com- mand. In regard to the results of the treatment Dr. Westbrook has spoken. Dr. Westbrook and I have used the cabinet about eight months, with about the same kind of results as those reported by Dr. Fox. We are not ready yet to report our eases in detail. Eight months is too short a time to judge of the results of any method of treatment in such a disease as phthisis. A report to be of value should be of a large number of cases extending over a considerable time. So far as our experience goes, it has been very encouraging. One or two cases of advanced phthisis have acted so well that we have strong hopes of the patients’ recovery. Patients in the earlier stages of the disease have nearly all experienced some benefit. The exceptions have, I believe, been either those who, easily discouraged, abandoned the treatment be- fore any result could have been expected, or else those who, from the rapid progress of the disease, or on account of the uncontrollable weakness of their digestive powers, or for other reasons, did not seem able to respond to any treat- ment. In regard to the dangers which have been spoken of in the discussion, undoubtedly there is some degree of danger, but the danger in the use of anaesthetics does not prevent our use of them. The risk of producing copious or fatal haemorrhage has been mentioned. Our experience has satis- fied us that bronchial haemorrhage can be stopped by the use of the cabinet. It is hardly conceivable that, with any pressure which one would be apt to use, the lung substance 36 THE PRACTICAL APPLICATION OP could be torn. If cavities exist in the lung, the air enters not only the cavities but the surrounding alveoli, so that the walls of the cavities can not be greatly stretched. Of course it is imaginable that a portion of lung might be so far dis- organized that an inspiration of greater than usual depth might rupture a vessel—in such cases, for instance, as are described where the vessels lie exposed in the walls of the cavities or stretch across them from side to side, the walls of the arteries themselves being probably disorganized. But such vessels as these would be hardly worth saving, for they would be certain to rupture before long, and the worst that the treatment could do would be to determine the time of the accident. A more real danger I believe to be that of producing emphysema. The lungs can doubtless be serious- ly injured in this way by an injudicious use of the cabinet; but, by using care in regulating the pressure and watching the condition of the patient’s lungs by repeated examina- tions, this evil can be readily avoided. The results of my experience, however, are opposed to the use of the high pressures advocated by Mr. Ketchum. He spoke of using a pressure of from half an inch to an inch and a half. We commenced the use of the apparatus with pressures varying from half an inch to one inch, but we soon found that the higher pressures unnecessarily exhausted the patient, and in one case produced considerable emphysema. I now seldom use a pressure of more than half an inch, and find the results more satisfactory. Patients in advanced stages of the dis- ease frequently experience great relief to their cough and dyspnoea by this treatment, but its application is subject to the drawback that they are so easily fatigued by the muscular effort necessary for expiration. Dr. Westbrook has suggested that in these cases the valves of the cabi- net be so arranged as to take off the pressure during expiration. I have never tried it. It would doubtless HIE PNEUMATIC CABINET 37 lessen the fatigue, but it would be open to the objection that we should not be getting the benefit of the sus- tained differential pressure which 1 believe to be the great feature of this apparatus. I prefer in these cases to meet the difficulty by making the pressure very light and the sittings short. 38 MEDICAL SOCIETY OF MEDICAL SOCIETY OF THE COUNTY OF KINGS. Meeting of March 16, 1886. The President, Dr. George R. Fowler, in the Chair; Dr. C. E. De La Yergne, Secretary. Pneumatic Differentiation and the Pneumatic Cabinet. —In the continued discussion of Dr. Fox’s and Mr. Ketchum’s papers, Dr. Brown said that his experience with the cabinet had been embodied in the paper read by Dr. Fox, who, by the way, was unavoidably absent that night, having met with a painful accident. It was evident that accurate diagnoses must pre- cede the application of the treatment, otherwise no proper estimate of its value could be arrived at from results that followed its use. He thought something ought to be said about the case which was reported as one of chronic interstitial pneumonia or fibroid phthisis. The result in that case was surprising, and was so fa- vorable as to seriously call in question the accuracy of the diag- nosis, still he did not think that the result was incompatible with the diagnosis made. The man’s clinical history followed very closely the clinical history of fibroid phthisis. He regret- ted that he did not have the notes of the physical examination. The question was, Could fibroid phthisis be made out at a re- coverable stage ? In that form of phthisis—the most chronic form—the inflam- mation slowly extended from the bronchi to the peri-bronchial THE COUNTY OF KINGS. 39 and interlobular connective tissue. An hyperplasia of this took place. Pressure was made upon the lobules. All of them were narrowed. Some of them collapsed. If the collapsed lobules could bo distended, and the disease arrested at that point, recov- ery was possible. While suggesting this as the pulmonary con- dition at the time treatment was begun, he admitted that there was a good deal of doubt in their minds as to the correctness of the diagnosis, as there was then resonance on percussion. lie believed that in reports of cases, especially those intended to exemplify the results of new methods of treatment, there should be entire frankness. He was not prepared to say to what factor in the operation of the cabinet tbe favorable results were due—whether to the calisthenic exercise and the introduction of unwonted supplies of air, the influence of the method upon the circulation, the good thus obtained being reflected upon the lung itself, or to the direct application of a remedial agent to diseased areas. Ho had then under treatment a young gentleman who had come to him six weeks before saying that he had been to Dr. Janeway, of New York, who had made a diagnosis of tubercu- losis. He was referred to the speaker for treatment by Dr. Catlin, who agreed with Dr. Brown in the diagnosis, but an examination of the sputa failed to reveal the presence of bacilli. The young gentleman had an irritable throat, and was unable to bear the spray. It was therefore omitted altogether, and he breathed ordinary air during his treatments, the vacuum being from 0’2 to 0-4 of an inch, and applications were made every other day. His night-sweats soon ceased, and had not returned, his appetite improved, and he began to gain in weight. The cough grew less and less troublesome, and now gave him little annoyance. About a week before, the spray was again tried, and was inhaled without trouble. No examination of the chest had been made lately. It might be remarked that this patient had taken cod-liver oil regularly since he came under observa- tion. From his experience with the cabinet he was compelled to conclude that for bronchitis the treatment was very nearly a specific; in primary infiltration a cure might be confidently 40 MEDICAL SOCIETY OF hoped for; in the third stage of phthisis it was likely to add much to the patient’s comfort, and in some cases had been fol- lowed by a complete cessation of symptoms. In his opinion the cabinet would occupy a high place in the department of pre- ventive medicine. That department had been neglected by the profession. He believed that a child of phthisical parents, with an ill- developed chest, who would take an occasional treatment in the cabinet, was more likely to overcome the inherited tendency to pulmonary disease than in any other way, or all other ways combined. The treatment seemed to establish a tolerance for cod-liver oil. None of his patients for whom it had been pre- scribed had been unable to take it and appropriate it. The im- provement in nutrition following the applications warranted the expectation that it would prove to be of great service in debili- tated conditions generally. Some of his patients asked how many treatments would be necessary. lie did not think that a proper estimate of its value in a given case could be made until several treatments had been given, and he usually fixed the num- ber at ten, when, if subjective symptoms had been relieved, he advised patients to continue, being guided thereafter by changes in weight and temperature, in cases of phthisis. Experience with the cabinet was necessarily limited, and it was impossible to define its sphere of usefulness so early in its history. It was well to be conservative. He thought it was proved that it was a valuable addition to remedial agencies in the management of pulmonary disease ; it should be used as such, and not to the exclusion of other well-tried methods. Dr. Westbrook asked Dr. Brown to define the meaning of “ primary infiltration.” Dr. Brown was not prepared to say what was generally un- derstood by the term. In his use of it, it meant the first changes that occurred in a lung the seat of a phthisical process. He did not mean by it tubercular infiltration necessarily. Dr. Westbrook had seen it used in reports of cases. Dr. Evans had had no experience with the cabinet, so that he did not know that he could add much by way of its discus- sion. He had had some experience, however, with voluntary THE COUNTY OK KINGS.t 41 inflation of the lungs, and with most excellent results. He was very much interested in the paper of I)r. Fox, and especially one part—i. e.} out of the thirty-four cases of phthisis reported there were no recoveries! In an article published by Dr. Will- iams irt tbe “ Medical Record,” in 1885, of thirty-three cases re- ported, ten recovered—quite a discrepancy between these two records which he could not understand. That the apparatus was essentially a compressed-air machine be was satisfied. Dr. Westbrook at the last meeting expressed that as bis opinion. Waldenburg’s apparatus could be used in various ways, espe- cially tbe douche apparatus. In a paper by Mr. Ketchum, read before tbe Section in Practice of the New York Academy of Medicine in December last, in tbe discussion which followed the paper Dr. De Watteville alleged as tbe essential difference between the two that the pneumatic cabinet increased the arte- rial pressure, while Waldenburg’s did not. Dr. Putnam Jacobi, in answer to that, said she bad taken sphygmograpbic tracings and found that tbe arterial pressure was increased by Walden- burg’s apparatus. There bad been very little said about the form of tbe medicament used. In New York they had been using a preparation of quinine, and bichloride of mercury bad been used, and also carbolic acid, iodine, etc. In fact, thero had been a great multiplicity of remedies used, and still very little had been said about their influences, so that it did not seem to muke very much difference, as far as he could see, what remedy was used in conjunction with pneumatic differentiation. He had used, as ho bad said, voluntary effort to expand tbe lung. When one considered that it was possible to increase the tidal volume of air from 20 cubic inches to 255 cubic inches, ar- tificial contrivances seemed to be supeifiuous. He could him- self inspire 255 cubic inches of air by voluntary effort. Mr. Ketchum, in bis paper on the physics of pneumatic differentia- tion, bad stated that tbe residual volume of air was increased from 28 to 40 cubic inches. A child five years of age could inspire 50 cubic inches of air by voluntary effort. With reference to the conduction of medicament to the air- cells, that had been one of the most difficult obstacles to over- come; in fact, the Academy of Medicine of Paris appointed a 42 MEDICAL SOCIETY OF committee to make investigation and determine whether it was possible to carry medicament to the air-cells. As a result, a majority of the committee reported negatively. A few experi- ments succeeded in throwing the vapor of iodine into the tra- chea and larynx. The vapor of iodine was one of the most volatile of vapors that existed. If iodine was placed on one side of a plate of gold, the evidence of its presence would be observed on the other side in a short time. He understood that the iodine-test was made in the pneumatic cabinet—i. e., the vapor of iodine was inhaled by a patient who had had an ab- scess in the lung, and in whom perforation of the chest-wall had resulted ; a starch bandage was placed over the opening in the chest and it was discolored characteristically. Now, by means of the voluntary inhalation of iodine on one day, on the next morning the evidence of it would be found in the expira- tory air; so that, while he felt that the expansion of the chest and air-cells was important, yet there were other and simpler means of accomplishing it. He could understand, however, that it would be of use in those cases where the patient’s respi- ratory muscular powers were so weak that they were not able to voluntarily expand the lung. He had a case of that kind in his office that very day. He was obliged to give the case up because the patient was unable to expand the lungs. It should be remembered, in introducing medicated sprays in conjunction with compressed air, that the pent-up expiratory volume, the result of reflex antagonism, would be met with in the larynx and trachea. It should also be remembered that the point of meeting was the point of greatest pressure, and that the point of greatest pressure was the point of condensation. Another thing was the influence of that treatment on tem- perature. Nothing had been said about that. He would like to ask Dr. AVestbrook and Dr. Platt whether they had noticed the influence of pneumatic differentiation on temperature, and also whether they had noticed any more benefit following the use of one medicine than of another. Dr. Williams arose to call attention to the remarks of Dr. Evans in regard to statistics of cases quoted. Dr. Evans did not wish to cast any reflections upon the sta- THE COUNTY OF KINGS 43 tistics. What ho meant was, of the thirty-four eases of phthisis reported by Dr. Fox, no recoveries were noted. Of those re- ported by Dr. Williams, ten wore reported as recovered. lie naturally expected to find some uniformity of result when the same means were employed. Hence the use of the word “dis- crepancy.” Whether this difference in result was due to differ- ence in ability to manage the apparatus, or more familiarity with its use, or the different medicines used, he did not know. Ho did not intend to cast any reflections, however. Dr. Williams thought that the doctor meant that they were reporting the same cases, aud that there was a discrepancy in the figures reported. Dr. Brown said there was also some misunderstanding as to what was meant by the term recoveries. He thought a case should run at least one or two years favorably after treatment and cessation of symptoms. As Dr. Fox had had the treat- ment but about a year, he did not feel warranted in reporting the cases as “ recovered,” or any recoveries at all. Dr. Evans meant by the term “recovery” a cessation of any symptoms which might lead a man to suppose himself not in health. Dr. Wksthrook could not give a more definite answer to the question as to the influence of the cabinet treatment upon tem- perature than to say that as the patients had improved the tem- perature had fallen. As a result of his clinical experience, which had included many cases of phthisis, he had come to rely more upon that than upon any other symptom as a sign of im- provement. If the temperature fell, and remained down, it was a fair inference that the patient was getting better; that was, that the disease was becoming inactive or “latent.” The process of caseation ceased to extend, the inflammatory products on the periphery of the diseased area became converted into fibroid tissue and formed a boundary-line between normal and abnormal lung, and the absorption of ptomaines or other pyro- genous substances ceased. If the general improvement was sufficient to prevent a speedy relapse, the patient might be said to be cured—at any rate, the disease had become temporarily latent. In regard to the relative values of different medica- 44 MEDICAL SOCIETY OF ments, lie did not know that they could as yet say much. He thought the least satisfactory of all had been the bichloride of mercury. In the strength in which they had used it, 1 to 1,000, it was rather irritating to the respiratory mucous membrane. Then, there was no object in using it, as there were other sub- stances much better suited to the treatment of catarrhal inflam- mations. As he had already stated at the last meeting, he had no faith in it whatever as a specific treatment, because it would be impossible to apply it by means of the cabinet to the infil- trated lung. They had used a solution of iodine and fluid ex- tract of pine needles on Dr. Fox’s recommendation. Hut per- haps the most satisfactory medicament had been a mixture of carbolic acid and some sodium salt with glycerin and water- For bronchitis, tannin or the mineral astringents were also use- ful. He thought it would be well if, in the discussion of the subject, more care were exercised in defining some of the terms used. For instance, the word recovery had been made use of, particularly by Dr. Williams and Dr. Evans. In using the term it would he advisable to state the meaning attached to it. Again, as to the condition of the lungs. He did not know what was meant by “ primary infiltration.” He supposed it might mean the first or incipient stage of phthisis, but Dr. Brown stated that he did not refer to tuberculosis. He did not, how- ever, express a belief in the non-tubercular origin of phthisis, so that there was some difficulty in understanding him. He did not wish to criticise Dr. Brown unkindly, hut simply used that as an illustration of the somewhat indefinite way in which medi- cal words were often employed. As to the treatment of chronic interstitial pneumonia, or fibroid phthisis, as far as he was ac- quainted with the art of physical diagnosis, he did not see how it was possible to predicate the existence of that form of dis- ease until there was a growth of fibroid tissue in the lung; and, when that had occurred, there was, as he stated at the last meeting, a firm, solid tissue, with obliteration of air-cells. It was impossible to restore its alveolar structure. He did not think that the process in its early stages was exactly as Dr. Brown had stated it. The inflammation not only invaded the connective tissue between the alveoli and about the bronchial THE COUNTY OF KINGS 45 tubes, but it also involved all tlie other structures of the lung. The alveoli were tilled with proliferating cells, which organ- ized into new connective tissue. The alveoli, alveolar walls, interalveolar and interlobular connective tissues were all fused together into one mass. When that had occurred and the mass was large enough to give rise to dullness on percussion, bron- chial breathing, and bronchophony, or to other physical signs equally distinct, a diagnosis could be made of fibroid phthisis; but until that had occurred he did not think that fibroid phthisis could be said to exist. It certainly could not be diagnosticated. There might be a condition of affairs which could be diagnos- ticated as peri-bronchitis, and from which more or less intersti- tial fibrosis would subsequently develop, but that, too, would have to reach a considerable degree before it could be recog- nized. If recovery—that was, a rcfifitittio ad integrum—oc- curred, it would certainly throw a doubt over the diagnosis. Ur. MoCorkle said that he would like to ask one or two questions, or, rather, refer to a point or two in the use of the cabinet. He was not familiar with its use, and his acquaintance with it extended only to what he had heard and seen at the ses- sions of the society. He was especially interested in anything pertaining to lung diseases, and had watched with a good deal of interest the discussion in regard to the pneumatic cabinet; but upon one or two points he had failed to receive any light. In regard to the medicinal agents used, he thought that, in the use of those agents, there was such a doubt as to the seat of their action, and the amount of good resulting, that the whole matter was still a question. In the first place, when the struc- ture of the lung was considered, and the caro with which nature had protected the air-cell for its safety, and the struggle that nature made before she would allow irritating medicines to enter the trachea and through it the air-cells, it seemed to him that great care should also be used by the physician in the applica- tion of medicaments. Vapors might be used which would stimulate the inflamed portion of the lungs, but what would be the effect of those same agents on the healthy lung-tissue? That was a question which ought to bo considered well in the use of any kind of 46 MEDICAL SOCIETY OF medicinal agents, where we had an instrument of such power as this instrument possessed, and he was surprised that no one liad referred to that point. Another point was that, in the treatment of any inflamma- tory disease, one of the great remedial agents was rest to the inflamed organ. If we had an inflamed stomach, intestine, or peritona3iim, we put it at rest, and hoped by that means to ac- complish recovery; but, if we had a diseased lung, we put the patient in the pneumatic cabinet, we employed every means but that of rest to accomplish the desired object. He knew not how this might appear to others, but it struck him as irrational treatment. The instrument might be one of great power in that condition of inertia following inflammatory disease when the inflammatory stage had subsided, but it seemed to him that one of the first and most important therapeutic laws was vio- lated when inflammatory diseases were treated by the cabinet. The vessels already filled with blood were distended, and when the functional activity of an organ was increased it was predis- posed to disease. That was illustrated in the diseases of other organs, as, for example, the heart. He had often noticed in phthisical patients who had recovered, that they had been for a long time amemic. The lungs represented the strength of the person afflicted. He did not live up to the standard of health, but to that of disease. If the diseased lung, by the aid of stimu- lants and tonics, was forced to work up to the full functional capacity of the healthy organ, failure was the result, and the lung went in the direction of degeneration. It would be no- ticed, as he said before, that patients with phthisis who recov- ered had been anasmic, and the functional work of the lung had been reduced to the minimum, thereby insuring the greatest possible amount of rest to the diseased organ. Just as the quality of the blood in some of these cases was improved be- yond a certain point, the danger of a recurrence of the disease and of a fatal termination was increased. This was a therapeu- tic law in which he had great confidence, and was worth bear- ing in mind in the treatment of those diseases. Dr. Platt was glad that Dr. McCorkle had raised that point. Of course, the principle that an inflamed organ should be given THE COUNTY OF KINGS 47 rest was a sound one; blit there must ho ft reason for it, and the reason probably was that functional activity drew additional blood to tbo organ, and thus increased the congestion. In the case of the lungs, it was impossible to give them complete rest, for tho cessation of respiration meant death. By the method under consideration, however, the usual evil result was avoided, because, instead of drawing blood to tho lungs, the tendency was to exsanguinate them, as ho (tho speaker) had already at- tempted to show. Dr. MoOorklk said that it was well known that the heart rested from seven to eight hours out of tho twenty-four, and that the passive action of the lungs represented that period of rest, so that the lung got a normal amount of rest. It was that period of rest that enabled it to do its functional work. No matter where the organ might bo, or what it might do, it must have that rest. I)r. Westbrook was glad that Dr. McCorklo had asked the questions he did, bocause they might occur to many general practitioners, and their answer would help to clear up tho general subject of aerotherapeutics, as applied with the pneu- matic cabinet. In the first place, lie would say, in reply to the question whether medicated sprays or vapors thrown into the air-passages might act injuriously upon those parts which were not diseased, that those who were engaged in laryngo- logical work were constantly spraying fluids in that way, and, unless recklessly used, no irritation of tho normal membranes resulted. For instance, in treating a catarrhal laryngitis, one would throw a spray into tho larynx, but quite a quantity of it would go into tho trachea. It did no harm there. The sub- stances generally used were in no way injurious to a healthy membrane—in fact, by cleansing tho respiratory mucous mem- brane, they helped to prevent the occurrence of inflammation as a result of the contact of irritating discharges, particularly in phthisis, and to cure the catarrh when it had already been pro- duced. This washing and disinfection of mucous membranes were considered by many to be of great importance, notably by Professor William II. Thomson, who, in his article on bronchitis, in the first volume of “ Wood’s Reference Hand-book,” placed MEDICAL SOCIETY OF 48 great stress upon disinfection as a curative measure. In the second place, in answer to the question whether the increased expansion and labor of breathing were produced by the cabinet as ordinarily employed, that had already been partly answered by Dr. Platt. He would add that the increased mobility of the chest-wall could not be strictly interpreted as increased work put upon the lungs. The lungs were passive organs, expanded under atmospheric pressure, and retracted by virtue of elastic fibers in tlie parenchyma and walls of the bronchi. While forced expansion would, very probably, have a bad effect on an acutely inflamed parenchyma, which had lost its elasticity and was very friable, it would not so affect a bronchitis; and in chronic diseases the old generalization that diseased organs must have rest did not apply. Many diseased organs were much better for exercise. He would call the president’s attention to the bene- fit obtained by many consumptives who visited great altitudes, where the respiratory activity was necessarily very much in- creased. The effect of the cabinet in arresting bronchial haemor- rhage was very significant in this connection. Concerning what had been said about the condensation of vapors in the lungs, he would remark that most of the medicaments used were em- ployed in the form of sprays, or nebulized liquids, and not of vapors. Iodine was about the only substance that was vapor- ized very extensively in the air-passages. Of course, any nebu- lized fluid would undergo slow evaporation to some extent, but whether reprecipitation would occur was very doubtful, as ho was not at all willing to admit the soundness of Mr. Ketchum’s opinion in regard to the increase of pressure during expiration. It would be well if Mr. Ivetchum could make a calculation of the quantities of the different vapors necessary to saturate the air at a temperature of 100° F. The dew-point might then be determined, and we should have an idea of about how much of any substance it would be necessary to evaporate in order to surcharge the air in the larynx and trachea. Mr. Ketciium, in reply, said that he was glad Dr. Westbrook had referred to the term “ vapor.” The cause of the mist, he thought, which occurred in any change of the hydroscopic con- dition of the air might be due to either an increased pressure or TIIE COUNTY OF KINGS 49 a diminished pressure. When there was a passage of water into vapor due to any cause, there was always an intermediate state of mist or fog. If they noticed, the water in the reservoir passed into vapor if the pressure was either decreased or increased. It was the water springing into mist, and then being absorbed by rarefied air into vapor. If, on the contrary, a bladder full of satu- rated air was suddenly compressed, condensation was effected. The President called upon Dr. Williams to close the dis- cussion. Dr. Williams said that it was known to most of the mem- bers that lie had been identified with the process which he had christened •‘pneumatic differentiation,” clinical results of which Dr. Fox and Dr. Brown had so carefully recorded that night. In the record of their cases they seemed to describe results rather than denominate them, a course which the speaker heartily commended, on account of the wide difference in the minds of careful men as to what constituted a recovery in phthisis. It had been a pet theory of his that, if they could devise a scheme by which they could certainly medicate the pulmonary tissues, they could manage a large range of cases. Ilis predictions had taken shape in a paper which he had the honor to present to the society some ten years ago. Mr. Ketchum had shown that night that that was possible, and had clearly pointed out the obstacles to be overcome. Now that topical medication was an accomplished fact, it remained for careful discrimination to see that it was advisedly and properly done. Its range was as wide as the materia medica. Vapor, gas. smoke, nebulized spray, and pure air itself, would have their votaries, but clinical experience alone would decide the com- parative value of each. This must necessarily be the most com- plete when they could obtain the advantages of hospital accom- modations. Aside from the value of the pneumatic cabinet as a means of topical application, its range of therapeutic power was perhaps equally great in its direct mechanical effect upon the lungs, and secondarily upon the whole physical economy. It was in that regard that the utmost precaution must be taken. Our lamented Professor Armor, who hud been an early and constant adviser, not only in its application, but in the plan by 50 MEDICAL SOCIETY OF which it had been placed before the profession, recognized its value and approved the extraordinary precautions which had been taken to guard humanity against its misapplication. Cabi- nets were at the disposal of all educated physicians, and were at present in the hands of such in almost every prominent city in the Union. Ilence they could confidently hope for further and cumulative evidence of its value. The president’s remarks plain- ly showed the necessity of not overtreating cases in which na- ture had already made a compromised recovery. He would refer the president and all others interested to his early publica- tions upon that subject. In such a condition as the president had described, a thoughtless or over-zealous physician might produce serious, if not permanent, mischief. Happily for them all, there was a time in the history of a phthisical case where the president’s remarks did not apply and where over-zeal pro- duced the most satisfactory results. With reference to the influence on temperature, of course in the cases where im- provement or recovery took place the temperature declined. There was a class of cases in which, if too much force was applied, the temperature not only would not decline, but would absolutely increase, and that was one of the strongest contra-indications. Relative to the question of compressed and rarefied air, it was apparent that some of the gentlemen who had spoken that night were mistaken in their ideas. It was first necessary to understand the instrument. In the first act — viz., producing rarefaction in the cabinet and allowing the patient to respire against the external air—there was not a particle of compressed air. To be sure, it produced a force, and in that regard only was it similar to Waldenburg’s condenser. There the similarity ended, for the physical consti- tution of the external air had not been changed. But a wider difference yet was produced in the ability to burden the air with moisture or any agent, and to chemically purify it. Through the influence of the rarefied air surrounding the thorax its cubic capacity was so increased that air, with its normal quota of oxygen and natural molecular space, was invited and circulated when no prudent amount of force could drive it. In the second act—i. e., compression—we had the condensed air in- THE COUNTY OF KINOS 51 side the cabinet, the patient expiring into the normal atmos- phere. The difference between this act and that of expiration into rarefied air was unique. The one was a vim a tergo and the other a vim afronte. The third act—viz., alternating from plus to minus the weight of the atmosphere—needed no comment as to its uniqueness or originality. This, more fully carried out, would be resuscitation. It was well for investigators to remem- ber that in treating phthisical cases by that process or by any means which caused patients to frequently present themselves before them, they were making a departure from the usual methods in the management of private cases. Heretofore it had been useless and aimless to make frequent physical examina- tions. In all recoverable cases they had felt in duty bound to prescribe climatic influence for the major portion of the year. They did not then, as by that process, hear a recital of every varying symptom perhaps daily. Fever came and went; inter- current inflammations were untreated and unnoted; diarrhoea, night-sweats, and haemorrhages were combated by the patient’s armamentarium, which his careful physician had provided, or were left alone, and at length the season changed or other cir- cumstances compelled or permitted him to return, when they had their first opportunity to observe and examine him. They hoped to find recovery. They sometimes did. Hut was it not an honest statement that subjective improvement, rather than recovery, was more frequently the basis of their satisfaction? In any event they did not begin to know the exact element in the history of improvement. The cabinet was entitled to equal consideration, though it could not then claim it. It was pass- ing through the crucial test, and its investigators were com- pelled to meet and treat the inconstant symptoms that arose in every case. Incidental lncmorrhages, colliquative sweat, fever, and every annoying symptom must each in turn stand as its accuser. Happily, in certain cases these symptoms readily dis- appeared under its use. In others it required more careful study and observation to condemn or exonerate. It was an in- strument of great therapeutic range and power. It would be kept and guarded as a professional instrument, and would find a wido and useful place in spite of occasional misapplication. 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