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present that this was a genuine case of tubercular arthritis. The sister of this patient died afterward of tuberculosis. The consolidated area in the left lung was distinctly crepitant for some weeks but finally cleared up under the administration of creosote. These two points in this case demonstrate that this was a case of tubercular arthritis.

What have small doses of creosote done? Shall we fold our arms and administer five drops three times a day and not undertake any larger dosage? I must thank my friend from Lebanon for so ably supporting me. I expected to meet with a storm of opposition; but someone must go out into these new fields and investigate. It is not necessary I think to administer the drug strong enough to kill the tissues in order that it may have an effect upon the tubercle bacillus. I administered the drug in a diluted form with milk, as much as a pint often being taken with each dose of creosote, and I still contend that beechwood creosote taken in this way is not poisonous in any reasonable quantity. As to the examination of the urine and the stools, I made the ordinary physical examination which all physicians make. There has been no decided creosote odor to the stools or urine at any time. I believe that creosote is broken up in the system, possibly something else other than creosote is eliminated, but what it is I am unable to say. I have frequently examined the urine to determine if creosote was eliminated as such but I have not been able to demonstrate it in the urine, or the stools.

Local Treatment in Common Diseases of
the Lungs

BY JOHN A. THOMPSON, M. D., CINCINNATI

Academy of Medicine of Cincinnati

A large proportion of the work of most practicians of medicine is the treatment of diseases of the respiratory tract. A few common diseases of the lungs bring to us a large percent of our patients. With these disorders so prevalent, it is always profitable to review our work and determine whether or not we are using the best possible means to aid in the recovery of those whose health we are expected to

restore.

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The common pathologic conditions we meet are acute catarrhal bronchitis, chronic catarrhal bronchitis with its complications, such as bronchiectasia and emphysema, bronchopneumonia, acute lobar pneumonia and its sequels, interstitial pneumonia, and pulmonary tuberculosis with its varied pathologic changes in the tissues of the lung. Less common are pulmonary conditions secondary to diseases in other organs, such as hyperemia, edema and infarcts. rare intervals syphilis attacks the lung either as a pneumonia, gumma or abscess. With the exception of interstitial pneumonia and tuberculosis, the diseases of the lungs that we are expected to cure involve primarily the mucous membrane. In both the excepted diseases there is a secondary inflammation of the pulmonary mucosa. Stated in the simplest possible way, the diseased condition that we are expected to treat in the lungs is an inflamed and infected mucous membrane. In normal conditions the mucosa of the trachea and bronchi is sterile. In acute bronchitis it is infected chiefly with streptococci. In other cases pneumococci, staphylococci and the influenza bacillus are present. These same organisms are found in chronic bronchitis, bronchopneumonia and their complications. They are also the pathogenic agents in the secondary infections of tuberculosis producing the bronchitis, the cavities and many of the septic conditions of that disease.

The reparative process of an inflamed and infected mucous membrane is not easily influenced by medicines which must be carried to it through the blood. It is easily and definitely aided when we can apply our remedies directly to the diseased area. Probably the reason expectorants are not more effective is that they are decomposed in the process of absorption, and we do not know in what form they reach the lung. Of the common expectorants chlorid of ammonium alone reaches the lung with the same chemical composition as when ingested. Remedies that can be used directly on an inflamed membrane are of known composition and effect. They can be changed to meet the conditions

present, with no uncertainty as to their form when they rcach the point where they are needed.

Remedies can be applied directly to the pulmonary mucosa either by nebulizers, sprays or by tracheal injection. Nebulized fluids or those broken up by sprays are of comparatively little value. They are carried only where the tidal air of respiration takes them and it does not enter the badly diseased areas. When a large quantity of a volatile remedy is put into the trachea and bronchi we know by the law of diffusion of gases that it will be carried into every portion of the lungs where a bronchus or alveolus is open. The only method by which a sufficient quantity of medicine can be introduced directly into the lungs is by tracheal injections.

Against this method of direct medication the objections are urged that it is painful and dangerous. It is noticable that these objections are made only by those who have had no experience with this treatment. The physician who has employed it and the patient who has received the benefit of it are both enthusiastic in its praise. Patients to whom I have given tracheal injections in attacks of acute bronchitis return and ask for a repetition of the treatment in subsequent attacks. This is sufficient proof that the treatment is not painful. Spasm of the glottis may be caused by remedies that are too irritating, but that can be easily avoided by a proper choice of the solutions used. The only other possible danger is that the cough following the injection may cause a hemorrhage in advanced cases of tuberculosis. If the medicine has been properly chosen there is little cough, and that is not violent after an injection. Thousands of injections have been given for the relief of symptoms in cases of pulmonary tuberculosis and the first hemorrhage is yet to be reported. The danger must be so slight as to be a negligible quantity.

Judging by letters I have received after the publication of previous articles on this topic the method of giving

tracheal injections is not generally understood. The technic is as follows:

The patient and physician are seated in the usual position for a laryngoscopic examination, with the light on the patient's right side at the level of the mouth. The patient protrudes the tongue and grasps the tip between the thumb and first finger of the left hand. The doctor focuses the light, reflected from his forehead mirror, on the base of the uvula. The laryngeal mirror, held in the left hand, is passed back carrying the uvula and soft palate with it until an image of the larynx is obtained. Guided by this image the operator passes the curved tip of his syringe, held in the right hand, back through the mouth and down in the throat until it is directly over the glottis. Then as the patient inhales, thus opening the glottis, the medicine is injected directly into the trachea. Usually there is a little cough following the treatment. Should the cough be violent or prolonged less irritating solutions must be used. The action of a properly chosen remedy is to relieve the irritation, cough and soreness for hours.

The vehicle in which medicines are dissolved must be an oil. Alcohol and water are too irritating, causing spasm of the glottis and severe pain when injected. This necessity for an oily vehicle greatly limits the remedies which may be used by this method. But we have a number of active remedies soluble in oil or miscible with it and volatilizing slowly at the temperature of the body. The vehicle used is either olive oil or one of the light petroleum oils. The latter is the better. In it we may dissolve menthol, camphor, creosote carbonate, monochlorphenol, oils of cinnamon, cloves, eucalyptus and others of similar action.

With this condensed statement of the principles of direct therapy in diseases of the lungs we can consider their application to individual cases. In acute catarrhal bronchitis injections should not be used until secretion has been reestablished. The mildest solutions cause pain in the first 24 hours while the membrane is in the dry stage of inflam

mation. The abortive treatment by sudorifics, such as Dover's powder, hot drinks or hot baths, is better at this stage. As soon as secretion begins again weak solutions of menthol and camphor may be injected daily with marked benefit. The cough is lessened, the sputum loses its purulent character and the quantity is much reduced. The cure of an attack of acute catarrhal bronchitis is generally accomplished by direct medication in one-half the time required by internal treatment. Another advantage of tracheal injections in these cases is that with them there is much less danger of a chronic, subacute tracheitis and bronchitis being left as a sequel to the acute attack. I draw this conclusion from observation of many cases of chronic bronchitis. Acute attacks in these cases aggravate the chronic disease. When direct medication is used acute exacerbations prolong the treatment but do not notably increase the chronic inflammation.

In uncomplicated chronic bronchitis the comparative value of internal and of local treatment may be illustrated by one of many cases. F. H. B., aged 60, suffered from chronic bronchitis for 18 years before receiving local treatment of the diseased membrane. He is a man of good physic and of excellent habits. He had been under the care of many excellent physicians with little or no benefit. He was very skeptical in regard to doctors' promises and heard my assurances of relief with the tolerant smile of one who hears again an oft-told tale. He was given injections every second day of a solution containing 10 grains each of menthol and camphor to an ounce of Ol. Petrolati Alb. As he improved the interval between treatments was lengthened. The quantity injected was at first half a dram, later a dram to a dram and a half. The result was a complete cure. The patient used a spray for the local inflammation in the nose and throat, but no internal treatment was given.

In chronic bronchitis, complicated by asthma, another case shows the superiority of tracheal injections. A. D. B., aged 40, physician, of good habits, had chronic bronchitis

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