J3> ■*"*>..>  V-

   >?? mi;

■> 5 i  :> >w.
> y>  > »■*.
 > >   ^  »  ?-
 > >   >  >'>-

> >  ■>  •»■> >»->>;
> >   D>  ^>>>.
 j»>  > >> j. >>.« s> z,
»••"»  > » > ">•.» >;> .

   >  ;> >■■ raj"

^> >D  ;^>
-> 5 .> ">  » >»
>>  > • >> -»
. ;»,»D>>
■ in *' >-> >• -



■ -»- » ?>• 3K'
6>> "3*

J> ■•.*■•■>.


)^ )>»



%l%





____o  >^ jam  ■■:>,•
ZJ&-3 i>5 >2B0 ^>
> -J > -<
>»  3D);

     I1 -X» j»»?  "3^ •>

> i>  ->  3 jo  ^  >>-> >

r ^ v-> s»
rs^^ft


>>> ^ V

 

Surgeon General's Office

c/frfunij
         No.
■c»-Qaa0QQ'i

"fc
 
 

-.'/>..  7yf7.   -?J-r  ...  I/.
h 
ON  INHALATIONS
                IN THE TEEATMENT OF

DISEASES OF THE  RESPIRATORY PASSAGES,
PARTICULARLY AS
EFFECTED BY THE USE OF  ATOMIZED FLUIDS.
By J. M.  DA COSTA,  M.D.,
PHYSICIAN TO THE PENNSYLVANIA HOSPITAL.  //  / *~S /j
A r/9-
   During my term of service at the Pennsylvania Hospital, as
well as prior  in private practice, I have made frequent and
constant use of inhalations in  the treatment, especially, of la-
ryngeal and pulmonary affections.  Some of the results thus
obtained were  communicated to the class attending the clinical
lectures, as, indeed, many of the cases were seen by them. But
as these results were chiefly gained by a plan of comparatively
recent origin, that of atomization, and  one the value of which
can only be settled by the conjoined labor  of many,  I have
thought, whether rightly or wrongly,  that they might be  of
interest to a larger circle than those that witnessed them, and
contribute something towards the knowledge of the profession
on the subject.  Let me further premise, that a number of the
cases which will serve as the basis of much that will be  said  in
this paper, especially those  under my charge at the hospital,
received no other treatment, and thus I sought to avoid that
stumbling-block in therapeutic reasoning which often inter- 
feres so sadly with our  efforts  to  arrive at definite conclu-
sions.
  The  attempt to use  inhalations in the treatment of disease
is, as is well known, not of recent  origin.  Hippocrates  not
only employed them, but describes an  apparatus for the pur-
pose, and with Galen they were a favorite mode of treatment.
Indeed, with all Roman physicians they became so; and both
by the  physicians  of antiquity and later by the Arabs the in-
halation of  sulphurous vapors in bronchial  affections, and of
arsenical vapors in asthma, were constantly advised—the latter
a prescription which, in our own times, has been revived by
Trousseau.  Hot, dry ar^was strongly recommended for  the
cure of consumption by Piso, in 1580;  and Bennet, a London
physician, living about  the middle of the seventeenth century,
directed his patients to breathe the atmosphere of a  chamber
filled with fumes  of medicinal substances,  especially of  the
gum-resins.  But it does not appear that any of these endeavors
to employ inhalations  were particularly successful, and they .
had  fallen  into disrepute when the detection  of oxygen and
other elementary gases led to the  mode of treatment being
revived by  Beddoes.   Yet the exaggerated statements with
reference to its action, the  uncertaia effects, and the attempt
to make inhalations serve the purpose of a panacea, produced
again,  very  naturally,  an utter want  of confidence  in them,
which was only disturbed by the  discovery in this century of
iodine  and chlorine.  These agents were eagerly seized hold
of by those physicians who had not lost all faith in inhalations,
partly  with  the view of acting on the affections of the respira-
tory organs; partly because a better knowledge of physiology
was teaching that we may make use of  these  organs to modify
the blood, and thus alter the  condition of the whole system.
The results obtained were to a certain extent successful;  and
the same may be said of the inhaling of the fumes of belladonna
and  stramonium,  of turpentine, of tar, and of the vapors of
muriate of ammonia—all of which have been recommended by
men of eminence still in our midst, and  are to this day resorted
to, particularly in asthma and in bronchial affections, and I
allude  to turpentineyn gangrene of the  lungs.  Little if any
good followed the use of inhalations  in consumption, and  it 
was perhaps from being so  generally  disappointed in their
action in this complaint that the profession allowed inhalations
to be in the hands of quacks, who, pandering to the popular feel-
ing that remedies to affect the lungs ought to be addressed to
them, availed themselves of these agents to allure and to deceive.
This was strikingly shown by the use the versatile  charlatan
St. John Long made of inhalations, which, conjoined to his lina-
ment, formed that treatment through which he became the pet of
the fashionable circles in London, and particularly of the female
portion.  In the room of the handsome adventurer were two
enormous inhalers, placed in the interior of a large mahogany
case resembling an upright pianocVFrom  it flexible tubes ran
in all directions, at which nwrcbers of  persons  were eagerly
drawing,  while dozens  of  excited women, of all ages, were
waiting until a mouthpiece should be at liberty.1   And all
over  the world were  men  who, more or less closely, and ac*
cording to their powers, copied the doings of  this  ignorant
pretender, aad have continued until now to do so.
   Such, then, is an outline of the history of inhalations by
vapors and gases.   But there  were some practitioners of good
repute who endeavored to bring solids  and fluids in contact
with the diseased membranes.  This, too, or  at all events the
use of powders by insufflation, had its origin among  the physi-
cians of antiquity,  though the most systematic attempts to ac-
complish this purpose belong to the present day, and insufflations
of alum, of nitrate of silver and other articles, through tubes so
curved that they could be passed as far as the larynx, have been
frequently tried.  These attempts were greatly stimulated by
finding that, in those  whose  occupations  expose them to  it,
minute particles traverse the bronchial  tubes and become im-
bedded in the lungs, as has been proved to  be the case in the
phthisis of coal miners, and knife  grinders, and  millstone
makers.2  Moreover, we know that those who talk most while
exposed are most subject to pulmonary complaints; for among
  1 "A Book about Doctors," by Jeaffreson.  1860.  Chapter,  "St. John
Long."
  2 See particularly a case by Peacock, in Brit, and For. Med.-Chir. Keview,
Jan.,  1860; and on the coal miner's lung, Greelihow, in Transact  of Path,
Society of London, 1865. 
4
 gunsmiths and  workmen in arms we are told that tho ones
 who suffer most are  " les  ouvriers  bavards et ceux  qui  on
 Phabitude de chanter en travaillant."1  But, notwithstanding
 these proofs that the lungs can  be reached by pulverized sub-
 stances, and the zeal with which the  subject of insufflation of
 powders has been pursued by several observers, it cannot be
 said to have shewn  itself of much value therapeutically.  In-
 deed, its only demonstrable value has been in cases of laryn-
 geal disease.
   The same may be  said of the application of fluids to the dis-
 ordered mucous membranes, as was so constantly and so skill-
 fully done  by Dr.  Horace  Green.   Serviceable  beyond all
 doubt in affections of the larynx, their injection into the bron-
 chial tubes has not a very wide range of utility.  For, besides
 the  great difficulty  of accomplishment, the diseases to which
 it is suited are not many,  and the certainty that  the liquid
 reaches the really affected parts is not great.
   Thus, then,  neither vapors and gases, nor solids nor fluids
 yielded results that could be looked upon as encouraging with
 regard  to the topical treatment of diseases  of the organs  of
 respiration.  Nay, if we except the inhalation of the vapors of
 tar  and turpentine,  and a few others above mentioned, the
 whole subject was receiving very little attention from the pro-
 fession, until a plan of breaking up fluid into very fine particles
 was proposed by Sales Girons.  This has reopened the whole
 question in how far a local treatment of the disorders alluded
 to is beneficial  or likely to  succeed.  But, whatever be the
 verdict on this point—and it is one of the chief objects of this
 paper to aid in contributing towards that verdict—it is certain
 that in the formation of a fine spray, or  "pulverization  of
 fluids," or u nebulization," or " atomization," we have gained a
 therapeutic  means of great value, which has an applicability
 much wider than merely to the treatment of the respiratory
 maladies, and which  henceforth will be employed, though it be
 rejected for the purpose for which it was originally  intended.
  The first experiments of Sales  Girons were crude.   They
were carried on in  a room set apart at  a watering  place.
The mineral water, either in its  natural state  or impregnated
» Gue'rad. Comptes Kendu de la Society d'Hydrologie Medicule. 
5
with various  medicinal  substances, was  projected through  a
tube with great force by means of an air pump  placed in an
adjacent apartment.  As the stream filled the tube  the fluid
was forced out of six or  more capillary openings, and, imping-
ing against the surface of a  metallic disk, was broken up into
a mist, which the  patients—for several  inhaled at the same
time—breathed.  Though protected by appropriate garments,
no sick person relished much the dampness and inconvenience
of the  whole procedure—one, it may be mentioned, in passing,
very similar to the previous attempt of  Auphan at Lamotte-
les-Bains, and differing chiefly in the fluid not being  dashed
directly against the walls of the apartment where  it was pul-
verized, much in the way as a waterfall which strikes against
                                 the rocks is broken up into a
                                 spray.   Unless,  then, some-
                                 thing more convenient could
                                 be  discovered—some appa-
                                 ratus which was portable,
                                 easily  managed, and  yet
                                 atomized fluid  very finely—
                                 the experiments would not,
                                 in their practical applica-
                                 tion, have  been of  much
                                 value.  After repeated trials
                                 this was successfully accom-
                                 plished by Sales Girons, and
                                 others  have since followed
                                 in  his   footsteps.   I shall
                                 briefly  describe these instru-
                                 ments,  of  which  now many
                                 forms   exist,  particularly
                                 such as I have found to be
                                 of  most  service,  pointing
                                 out what 1 believe to be the
                                 chief merits and defects of
                                 each.
                                   The  first of the portable
Fig. 1.  The original Apparatus of Sales Girom*. ^[n^  projected by Sales
Girons and made by Charriere, consists  of a vessel  in which
 
6
 the fluid to be atomized is poured, and which is attached to an
 air pump placed above it.  The air, compressed on the surface
 Of the fluid, drives  this through a very fine opening, arranged
 with a stop-cock, against  a small metallic disk, where  a very
 minute spray is formed.  The condensed fluid passes off through
 a gutta-percha tube.  The amount of pressure is indicated by
 a  manometer.  A pressure of from three to five atmospheres
 is sufficient.   A modification of this apparatus, in which  the
 vessel is made of glass instead of metal, is generally known as
 the second model of Sales Girons.   But Sales Girons himself
 has recently greatly simplified his whole apparatus, left out the
 manometer, and made the instrument lighter and very much
 easier of employ.  It consists
 of a pump which forces  the
 liquid through a fine opening
 in an  ingeniously  arranged
 stop-cock against a metallic
 disk, as in the other nebuliz-
 ers.  The opening in the stop-
 cock can be  increased or di-
minished  in  size by simply
turning it in  a backward or
forward direction, and a very
fine spray is  undoubtedly  ob-
tained by this instrument.
   The first mentioned model
of Sales Girons is  now but
little used; but it lias an his-
torical  value, since  on the
same principles many others  rig<2'  Thene^Atomizer°fSaies Girons.
have been constructed—for instance, the atomizers of Fournie,
Waldenburg  and Lewin.  The latter  instrument  has  a very
great advantage  in its consisting  chiefly of glass: the tube
through which the medicated fluid passes is of glass, the disk
against  which the stream of fluid strikes in  the  cylinder of
glass is gilt, and thus is unquestionably  avoided one of the
most serious objections to the atomizers of Girons, and which
renders them unfit for the use of chloride of iron, nitrate of
silver, and other articles that act on metal.
 
7
   On  a similar principle as the last model of Sales Girons is
a  nebulizer, in which the pump works by a long handle, and
the fine stream impinges against the  side of the cylinder, but
not against a metallic disk.  I think this apparatus was origi-
                                     nally made by Matthieu;
                                     and to it, as well as to
                                     the last invented one of
                                     Sales  Girons, may  be
                                     attached  a little  tube,
                                     through which a  capil-
                                     lary jet passes with such
                                     force that it penetrates
                                     the skin, and may be used
                                     to inject  medicines hy-
                                     podermically.
                                       In all the instruments
        otto it beyiwers, n r          alluded to  the  fluid is
        Fig. 3. The Pump Nebulizer.         forced by strong  press-
ure  against  some firm  body, where it is broken up into very
fine particles.   But another  principle  has been  made use
of to accomplish this purpose, namely, the action of a current
of air compressed  in a large  ball, and which, intermingling
with the fluid, changes this into a minute spray as it rushes out
of a capillary opening.  This instrument, the " Nephogene"
of Matthieu, is handled with readiness; but it is apt to get out
of order, and the spray is  thrown with greater  power than is
usually advisable;  moreover a large  quantity of atmospheric
air is  projected into the air passages with it.   A far better
application of using a current of air as the means of atomizing
the medicated liquid was made by Dr. Bergson, by employing
the same kind of tubes as are now so extensively sold as odor-
ators,  for  the  pulverization of different  scents.  Two  glass
tubes,  with capillary openings, are placed at right angles  to
each other, in such  a manner that the  end of the vertical tube
is  very close to and about opposite the centre of the capillary
opening in the horizontal tube.   Through this the air is blown
while  the vertical  tube is  dipped in the fluid to be atomized.
The  air in the latter tube is rarefied; the liquid rises to the
capillary opening and is there pulverized by the current of air
 
8
from  the  vertical tube.   Two tubes properly arranged  are
then all that is strictly required for this simple apparatus, for
the air may be blown by the mouth through the horizontal
tube.   But in point of practice this procedure is both irksome
and unpleasant, and to  avoid it  an ordinary Davidson's rub-
ber syringe may be attached to the  horizontal tube; or, better
still, a continuous  stream  may be  obtained, as proposed by
Bergson, by a bellows, connected  with an  air chamber.  The
bellows is worked by the foot.  Yet more convenient is a sim-
ilar arrangement of Andrew Clark, consisting of two  balls, the
lower of which  is pressed by the hand, and the upper  of which,
surrounded by a silk network, acts as an air chamber.
Fig. i. The Hand-ball Atomizer.
  The principle of Bergson is  distinguished by great simpli-
city, and is very readily applied.  The tubes may be made of
silver or of glass.   Those of the latter are  generally prefera-
ble.   They are much more easily kept clean, and can be used
with articles which corrode the former.  On the other hand
they are more easily broken.   Those of glass can  be kept
clean by soaking them occasionally in muriatic acid and water
or pulverizing a little of  this mixture through them.   If the
tubes become clogged,  a  bristle or  a very delicate  metallic
wire is the best means of removing the obstruction.   A pin or
a needle is apt to  break  the fine points.   The tubes may be
made of any  length or calibre.   To produce a delicate spray, 
9
the openings at the ends, where placed in juxtaposition, ought
to be very small.   The  hole  in  the horizontal  tube may be
somewhat larger  than the capillary opening in the vertical
                                    tube.  A modification in
                                    the shape of the tubes, as
                                    seen in Fig. 5, was pro-
                                    posed by Prof. Winter-
                                    ich, and is often of great
                                    service.   By  virtue of
Fig. 6.  .beigson's Tubes of modified shape, united by thlS  arrangement  We
           an India-rubber band.           CJm generate  the  sprav
within various parts of the body.  I have had tubes of the
kind made of all sizes and of different curves—to pass up the
nostril, as in the treatment of catarrh; to place in the ear and
reach the membrane of the tympanum;  to apply near the back
of the throat, or immediately over the entrance of the larynx—
thus furnishing a far better means for local treatment than the
ordinary sponge probang, and even better than the laryngeal
fluid  pulverizer of Gibb.   If it were judged expedient  as  a
therapeutic  means, they could be so shaped as to throw a spray
even  into the interior of the uterus or  bladder.  The instru-
ment adapted by Richardson for  local anaesthesia is a  spray
producer acting on a  similar principle  to that just described,
and may also be made use of in the treatment of throat affec-
tions—in fact, for very many of the purposes for which a spray
producer is  needed.
                 Fig. 6.  Richardson's Spray Producer.
  We have now discussed the atomizers  in which  air acts as
the forcing power, or in which the fluid is driven by a piston
through a narrow opening.   They require, of course, a certain
amount of exertion on the part of the patient, or an assistant. 
10
 This is  obviated  in  the  ingenious  apparatus  of Siegle, who
 substituted steam as the motive power.  Adopting the arrange-
 ment of tubes of  Bergson, he has added to it a small boiler,
 made of metal  or of glass, in which steam is  generated  by
 means of a spirit lamp.   The steam plays the part of the com-
 pressed air, and as it escapes projects as a fine spray the liquid
 placed in the cup.   The degree of pressure is indicated by a
 thermo-barometer, marked 1 and 2.  It is  safe enongh to  let
 the mercury range between 1 and 2;  above this there is some
 danger.  By lowering the flame  the steam is generated with
 less rapidity and  force.   A small lamp under the glass cup
 containing the medicated fluid heats  this, and thus the inhala-
 tion may, if necessary—which, however, it extremely rarely is
 —be given very warm.   Fig. 7 represents Siegle's apparatus
 in its most perfect form.
 In addition to the  thermo-
 barometer we find a safety-
 valve.
   Now, on Siegle's princi-
 ple, numerous  instruments
 have  been  constructed.
 The size of the apparatus,
 its shape, the lamp, have
 been modified; but few of
 the modifications are really
 improvements.   It  may,
 however, for ordinary pur-
 poses, unquestionably be
 much simplified; and Mr.
 Gemrig,  an  instrument
maker of Philadelphia, has
constructed, according to a
 design I gave him, a steam
atomizer, which is  both simple and very convenient.   It c
sists of a copper boiler, with a spring safety-valve in place  of
the thermo-barometer.  By unscrewing the  safety-valve the
water can be poured into the boiler.   This fits into a metallic
tube, at the bottom of which a spirit  lamp is placed, the  flame
 of which can be  heightened or lowered.  The atomizing tubes
Fig. 7. Siegle's Large Atomizer. 
11
are inserted into a cork, or a perforated piece of gutta-percha,
which is  readily fastened by  a metallic rim with  a bayonet
catch.  In some of Siegle's instraments this point is omitted,
OTTO fy REYNIJEKS, H Y.
 Fig. 8.  Siegle's Apparatus, with water-gauge (B) and valve (F), as modified by Erohne.
and the cork or piece of rubber is liable to be blown out when
the  steam  is  generated.   In  his largest  apparatus (Fig. 7),
screws hold down  the India-rubber at two of  the openings.
Leaving out the thermo-barometer is, in any apparatus, except-
ing those  for  purposes of very accurate study,  a great gain.
It is irksome to the patient to  be constantly watching it whilst
inhaling, and is apt to get broken.  The simple apparatus just
                                       Fig. 10. Boiler with tubes attach-
                                         ed and spring safety-valve.
                        described is shown in Fig. 9; its com-
                        ponent portions are seen in Figs. 10,
                        11, 12 and 13.  When in action  the
                        boiler should be about two-thirds full
Fig. 9.  simple form of steam At- 0f water, and after the medicated fluid
         omizer.
 
12
has been pulverized  the  tubes should be cleansed by letting
the instrument nebulize pure water.
  As the various apparatuses for atomizing liquids have  been
passed in review—and in so doing I have endeavored to de-
scribe rather the different principles that have been suggested
for their construction than attempted to  give  a complete list
                   of all the instruments which have been pro-
                   posed—I may now state what I believe to
                   be their relative efficiency.   The most per-
                   fect as  well as  the most efficient  is that
                   of Siegle, or some of those  framed on his
                   plan.   The steady stream, the possibility of
Fig. 11. MetaUic tube,
 at the upper part of
 which the boiler is
 placed  and  at the
 lower part the lamp.
Fig. 12. Lamp, with screw
 to raise or depress the
 wick.
Fig. 13.  Cup for medi-
 cine, and rest with slide
 to hold it.
working the apparatus without fatigue and without an assist-
ant, the  small quantity of medicated fluid required—while  in
most of those which are set in action by a pump the quantity is
very great—are  all features of pre-eminent value.  Then the
minute division of the fluid and the warmth of the spray that
reaches the respiratory organs, are also points of decided con-
sequence.  But under some circumstances other atomizers will
answer better; for instance, in the  treatment of affections  of
the throat or nares, or even in many of those  of the  larynx,
the nebulizer depicted, Fig. 3, or Bergson's tubes with the bel-
lows attached, may, for  the most  part, be  more easily and
advantageously  employed.   Again, they may be  resorted to
when the patient is in the recumbent position; when he lies in
such a manner that an  instrument with a lighted lamp  cannot
with safety be placed near him; when the heat of the weather
renders it annoying to use a  steam apparatus; when  a cold
rather  than a warm inhalation is  therapeutically desirable;
when, on account of the time lost, it is inconvenient to have to
generate steam;  or when the patient is careless, or not intelli- 
13
gent enough to learn to use an apparatus which  requires both
care and some intelligence to use properly.  Then, in very many
cases, particularly those of affections of the  fauces and wind-
pipe, the quantity of medicated fluid necessary is but small, as,
for example, when solutions of caustic are required.  And here
the hand-ball atomizer will be  found very convenient.   In-
deed, I think  that, excepting  the steam nebulizer, this is  the
best form of spray producer—superior  to that of Sales Girons,
and to  the one depicted  in Fig.  3; and  for the purposes
just alluded to it is even better than the steam atomizer, while
its ready use and portability, the fact that the fluid can be  in-
jected without any or with but slight co-operation on the part of
the patient—in  children especially a very great advantage—
and the manifold employ to which it  can be put,  are additional
recommendations.  Yet it cannot be said to  take  the place of
the steam atomizer  in the treatment of diseases of the lung.
It becomes too irksome and fatiguing  to work it long enough
to produce  the quantity  of spray required  for each inhala-
tion.
   But whatever apparatus be employed, there are some points
to be observed in the use of inhalations, the  neglect of which
will seriously interfere with  the benefit to  be  derived from
them, and may, indeed, cause them to be abandoned in disgust.
And, in the  first place, we should instruct  our  patient in  the
application  of the instrument, show him how  to  keep it clean,
how to tell  when it is working  properly.  This implies that
he should have one in his possession.  In truth, excepting when
resorted to in certain affections of the larynx  and fauces, or for
a mere temporary purpose, and particularly when  required in
chronic diseases of the lungs, the inhalations ought not to take
place at the  physician's office.  The patient must employ them
once or several times daily, and unless  he can attend  to them
himself, in the same manner as he knows how to  take his tonic
pill or his cough mixture, the treatment will be inefficient.  It
is evident, then, that he must, as  a rule, carry on  the treatment
at his own house.  At the first inhalations the physician should
always be present.
  When the patient is ready for the inhalation he should sit in 
14
front of the apparatus, in a convenient position, and in such a
manner that the spray is formed on a level with  his  mouth.
The mouth must be kept wide open and the head  slightly in-
clined backwards.   The distance proper to sit from the spray
producing  tubes varies.   When he begins the inhalation, he
ought to be about six inches from them.   This distance may be
increased from one to two feet, according to the object we have
in view.  If we wish the patient to inhale a large quantity of the
spray, and  at a high temperature, let his mouth be near to the
apparatus.   And we direct him to take deep breaths when we
desire to reach the bronchial tubes and more  distant portions
of the respiratory channels, while we insist upon shallow breath-
ing if our intention be to act on the fauces  and upper part of
the air passages.  But under no circumstances should he breathe
in such a manner as to be fatiguing to him;  and it will be often
very necessary to restrain him from respiring with much effort
and hurriedly.
  In persons with sensitive mucous membranes the act of inha-
lation causes considerable cough.   But even this can ordina-
rily be avoided by letting them breathe at first the spray warm
and close to its point of production, and by commencing with
inhalations of pure water.  In most cases, after a  few  inhala-
tions, no cough is produced; nay, strange  to  say, coughing is
more apt to occur when the inhalation is over  than whilst in
progress.
  A point always to be attended to is to see that  the tongue
is not in the way of the current, and that the spray can really
reach the  back of the throat.   It is
well to  direct the patient to press his
tongue against the floor of the mouth.
If he cannot easily do this, a tongue
depresser may be employed;  but I have
found it more advantageous to insert
a short, small  glass speculum, from
three to four  inches in  length, into
the mouth.  This keeps the tongue out
of  the way, and yet he  can breathe
very readily through the tube.  To pre-    Fig. u. Face shield.
 
15
vent the face from becoming wet, a face shield may be employ-
ed, preferably made of glass  or wood.  It can  be attached
to the atomizer, as it is in the very serviceable instruments
made by  Dr. William Read, of Boston, or  be  held by the
patient, and so arranged with  a depressed rim, into  which
a  gutta-percha  tube is fixed, that the drops of fluid  which
collect  flow into a glass.  But  as a rule I find that pa-
tients  prefer dispensing with  a face shield.   It is, of course,
always  necessary to  protect  the clothes  with  a  napkin or
towel, and to have a  vessel at hand into which any of the
fluid which may accumulate in the mouth can  be expector-
ated.
   As regards the frequency and the time of the inhalations, it
is difficult to lay down general  directions.  But this much  is
certain: for the treatment to be effective, the patient should
inhale daily, and breathe the  medicated spray for about ten
minutes or longer, taking in that time about one  hundred res-
pirations  or more, and resting for some seconds after inhaling
continuously for a few minutes.   In many cases it is better to
have him  inhale twice  or three times daily; and it is always,
perhaps, more convenient to let him inhale a certain quantity,
say one ounce of the medicated fluid, than to annoy him by di-
recting him  to  count  the frequency of the act  of breathing.
With a well constructed steam atomizer, the time of each inha-
lation should be from ten to fifteen minutes, and about the same
time is required at each sitting with  the nebulizer of  Sales
Girons, or any of those working with a pump.  The first inha-
lations ought always to be short, so as to accustom the patient
to them;  and it is astonishing how, though they irritate him
at the beginning of the treatment, he becomes less and less sen-
sitive to them.   The patient ought never to inhale  on  a full
stomach, and should abstain from going out of doors for a  quar-
ter of an hour after the inhalation.
   In these remarks I have had  chiefly reference  to the treat-
ment of pulmonary affections, and secondarily  to that of laryn-
geal diseases.   But as the form of therapeutics  under consid-
eration applies also to disorders of the fauces  and adjacent
structures I may briefly indicate in what manner the mode of 
16
 procedure is to be modified in their treatment.  The inhala-
 tion is of shorter duration, and need not, excepting in certain
 urgent cases, be done so frequently.  The greatest care should
 be exercised to cause it to reach the affected spot; and to effect
 this I have often found the  method above mentioned, by  pass-
 ing the current through a small glass speculum introduced into
 the mouth, very efficient.  It has, moreover, the advantage of
 bringing the diseased surface thoroughly into view, and of lim-
 iting the action of  the pulverized  fluid  much more completely
 to it.  When the spray is thus passed through a speculum, and,
 even if the tongue be not in the way, by simply directing the
jet to the affected textures, we can obtain results which are not
 attainable by means of ordinary local applications^  The spray
 reaches parts more readily  than the probang, and in certain
 cases produces a  preferable  and more permanent action.  Its
 superiority over gargles is manifest, touching structures never
 or but scantingly reached by these, as for instance  the poste-
 rior wall of the pharynx; so striking is this superiority, that
 for really useful purposes the day of gargles has passed.  Even
in enlargement of the tonsils, I  have used pulverized fluids with
considerable success.   In one case, particularly, that of a little
boy greatly troubled  with chronic pharyngitis and enlarged
tonsils, and liable on any exposure to acute exacerbations, they
effected a cure which no other means could have accomplished.
For each attempt to reduce by caustic or astringent solutions
the tonsils, which nearly blocked  up  the half arches, was  a
signal for an outburst of passion and for violent resistance on
the part of the  child.   To the  treatment  by pulverized fluids,
such  as of strong solutions of tannin, he  submitted  without
objections.
  Let me  add, in concluding  the  mode of inhalation  and
the modification  necessary  to  suit them  to individual parts,
that the  force  of the current is an element also to be taken
into  account.   A  very  strong current  is  not suitable for
pulmonary affections; it is   more  suitable for those of the
fauces.  The spray projected with too much force is apt not
to enter the air passages, but to condense on the walls of the
throat. 
17
   In the preceding considerations, and while discussing the
 mode of applying the  medicated spray, it has been assumed
 that this can be made to reach not only the fauces and pharynx,
 but the respiratory channels.  Now, with reference to the for-
 mer point there can be no question, but much skepticism has
 prevailed  as regards the entrance into the  air tubes of the
 atomized fluid; and before passing on to indicate the uses of
 these agents, it is  incumbent to inquire into the evidence on
 which it has been assumed that they penetrate into  the lungs,
 or even  into  the  larynx.  Not  to mention  further the well
 known facts alluded  to in connection with the coal miner's
 lung, and which have a strong bearing on the subject, the evi-
 dence of fine  particles reaching the air  passages  is of two
 kinds: first, that furnished by demonstrative experiments made
 on animals and man; and, secondly, that attained by perceiving
 the effects  of inhaling the atomized  liquid, particularly its
 prompt  effect in producing  or allaying  spasm,  in  checking
 hemorrhage and the like.
   To  the  first category  belong the interesting experiments
 of Demarquay, which, repeated in  the presence  of Poggiale,
 were used  by him as the  basis of his able report to the
 French Academy.   Dogs and rabbits, with their mouths forced
 open and their nostrils closed, were made to  inhale for five
 minutes  a pulverized  solution of perchloride of iron, of the
 strength of 1 part of the iron to 100 of distilled water. The
 animals  were afterwards killed, and throughout the  larynx,
 trachea, bronchial tubes, and  even  in the  lung structure, the
 presence of the persalt of iron was clearly detected by the
 production of Prussian blue with the ferrocyanide of potas-
 sium  and acetic acid.  But it was  objected to these experi-
 ments that they were made on animals, and that all the circum-
 stances were such that it was unfair to infer  that the same
 results could be obtained in  man.  To meet  these clamors,
Demarquay experimented on a nurse at the Hospital Beaujon,
who breathed through  a canula in her trachea.  She inhaled a
pulverized solution of tannin while  the tracheal opening was
closed with  a slip of paper, moistened with a solution of
perchloride of iron, and held in place by means of a strip of
sticking  plaster and a napkin.  After inhaling for  a minute
           2 
18
the sticking plaster and the paper were removed, and a strip
of paper impregnated with a solution of perchloride  of iron
was pressed, with the aid of a delicate forceps, into the trachea.
In  the first two experiments there was no reaction; in the
third the black discoloration of the paper proved that the solu-
tion of tannin had entered the air passages.   Fieber, in Vienna,
repeated the experiment on a man twenty-two years of age.  It
only succeeded on the fourth attempt.   A few months since I
tried it three times on a man about twenty-six years of age, a
patient under my charge  at the Pennsylvania Hospital.  He
had  cut his throat in an attack of mania a potu three months
before he came under my observation, and wore a canula.  I
made him, after  removing the canula,  and while closing the
tracheal  opening with the finger, as done by Demarquay in his
third,1 the successful experiment, inhale, for nearly two minutes,
and by means of a steam atomizer, compound solution of iodine,
15 drops to the ounce, and then passed a thoroughly starched
linen rag into the opening.  No satisfactory reaction was per-
ceived; neither was it when a canula, covered  on  its upper
surface with a starched piece of linen, was employed.  Nor was
an experiment with  tannin and chloride of iron more success-
ful.   A laryngoscopic examination showed the cause of failure.
The  false vocal cords were tumid, greatly engorged, rigid; and
the motion of the cords was hardly perceptible even when the
man, while the tracheal opening was closed, was doing his best
to breathe through the mouth.  They were scarcely dilatable,
though after a course of laryngeal catheterization they be-
came so.
  The difficult success of Demarquay and Fieber, the total want
of success of Fourni£, who experimented on the case of Demar-
quay, were chiefly due to the great difficulty of completely closing
(owing to the  anatomical  relations of the parts)  the tracheal
opening—an indispensable condition for success; and to  the
inability of the patient to  remain  but for a very  brief period
deprived of the canula.   In this  respect  my case was better
suited, yet it presented other and greater obstacles.   In truth,
a union of all conditions favorable  to complete success is rare;
1 Die Inhalation, etc., 1865. 
19
 hence, while we may claim the positive results obtained as con-
 clusive, the failure to obtain these results, it is evident, is not
 equally so.
   Still, though we can very rarely on man  demonstrate to the
 eye the passage of atomized fluids down the trachea, it is easy
 to satisfy ourselves of their entrance into the larynx.  This
 observation which I  have made will  prove it.  Let a person
 inhale  pulverized distilled water, to which some  drops of a
 solution of blue or red aniline have been added.  Let him
 then be immediately examined with a laryngoscope; an  in-
 tense color, visible on the vocal cords and at the beginning of
 the trachea, will show where the aniline has reached.  Bataille,1
 inhaling a solution of rhatany, noticed on himself, by means of
 the  laryngoscope,  the  red discoloration  of the  larynx and
 trachea.  He also  expectorated for a whole day subsequently
 a reddish  sputum, which,  from its character, he believes to
 have proceeded from the bronchial tubes.
   Yet  another  demonstration  of  the  penetration  of  the
 atomized liquid is furnished by  post mortem inspection  of
 pathological processes.  A number of the rabbits Demarquay
 experimented on,  and which were not further interfered with
 after they were  made to breathe the  solution of the perchlo-
 ride of iron, died of pneumonia, generally of very circumscribed
 kind.  Trousseau reports  the same  consequence from inha-
 lations of tannin in a lady, who, finding herself benefited by
 them, inhaled for several hours daily until  a fatal pulmonary-
 inflammation supervened.  Still more significant are the cases
 reported by  Lewin and Zdekauer.  In  Lewin's case, inhala-
 tions of chloride of iron were used to arrest  a hemorrhage
 from the lungs.   The patient soon  afterwards died,  and little
 particles of iron were found by Schulz, the chemical assistant
 of Frerichs, in a cavity in the upper lobe of the right lung.2  In
 the similar case of Zdekauer,3 the Russian professor, assisted
by Holm, detected a far larger quantity of iron everywhere in
the tissue of the lung than appertains to the blood it contains.
  These facts, some of which were elicited  and dwelt upon in

        i Gazette Hebdom., 1862.
        5 Inhalations Therapie, p. 190.
        3 Quoted in Wiener Med. Wochenschrift, 1861, No. 30. 
20
the report  and discussion  before the French Academy, and
which convinced, as we may judge by the adoption of all the
points of the report, that critical body of the  penetrability of
atomized fluid, can leave then no doubt on  the subject.  But
there is another matter, which it seems to me may be advanced
as evidence, namely, the  immediate effect perceived from the
inhalation of certain articles.   For instance,  if cold water be
inhaled a sensation of cold in the  larynx and trachea, extend-
ing thence into the chest, is very common.   Many articles in
strong solution, and tannin may be  mentioned among them,
give rise to a feeling of oppression  and of violent burning in
the chest.  From the inhalation of a strong solution of alum I
have seen on two occasions asthmatic, wheezing breathing very
speedily produced,  with loud dry rales  discernible at various
parts of the chest; the attack lasted  for eight or ten minutes.
Further may be mentioned what, in a patient under my care,
affected with bronchorroea, I have repeatedly observed, the
sense of tightness in the  chest attended with a very greatly, I
might say immensely, diminished expectoration very soon after
inhaling any strong astringent solution, particularly of alum
or of tannin.
  The question of the pulverized  fluids reaching the respi-
ratory channels is thus, to any unprejudiced mind, no longer
one of unbelief. But it  still remains to be solved how much
of a given  solution arrives there, and  what proportion finds
its way into the deeper textures.  Again, is the temperature a
modifying agent; do chemical changes take place in the atom-
ized liquid  when  inhaled;  and under what circumstances is
the passage of the spray prevented?   To  enter into  these
questions at any length would necessitate long and tedious dis-
cussion, involving allusion to many chemical and physical laws.
Let  me merely state that, though attempted  to be solved by
Waldenburg, with great care, we  do not know how much of
the fluid gets into the respiratory structures;  and that we shall
have to decide its passing  in  any quantity chiefly by physio-
logical and therapeutic experiments.  Chemical reactions only
take place in certain articles pulverized, as in sulphurous wa-
ters.  The temperature of the stream varies with the tempera-
ture of  the  surrounding  atmosphere, the apparatus employed 
21
the distance of the patient from the spray-producing tubes, and
the temperature of the fluid to be pulverized.  Bearing this in
mind, we can  ordinarily regulate the heat of the stream with-
out much difficulty; and in  point  of fact  it must always be
recollected that it takes very readily and speedily the temper-
ature of the surrounding air.  Practically, therefore, the sub-
ject of the temperature of the spray does not occasion  much
perplexity.  The spray from a steam atomizer is warmer, par-
ticularly when inhaled rather near to  its point of production,
and from its comparative warmth is generally more acceptable
to the person inhaling.
   With regard to the  circumstances interfering or preventing
the passage of the spray into the respiratory passages, I have
already alluded to the intensity of the current.  I may add that
breathing through the nose;  the tongue not being sufficiently
depressed; the head being inclined forwards;  and all  other
postures which would change  the angles favorable to  the
progress of the pulverized fluid, or interfere with the freedom
of respiration, are obstructing elements.   I have tested these
points experimentally  by letting  a man breathe  an atomized
solution of aniline  in conditions unfavorable to the entrance
of the spray, and have then  examined him with the laryngo-
scope to obtain a view of the discolored laryngeal membrane.
I found that though he may be kept inhaling steadily for four
or  five minutes, there is scarcely a perceptible  alteration in
color at the beginning  of the respiratory passage, and it is
therefore highly improbable  that any of the pulverized liquid
should have passed lower down.   Many of the negative ex-
periments, whether on man or on animals, have been, I think,
clearly due to a neglect of the points mentioned.
   It was necessary  to  discuss these hindering causes, because
it was necessary to  inquire in how far we could guard against
them,  and while showing that they  might explain some of
the discrepancies of different observers, to make evident their
bearing in ascertaining the  doses of medicine required for in-
halation.  In  truth this question of doses is one far  from easy
to determine, and can only  be fixed experimentally—can, in
other words, only be settled by a careful study of respiratory
therapeutics, in which due importance is attached to the sources 
22
 of fallacy indicated, and in which they are avoided.  More-
 over, the dose varies with the apparatus; or rather, though the
 dose be the same, to  obtain that dose in  the mouth we  may
 have to use more of the medicated fluid or a stronger solution
 with one atomizer than with the other.  Thus, in the appara-
 tus of Bergson, it takes, according to a calculation of Lewin—
 whose own glass atomizer  is, however, still more wasteful of
 the  medicated liquid—eight ounces of fluid, which  quantity
 can be pulverized in from  twelve to fourteen minutes; to in-
 sure, therefore, three ounces of spray reaching the oral cavity,
 we  must use in amount of solution nearly three times  the
 dose required.   In Siegle's  steam  apparatus,  one ounce is
 atomized in about the  same time,  and  perhaps not  more
 than a fourth is lost, but the steam dilutes the solution pre-
 pared by nearly one-half; a solution in the cup of ten grains to
 the ounce would therefore be reduced by the vapor to between
 five and six grains to the ounce, and of this about four grains
 would be really inhaled through the mouth.
   Speaking generally, the dose to be given does not vary ma-
 terially from that employed  internally.  But, with reference to
 narcotics, this does not hold  good, as they are readily absorbed
 and act efficiently in smaller doses.   Concerning astringents,
 too, though they are often employed in doses approximating in
 their strength those for external use, when designed to reach
the deeper structures, we  must, bearing in mind the delicacy of
 these textures, carefully graduate the dose.  Any agent which
is soluble in water, or in a watery infusion of an aromatic, or in
very dilute alcohol, can be used by an atomizer.  Substances
 soluble in glycerine, or  capable of being suspended  in  thin
emulsions, too, may be employed, but not, as a rule, satisfac-
 torily.   I now subjoin a table, in which the dose is calculated
to the ounce of water, for any form of steam atomizer throwing
a fine spray.  It represents  the articles which have been most
employed, and  there is scarcely one in the table that I have
not used in the doses mentioned.  Where the dose is not stated
from personal knowledge, or where a particular kind of appli-
cation is alluded to, I have added the name of the observer.  I
have also indicated the pathological conditions  to which the
doses are suitable. 
23
                TABLE OP DOSES  FOR INHALATION.
   ALUM,  10 to 20 Grains.—In this dose suitable to chronic catarrhal affec-
 tions of pharynx  and air tubes, particularly in bronchial affections with
 excessive secretion, when, as in most inflammatory conditions of respiratory
 mucous membrane, it may be advantageously united with opium.   In rather
 larger doses, 30 grains to the ounce, useful in pulmonary hemorrhage.  Is, as
 an astringent, generally more of a sedative and more suited to conditions of
 irritation than tannin.  (Fieber.)
   TANNIN, 1 to 20 Grains.—Useful for the same affections as alum.  Em-
 ployed in cases of laryngeal ulceration and excrescences, in oedema of the glottis
 (Trousseau), in croup.  Here, as well as in pulmonary hemorrhages, in large
 doses.  In ordinary cases of laryngeal or bronchial disease, begin with a
 small dose. If the remedy occasion much heat and dryness, it is not to be
 employed.
   IKON (perchloride of), £ to 2 Gbains.—In  earlier stages of phthisis.   In
 chronic pharyngitis or laryngitis may be  used stronger.  As a weak inhala-
 tion in hysterical aphonia.   Of  greatest strength in pulmonary hemorrhage,
 2 to 10 grains to the ounce, or  10 to 40  m. of Monsel's salt to the ounce.
 The lactate, citrate or phosphate may, in ordinary cases, in which we wish a
 non-astringent salt of iron, be also used, though they are not, on the whole,
 as available as the chloride.
   NITRATE OF SILVER, 1 to 10 Geains.—In ulcerations  of pharynx and
 larynx,  in follicular pharyngitis.  A face shield  is  always to be used.  10
 grains to the ounce only in cases of ulceration.
   SULPHATE OF ZINC, 1 to 6 Geains.— In bronchial catarrh with excessive
 secretion.   In aphonia, connected with chronic laryngeal catarrh.
   CHLORIDE OF SODIUM, 5 to 20 Geains.—Promotes expectoration and
 diminishes sputa; and employed in phthisis.
   CHLORINATED SODA (Liquor Sodce CMorinatce),  i to 1 Deachm.— In
 bronchitis, with offensive and copious expectoration; in phthisis.
   MURIATE  OF AMMONIA, 10 to 20 Geains.—In laryngeal and bronchial
 catarrh, acute as well as chronic.   To promote expectoration; also in capil-
 lary bronchitis.  The dose best borne is  not above  about  10 grains  to the
 ounce, though as much as two drachms to the ounce have been  employed.
 (Siegle.)
   OPIUM  (watery extract of), J to $ a Geain.—In irritative coughs, and as
 an adjunct to allay irritation.  Also for  its constitutional effects.  Dose of
 tincture of opium 3  to 10 drops.  Acetate of morphia one-twelfth to one-
 eighth of a grain has been administered, but  large  doses require much
 caution.
   CONIUM (fluid extract of),  3 to 8 Minims.—Irritative cough; asthma;
 feeling of irritation in larynx.
   HYOCYAMUS (fluid extract of),  3 to 10 Minims.—Spasmodic coughs;
 whooping cough.  One-half  a grain  of the  extract, gradually increased, or
the tincture may be employed.
  CANNIBIS INDICA (tincture of), 5 to  10 Minims.—In spasmodic coughs;
phthisis.
  IODINE  (Liq. Iodinii Compos.), 2 to 15  Minims.—In chronic bronchitis; in
phthisis. 
24
  ARSENIC (Liq. Potass. Arsenit.), 1 to 20 Minims.—Nervous asthma.
 (Trousseau.)
  TAR WATER, 1 to 2 Deachms of officinal solution.—In offensive secretions
 from bronchial tubes; in tuberculosis; as an antiseptic in gangrene of lungs.
  TURPENTINE,  1 to 2 Minims.—In chronic bronchitis, with offensive
 secretions; in bronchorrcea; in gangrene of lungs.
  LIME WATER, used of officinal strength, or stronger.—In diphtheria; in
 membranous croup.
  WATER, Distilled.—Cold, in pulmonary hemorrhage.  Warm water in
 asthma, in croup; in bronchitis.

   It is always  preferable that the solutions  should be made
 by the addition of distilled  water; and it saves much annoy-
 ance in the working of the  atomizer if some  of them—for in-
 stance, those of tannin—are  strained.   In some cases the
 dose recommended cannot  be  borne at first.  It is, indeed,
 always best, excepting  if the  prompt action of a narcotic be
 needed, to begin with  small  doses, and educate,  as it were, the
 respiratory mucous membrane to tolerance.
   As the mode  of  using inhalations and the general questions
 connected with their employ have now  been considered, we
 may turn to  the more  strictly clinical part of  the  inquiry, and
 examine, by  the light of observation, into their real value as a
 therapeutic means.  In so doing I  shall  only be able to dis-
 cuss the applicability  of the atomized fluids  to the treatment
 of some of the principal diseases of the respiratory organs;  for
 to do otherwise would be  to write a treatise on  respiratory
 therapeutics  rather than an essay bearing on the subject.  Nor
 can I introduce in detail all  the material I have collected even
 on  the matters brought forward, but shall allude only to such
 parts of it as are the most significant, embodying,  however, all
 in any deductions made.
  And first, to look at laryngeal affections. Here I have found
 atomized liquids of most  service in  the catarrhal conditions,
 whether connected with  pharyngitis  or not.  In  the  loss of
voice and irritative cough  associated with catarrhal laryngitis,
 not, however, while in its  most acute stage, I have repeatedly
 known inhalations of alum, about ten grains to the ounce, com-
 bined with five to six drops  of laudanum,  or with  conium, pro-
 duce a most happy and soothing effect, and exert sometimes an
 almost  immediate influence  on  the voice.  Thus,  in a case of 
25
ten days' standing, in an elderly gentleman, the voice became
after each inhalation, two to three being employed daily, quite
distinct, though at first it resumed its whispering tone between
them.  In  a few days a permanent result was  perceptible.
Inhalations of pulverized warm water, with or without nar-
cotics, are very grateful in the acute or  subacute catarrhal
conditions,  since they  relieve  greatly the sense  of dryness
and of heat.  In the more chronic  cases,  and when marked
swelling of the mucous membrane  of the larynx and vocal
cords is perceptible, the effects of the inhalations are not always
quickly evident; but in these  cases, too,  I have used alum,
tannin, sulphate of zinc, or the  subsulphate of iron, with great
advantage, commencing with small doses.  For instance, I was
consulted by a clergyman who had strained his voice by inces-
sant speaking, and had in addition caught a severe cold.  His
voice, from having been one of remarkably fine compass, had
become coarse, and was at times so hoarse as to be whispering.
The laryngeal  mucous membrane was much congested, and
there were a few rales in the chest from accompanying bron-
chitis.  He coughed much, complained of an uneasiness in the
throat, and was rather short of breath; otherwise no symptoms
of any disorder  existed.   He had tried for three or four weeks
various internal medication, without benefit.  I directed him
inhalations of tannin, five grains to the ounce, subsequently
somewhat increasing the strength.  After the sixth inhalation
his voice improved most strikingly, and it continued to improve
for ten days, at which time he left the city.  When not endeav-
oring to speak too loud the voice was quite clear, and had re-
gained its natural tone; the cough had almost ceased.
  From the subsulphate of iron I have seen similarly good and
even prompter effects.   Not long since I employed it in a case
in which great swelling of the epiglottis existed, concealing to
a very considerable extent the  structures within the laryngeal
aperture, and attended with much difficulty in swallowing and
aphonia.  The disorder had lasted for more than two months,
and the loss of voice had been gradually progressing, until, five
days before I saw the patient, the voice had been reduced to a
mere whisper.  Several drachms of a solution of Monsel's salt,
sixteen minims  to  the ounce,  were  injected by a hand-ball 
26
atomizer, and before  the young man left the office his voice
was distinctly audible.  He came back two days afterwards,
speaking quite plainly, and stating  that he had been able to
swallow solid food, the first for weeks.   The inhalation was
repeated, and both voice and power of deglutition again mark-
edly improved. Subsequent examination with the laryngoscope
showed the most  evident reduction in the  tumefaction and
change in the color of the engorged structures.
  In  the various  forms of  ulceration  of the laryngeal struc-
tures, the method of treatment under discussion has been ap-
plied by means of pulverized solutions of tannin, of corrosive
sublimate, of iodine, of iodide of silver and of nitrate of silver.
I have used tannin, sulphate of copper and nitrate of silver in
several cases, but have not been struck with the good results.
For example, in a gentleman, forty-two years of age, on whose
right false vocal cord the laryngoscope detected an ulcer with
irregular  borders, inhalations  of the  compound solution  of
iodine, commenced with 10 drops to the ounce  and gradually
increased, were faithfully tried for  fully three weeks without
any perceptible benefit being produced. Subsequent touching
with nitrate of silver, the hand being guided by the reflected
image of the  parts in the  laryngeal mirror, proved far more
effectual, both in the improvement manifest in the ulcer and in
the symptoms of impairment of voice, difficulty in swallowing
and cough.  The  ulcer, judging from the history of the case,
was  probably scrofulous.  In the following case of laryngeal
ulceration the treatment by inhalation was also fully tried.
  A man, forty-five years of age, was  admitted into the Penn-
sylvania Hospital on the 13th of February of this year, with a
cough which he traced to exposure  dating eight weeks back,
though when  questioned  he stated  that he had a very slight
dry cough, off and on, for  a month  previous  to  this.  The
severe cough accompanying the cold he caught was  attended
with sore throat, and soon  afterwards with  hoarseness.  On
admission he was  noted to  be pale and to present a sickly
aspect; respirations 24; expectoration  but slight in quantity,
tough and whitish; and neither fever  nor deficient appetite.
No abnormal physical signs were discernible in the lungs, save
a slight harshness at the lower part of the left.  There was 
27
 difficulty in swallowing, without  pain on pressure over the
 larynx; the voice was  hoarse, but not completely lost; the
 fauces were not reddened.  On laryngoscopic  examination a
 large superficial, yellowish ulcer was seen on the right false
 vocal cord, extending to the ary-epiglottidean fold.  There was
 also  considerable thickening of these structures  as well  as
 those of the left side, but the true cords seemed unaltered and
 approximated fully in the act of vocalization.   The man de-
 nied the existence of any syphilitic taint.
   On the 26th  of the month, having since his  admission had
 his larynx touched several times with nitrate of silver, besides
 taking tonics, he was directed to use daily inhalations of alum,
 30 grains to the ounce.  On the 9th of March this treatment was
 stopped, and he complained of his throat feeling very sore—
 an occurrence which, with a sense of oppression and tightness
 and  an aggravation of the cough, I have several times noticed
 from the use of very strong solutions of alum.  Finding, on
 examination with the laryngoscope, ulceration  beginning on
 the  other cord, and perceiving no amelioration in any of the
 symptoms, the alum solution was not resumed, but sulphate of
 copper inhalations, 2\  grains to the ounce, were substituted.
 On the 18th, as they had  produced no effect  on the  ulcers,
 though the  swelling was  less, the strength was doubled, and
 he inhaled  an  ounce of the solution  daily without any incon-
 venience, though twice it made him sick at the stomach.  His
 general condition was not satisfactory, and in  addition to
 iodide of iron and an anodyne  cough mixture, he was placed
 on cod liver oil,  a  tablespoonful three times daily.  A few
 days afterwards an examination of the chest  showed coarse,
 dry rales  in expiration in both lungs, and a more high pitched
 percussion note  with greater resistance at the right apex.  The
 coarse, dry rales were there, too, more distinct; there was
 more cough, followed by a  frothy and  copious expectoration;
 and, altogether,  it was  evident  that  a tubercular  infiltration
 into  the lung was taking place.  From this time on the history
 was that of a well developed case of  phthisis.   He had  much
 cough and profuse expectoration, with rapidly progressing ema-
 ciation, and then night-sweats.  The dry rales  gradually dis-
appeared, giving way to harsh breathing, and a month after the 
28
note last mentioned signs of softening were clearly discernible
at the right apex.
  But to return to the laryngeal symptoms and their treatment
by inhalations.  The inhalation of copper, which was kept up
until the 26th of March, considerably lessened the frothy expec-
toration and reduced  the swelling, but it did not put a stop to
the progress of the ulceration.  Nitrate of silver, with a brush,
was then several times used, and on the 7th of April two fluid
drachms and a half of a solution of nitrate of silver were admin-
istered by means of the hand-ball atomizer.   The injection pro-
duced a burning sensation, lasting two hours, and a decided
abatement in the cough.  But on the 9th the ulceration, instead
of decreasing, was found to have extended to  the right true
vocal cord,  which was decidedly excavated  on- its margin; a
few isolated, yellowish spots were also seen on the wall of the
trachea.  The poor man had much difficulty in swallowing, but
had not completely lost his voice.
  From the 9th to the 16th of April,  he took, with the steam
atomizer, six inhalations of nitrate of silver, half an ounce at a
time,  of the strength  of  fifteen grains to  the  ounce.   Twice,
after inhaling, he was sick  at his stomach.  Subsequent to each
inhalation, it was noted that his larynx smarted for an hour;
but for a few hours the expectoration ceased.  From this period
on until he  left the hospital, April 30th, and very shortly be-
fore his death, the inhalations were not regularly kept up.  A
few local applications were made by means of a sponge, and he
expressed himself always as being relieved  by them.    His  in-
creasing weakness caused him to prefer them to the inhalations.
But nothing really gave him much relief; the difficulty in swal-
lowing was so great that he had to be nourished exclusively by
fluids; there was tenderness on pressing between the hyoid bone
and larynx;  the cough was very annoying, and the  sputa, no
longer so frothy, were obviously nummular; the voice was re-
duced to an almost inaudible whisper.   The last laryngoscopic
examination, made  after  the  inhalations had  been  stopped,
showed that the ulceration  had greatly altered the true cords.'
The false were  less swollen, and the  ulcer  on them  had not
increased, but an ulcer was also seen on the outer edge of the
left arytseno-epiglottidean fold. 
29
  In reviewing this singular case, we are struck with the sud-
den beginning of the affection in the larynx and with the laryn-
geal phthisis, preceding that  of the lungs.  But this  point
of the case cannot be here discussed.   I  have introduced it
rather to study the effects of the inhalations; and though these
were, on the whole,  of service in reducing the swelling, and
even  perhaps in influencing favorably some portions of the
ulcers, and though thus we may claim that a certain degree of
comfort was procured, it cannot be said that either the sulphate
of copper  or the  nitrate of silver arrested the extension of
the ulceration.  Nor were the results obtained by the latter
agent greater than those produced by the local application of
nitrate of  silver with a sponge or brush.  In simple ulcers
inhalations may be of more decided  use; though even here I
prefer, so far as I  have tested the matter, the other  method of
local treatment.
   In ozdema of the glottis  tannin has been greatly lauded by
Trousseau.   In  the  first volume of his Clinique M^dicale  he
records a case in which  a strong solution of tannin was inhaled
every  hour,  with  the most obvious  effect on the attacks of
suffocation, and  indeed on the disease. During the second day
there was  but one fit of suffocation, and the respiration had
lost its noisy character.  The attacks recurred once in twenty-
four hours  for three  days, but on the fourth day of treatment
the respiration was natural.  The young woman left the hospi-
tal a few days afterwards, perfectly convalescent.
  The same treatment, too, proved successful in  the hands of
Barthez,1 at the Children's  Hospital, St. Eugene, in laryngeal
diphtheria  and in croup. He cites four cases in which a tannin
solution, from five to ten  per cent,  strong, was inhaled from
eight to twenty  times in the course of twenty-four hours, each
inhalation  lasting from  fifteen to  twenty  minutes, and  being
always folio wed by evident  temporary relief.  Two of the
children  recovered,  the other two  died.    But the  autopsy
proved  that the  false  membrane  had entirely  disappeared.
Death was  due to  the diphtheritic poisoning.  The results of
the tannin inhalation are attributed  by Barthez to the astrin-
1 Traitement des Angines Diphtheritiques par la Pulverisation. Paris, 1861. 
30
gent effects of the tannin on the membrane, which, when cor-
rugated, rolls up at the edges, and is thus prone to be gradually
detached.   But Fieber, who treated fifteen cases with tannin
solution much in the same manner, and who reports ten  cures
among them, attributes the success  to the dissolving influence
of the remedy.  Yet, when we come to  examine critically the
instances recorded by Barthez, the former supposition becomes
far the more probable.   Thus, in  analyzing his cases, I find
that the first was sick for five days before admission, and seven
days under  treatment, making, so far as can  be judged from
the record, from nine to  ten days  that the membrane lasted.
In the  second case the treatment did not begin until the second
day of the sickness; the child died on the twelfth day. In the
third case, which seems to have been one of pseudo-membranous
croup rather than of laryngeal diphtheria, the treatment com-
menced on the fourth day of the malady, and by the ninth day
the little patient  had recovered.   The fourth case was  eight
days sick  when the  treatment by  inhalation  began, and was
subjected  to it for  four or  five  days  before  full recovery
took place.  Now this does not look like any marked solvent
power  of the remedy, for diphtheritic membranes are not per-
manent structures, but are very apt  to disappear from the cir-
cumference to the  centre within a week after their appearance.
Hence, if we accord any value to the treatment—which, bearing
in mind the  usually fatal character of laryngeal diphtheria and
the grave character  of pseudo-membranous croup,  we cannot
totally refuse to do—we  must also admit that the action is not
rapid, and not what we might expect from a solvent.  Nor can
we overlook the effect of the  water in the combination as a
cleansing  agent, and as  tending to aid in removing and in
expectorating the breaking down  textures; for Siegle1 used
inhalations of pulverized warm water alone in a case, appar-
ently hopeless, of  membranous croup, with the greatest  relief
to the child, and with the result of causing it to expectorate
with the dense mucus shreds  of the membrane.   The  child
recovered.
  But to return to diphtheria.  Other agents besides tannin
1 Hala und Lungenleiden, 1865. 
31
 have been resorted to, to counteract its local manifestation, both
 when the larynx is implicated and when the membrane has not
 extended to it—chloride  of iron, chlorate of potassa,^alum.
 Lewin1 has reported at length fifteen cases, eleven of which
 recovered.  I have analyzed these cases, and find the following
 result.   But in four of the eleven that recovered (Cases IV.,
 VI., VII. and XI.) was the  larynx  implicated,  and in these
 four the membrane was chiefly on the  upper surface of the
 epiglottis.   Only in one, Case XI., did it extend to the under
 surface of the epiglottis and to the arytenoid cartilage.   Of
 the  four fatal cases the larynx was in  three very  decidedly
 affected.  This result  is therefore by no means remarkable,
 particularly as cauterizations and internal remedies were at
 the same time used.  Indeed Lewin himself speaks more of the
 action of the inhalations in preventing  the membranes from
 reforming than of their power to remove those already formed.
   Yet another remedy that has been recommended, both in
 diphtheria and in croup, is lime water.   Kiichenmeister and
 others have found that the pseudo-membrane was  soluble in
 concentrated acetic  acids,  in  alkalies, in carbonate of lithia,
 but with greatest readiness in lime water, and the attempt has
 been made to employ this by atomization as a solvent.  Biermer2
 was the first to use it.  The patient was a girl, aged seventeen,
 admitted into the hospital at Berne for croup, which had lasted
 for four  days;  the suffocative phenomena were very marked.
 To moisten the respiratory passages pulverized water was
 tried, first warm, then  boiling.  After inhaling an hour, with
 much comfort, vehement coughing occurred, whereby a quantity
 of mucus and shreds of false  membrane were discharged, causing
 decided relief.   This became still more evident when warm
 lime water (one part of lime to thirty of water) was used with
 the pulverizer  every second hour, each  inhalation  lasting  a
quarter of an hour.   Thick, purulent matter and crumbling
pieces of membrane were expectorated, and the signs of laryn-
geal obstruction gradually disappeared.
  Biermer insists on the necessity of using the inhalations hot.
1 Inhalations Therapie, 1865.
s Schweizerische Zeitung fur Heilkunde, 1864. 
32
Dr. Kiichenmeister and Dr. Brauser1 have  each published a
successful case treated in the same manner, and a substitute for
the pulverized inhalation has been attempted  in this country
by Dr. Geiger, who poured hot water on  unslacked  lime, and
caused the steam arising from it to be inhaled.  He reports
several cases of pseudo-membranous  croup with a  fortunate
issue.2
  Not  having tried atomized lime water in  croup or in laryn-
geal diphtheria, I cannot speak from personal experience either
of its effect or want of effect.  But I have watched, in  two
cases of diphtheria, with some  care, the action of lime water on
the visible deposits.
  In the first case, that of a  lady,  seen in consultation with
her physician on the fifth day of her confinement, the deposit
covered the roof of the mouth, the half arches and part  of the
wall of the pharynx.  There was also, and indeed the progress
of the  case placed the matter beyond doubt, reason  to believe
that nasal diphtheria existed.  She was taking  chloride of iron,
full nourishment and stimulants.  I directed a stream of pul-
verized lime water about eight times stronger than that officinal
in our pharmacopoeia—the  liquor  calcis saccharatus of the
British pharmacopoeia—on the  affected part,  by means of an
excellent  hand-ball atomizer,  for three or  four minutes  at a
time.  This treatment was carried on every few hours, but no
perceptible influence on the membrane could be detected.  The
application was cleansing and very grateful, particularly so
when thrown up the nostril.   And here let  me, in passing,
state that the spray was felt to arrive in the throat, and  that
though the remedies we resort to may not succeed in dissolving
the membrane, I beg to  draw attention most earnestly to this
use of the atomizer in nasal diphtheria, and particularly in the
nasal diphtheria of children, as an  excellent means of  acting
locally on the affected part.  But  to return to the case. It
terminated fatally, the  membranes in the  mouth remaining in
a very  thick layer.
  The  second case was that of a gentleman,  thirty-five years
i Referred to in British and Foreign Med. Chir. Review, July, 1865.
a Medical and Surgical Reporter, April, 1866. 
33
of age.   Here there was no nasal diphtheria, nor were the-
constitutional symptoms by any means so grave; and after the
disappearance of the membranes, which took place in about
nine days, convalescence was rapid.  As local treatment, early
in the affection, a strong solution of sulphate of copper was
employed.  But I also, both at the time  and afterwards, made
use of atomized solutions of lime, in the same manner  as in
the preceding case, and  not hot.   The remedy was again very
grateful  and cleansing; yet, though  I selected repeatedly the
same spot  on the left half  arch  to  throw  the solution on, I
could not see that it had any perceptible effect in thinning the
deposit.
  If lime water be then a solvent of the membrane on living
textures, it is so very gradually, and  much of it would have to
be employed  to produce a decided result.   In cases running
an acute course it could therefore not be depended on. Indeed,
to take Prof- Biermer's case as an  example, how much may
have  been  due to the  inhalation of the warm fluid alone?
That warm water by itself is  serviceable we know from Siegle's
case, already mentioned.
  In hooping cough,  Dr. Steffen1  claims to have had  success
with an  inhalation of common salt  and onjum, and with five
grains of tannin and three drops of laudanum in two ounces of
water, used daily.  But though the inhalations seemed to have
afforded  some comfort to the children, the duration of three of
the cases was from two to  three weeks, and one case lasted
nine weeks.  Hyoscyamus, alum and perchloride of iron have
also been employed in this disorder.
  Turning  now to pulmonary affections,.we shall inquire into
the effects of inhalations on bronchitis, phthisis and'hemorrhage
from the lungs.  In acute bronchitis,  inhalations of pulverized
warm water will often afford much comfort and assist in pro-
moting expectoration.  Medicated inhalations I have not used,
nor do  they  seem to have  been much resorted  to.  But in
chronic bronchitis it is evident that they have a large field for
employ, and the results are sometimes very striking. To cite
a case.
' Journal fur Kinderkrankheiten, Jan. and Feb., 1866.
  3 
34
  Mrs.----, 48  years of age, consulted me in  January for a
cough which she had had for upwards of a year and a half.   Get-
ting much better during the earlier summer months, she had,
in the autumn of last year, after severe and prolonged exposure
to wet, a violent bronchitis, or broncho-pneumonia, attended
with probably much pulmonary congestion, and shortly followed
by a hemorrhage.  She stated that her cough was very distress-
ing; the expectoration purulent, profuse, having an unpleasant
odor.   Moreover it had contained blood  daily, for  several
months, varying in quantity from mere streaks  to an  amount
which gave to the whole sputum in the cup a decidedly bloody
appearance.  Her breathing was oppressed; at  times so much
so as to be wheezing and asthmatic.  Examining  the lungs, they
were  found to be filled with rales, dry and moist, the latter
far preponderating. There was no decided dullness on percus-
sion, though at the upper part of the right lung an impairment
of resonance  existed, which may have been  due to the partial
consolidation of the pulmonary tissue occurring at the time she
had the attack of bronchitis or broncho-pneumonia, subsequent
to  the exposure alluded to.   The  appetite was good;  the
general health  excellent.  As she had  tried many remedies
faithfully, some  under the  advice  of an  eminent physician, I
determined to use atomized fluids by inhalation, and directed
an  ounce of a solution of alum, 15 grains  to the ounce, with
6 drops of fluid extract of conium.  The  first inhalation pro-
duced not  only no relief, but  a decided constriction in the
chest; the  second,  taken  the  next day,  led to  a severe
paroxsym of difficult breathing.   Finding  the astringent action
of the remedy  too  great, I reduced  its  strength to  about 8
grains to the  ounce.   She bore this perfectly well, and  already,
after the third inhalation, counting in the  first two, a change
in the sputum was noticeable.  It was somewhat less  copious,
and the  quantity of blood  in  it  was obviously diminished.
She took altogether, while  in Philadelphia—of  which she was
not a resident—nine inhalations, and when  she left the city,
though the expectoration was still  very copious and as yet
but slightly changed  in character, it no longer contained a
trace of blood.
  During her stay here little or  no internal  treatment was 
35
employed;  but on leaving, while urging her to continue  her
inhalations by the atomizer, and to  vary them at  times by
breathing the vapor of tar,  I  also directed her chest  to be
painted with  croton oil, and gave her a cough mixture, of
which wine of tar and fluid extract of wild cherry formed the
chief ingredients.
  This treatment was carried on for fully two weeks, when I
was informed, by letter, that she had used the common inhaler
with tar and warm water twice each day, that she had finished
her  cough  mixture, had employed the alum inhalation  daily,
and that she still had " slight  turns  of wheezing  on lying
down, which lasted from half an hour to an hour, but none so
bad as that  one in  Philadelphia, and  they  are  somewhat
relieved by inhaling hot camphorated water.   The expectora-
tions are all, or nearly all, from 4 or  5 A. M. to 10 A. M.
After that there is but little cough.   The expectoration last
week was for a day or two offensive, but is very little so now.
It is lighter colored, and has not been  at  all bloody since we
returned."
  After this, for six weeks daily, she went on steadily with
the alum inhalations, increasing the strength to 20  grains or
somewhat upwards to the ounce  of water.  She also resorted
occasionally to the ordinary tar inhalations alluded to, and at
times to pulverized solutions  of common salt.  The cough
medicine was  abandoned and wine  of tar taken, though this
was not persevered in; the alum inhalations were her main
dependence.   Under this treatment she  gradually recovered:
the cough and all expectoration ceased;  the asthmatic seizures
no longer took place, and when I saw herein Philadelphia, in
April, she had been for several weeks perfectly well.  She had
at that time some rales in her chest, and a very  slight expecto-
ration from  a catarrhal condition of  a few days'  standing,
but  otherwise she presented all the  signs of good health.
The partial  dullness  under  the right  clavicle had all  but
disappeared.
  This case  is certainly very interesting  as regards the  use
of inhalations.  The  unfavorable consequences at first from
the   too strong  solution of alum employed;  the speedy  dis-
appearance of blood from  the  sputum; the gradual  cessation 
36
of the expectoration; the slight general treatment made nse
of—and to no portion of which does it appear that any decided
importance  can be attached—are all decided features in the
case.   And though we may affix some value to the  inhalations
of chloride of sodium and of tar, yet it is  evident that the
most efficient remedy was the alum.
  Besides this remedy, good results may be obtained from the
use of tannin,  of sulphate of zinc,  of iodine, and, where we
wish to promote the expectoration, of muriate of ammonia or
of chloride  of sodium—to all of which a small quantity of a
narcotic solution can be serviceably added.   Yet these agents
are not always of advantage.  The extent of the alteration of
the mucous membrane has a great deal to do with the success
of the treatment.  I have a  gentleman under my care who has
had chronic bronchitis, with excessive secretion,  for  twelve
years, scarcely influenced by the various climates which he has
sought. In his case inhalations of iodine, of tannin, of carbolic
acid, of lobelia, of sulphate of zinc, of  alum, of  muriate of
ammonia, of chloride of sodium, have thus  far  been  used to
little if any purpose.
  There is no  disease for which inhalations are more likely to
be eagerly resorted to than phthisis.  I have employed them
and noted their effects with care in quite a large number of
cases;  but it is impossible here to give more  than the  general
results, and in so doing it will be convenient to separate the
effects of the inhalation on the disease itself and on its more
prominent symptoms.   I will  take for analysis 10  cases,
treated at the Pennsylvania Hospital, and in which either no
other remedies were prescribed, or merely remedies to fulfill a
temporary indication.   In four cases chlorinated soda  was
used,  the  liquor sodse chlorinatae  of our pharmacopoeia.  It
was employed every day, in doses varying from half a drachm
to a drachm to the ounce; or sometimes two  inhalations were
administered daily,  of  half  a drachm  each.   In the doses
mentioned it was perfectly well borne, and  although at  first
it irritated and had to be given in a more diluted form, after a
few days it was taken without difficulty.   In the first case—a
case in which  softening was just  beginning—the inhalations
were used daily for eighteen days.   They caused no difference 
37
either in the physical signs or symptoms, though the  patient
stated that he coughed  less and  that the expectoration was
much easier after them.  In the second case  the effect on the
cough was similar, and  the  sense of tickling in the throat,
for which the patient had previously tried several remedies in
vain, was quickly relieved.  A decided improvement also took
place in her general  condition; but the  same  dullness under
the right  clavicle with crackling,  which existed at the begin-
ning of the treatment, was found after she had for twenty-two
days inhaled daily a  solution of the  strength  of one  drachm
to  the ounce.  On the whole, however, the  remedy appeared
to  have  a beneficial  influence.  In the third case twenty-five
daily inhalations were used.   The cough improved.  The dis-
ease, which had not advanced to softening, remained stationary.
But neither physical signs nor general condition  showed any
decided amelioration. In the fourth case the chlorinated soda
was not used very long and produced no appreciable effect.
   The results in these cases were not particularly encouraging,
though not totally  negative.  Two  cases were  then  treated
with iodine inhalations;  liquor iodinii compositus, viii. minims
to ij. increased to xv. minims to ij., taken daily or twice daily.
Both improved—one strikingly.   This was a case of tubercular
disease of both lungs, following right-sided  pleurisy.   There
was crackling (not, however, coarse) at both apices, and he was
losing flesh and strength rapidly,  notwithstanding that he was
taking cod liver oil and iron.  The cough was dry and irrita-
tive.  He used  every day, for a month,  iodine inhalations, at
first eight minims in each, then  fifteen  minims  morning and
evening.   The internal  treatment was stopped.  He gained
several pounds of flesh; his appetite became good; the  respira-
tions came down to  18, the night-sweats ceased, and an un-
doubted change took place in the physical signs; the crackling
almost disappeared, the dullness lessened. The inhalations at
first produced some irritation  and  a little cough. They were
always followed by slight expectoration.
  Solution of chloride of iron was  used in 2 cases.  In the one
there was coarse crackling, with distinct blowing and rather
low-pitched respiration under the right  clavicle, and coarse
crackling on the left side; the symptoms were those of phthisis 
38
passing into the stage of softening.  One-eighth of a grain of
perchloride of iron was used morning and evening for sixteen
days.  It rather reduced the expectoration, but did not influ-
ence the progress of the disease.  In the second case the effects
were decidedly beneficial.   When admitted into .the hospital
there was dullness on percussion, with harsh breathing under
the left clavicle; hacking cough of several  months' standing;
great pallor and marked anasmia, which may, however, in great
part, at least, have been due to a severe attack of menorrhagia.
The pulse was 108; the respirations 26.  The  perchloride of
iron was administered in the same way as in the preceding case.
In a week after she had  commenced it, the lips were  of far
better color, and she began to gain flesh and strength*  The
dose was, after  seventeen  days, increased to one-half a grain
daily, which she took  for ten  days, all the time improving.
For a  short period a  solution of pyrophosphate of iron was
substituted, but she went back to  the  chloride.   The iron in-
halations were used for about six weeks, and  shortly before
leaving the hospital her cough had all but disappeared.   There
was a scarcely appreciable difference in the percussion note be-
tween the two sides of the chest, and the respiratory murmur
bad lost its harshness.   She did not feel quite so strong and
well as ten days previous, in consequence  of an attack of in-
termittent fever.   I have heard that since she left the hospital
she has had two hemorrhages.
  In the 2 remaining cases out of the 10, chloride of  sodium
and muriate of ammonia  were chiefly employed.  They were
not without influence on the cough, and on the expectoration;
but were apparently no check to the disease.
  Thus it will be seen  that iodine and iron inhalations both
had a decided effect where softening had not as yet occurred.
But did they do so in virtue of any local  action, or of their
general power  on the  economy after being absorbed  by the
respiratory mucous membrane ?  This question is one difficult to
solve, save by the most careful  observation of a large number
of  cases.   But  under  any circumstance  it would certainly
seem that these remedies  merit a trial in cases of  early pul-
monary tuberculosis.    Supposing the inhalations to be well
borne and rather comforting to the patient, as they mostly are, 
39
 do we not then introduce desirable  medicines into the system
 without inconvenience, and  by carefully making  use of the
 lungs, save the stomach ?
   In turning to the symptoms of phthisis we find, as regards
 the cough, especially when  occurring  in  paroxysms, that pul-
 verized solutions of the watery extract of opium, of conium,
 or of cannibis indica  afford relief.  In cases  of cavities with
 purulent contents, or under any circumstances to render the
 sputum more easy of expectoration, solutions of common salts
 or of muriate  of ammonia are of avail.  Where  the sputa are
 copious and offensive, tar has been recommended. • But judg-
 ing by the case of a gentleman whose lungs were riddled with
 cavities, and whose expectoration was purulent, profuse,  and
 very fetid, tar inhalations  pursued in the ordinary manner
 are better, certainly  quite as well, borne, and afford more
 comfort.
   As regards  hemorrhage from the lungs, the evidence that has
 been collected in favor of the treatment by atomized liquids
 appears very decided.   A number of cases have been reported
 by Sales Girons, by  Lewin,  by  Siegle, by  Zdekauer  and
 others, in which, instantly after inhalations of strong solutions
 of alum, or  of chloride of iron, the hemorrhage stopped.  I
 have used alum, chloride of iron and persulphate of iron, and
 have thought  that the  remedies had so  distinct an effect that I
 should not be  willing to abstain from resorting to them in  any
 case of pulmonary hemorrhage at all unyielding.   At the same
 time, as the cases in which the inhalations were employed were
 on active internal treatment, I do not bring them forward.
 There is nothing more difficult to  establish than the relation
 between cause and effect in hasmoptysis.  The post hoc propter
 hoc is here so uncertain that evidence, to be accepted, ought
 to be of the most unimpeachable kind.   Of my four cases this
 cannot be said.  I will, however, state that, contrary  to what
 may be expected, the inhalations gave rise to no irritation nor
 coughing or oppression.  They may be used very strong.   In
 one of the cases  alluded  to, our Resident Physician at the
 Pennsylvania  Hospital, Dr. Herbert,  employed a saturated
solution of alum; in another, a drachm of Monsel's solution of
subsulphate  of iron to  an ounce of water.  The cases under 
40
 discussion were  all extremely  severe.  In  mere spitting  of
 blood, or in instances  of blood-streaked sputum, the influence
 of tho astringent remedies  are often very obvious.  The case
 of the lady above reported, affected with bronchitis, is a case
 in point.  I have seen one quite as  striking, in which two in-
 halations of a solution of subsulphate of iron arrested a bloody
 expectoration which had lasted for four months.
  Summing up, now, the results of this inquiry, it may be stated
 to lead to these conclusions:
  That inhalations by means of  atomized fluids are an unques-
 tionable  addition to our therapeutic means;  but that they are
 nothing  but an addition,  and not  a substitute for all  other
 treatment.
  That in most acute diseases of the larynx, and still more  so
 in acute disorders of the lungs, their  value, save  in so far  as
 those of water may  tend to relieve  the sense of distress, etc.,
 and aid expectoration, is very doubtful; though in some acute
 affections, such as in oedema of the glottis and  in croup,  medi-
 cated inhalations have strong claims to consideration.
  That in certain chronic morbid states of the larynx, particu-
 larly those of a catarrhal kind, and in chronic bronchitis, they
 have proved themselves of great value.
  That in the  earlier stages  of phthisis, too, they may be  of
 decided advantage, and that at any stage they  may be a valu-
 able aid  in treating the symptoms of this malady.
  That their influence on such affections as hooping cough and
 asthma is not satisfactorily proven.
  That they furnish a decided and  unexpected augmentation
 of our resources in the treatment of pulmonary  hemorrhage.
  That they require care  in their employ;  and that in  acute
 affections we should consider whether,  as they have to be used
frequently to be of service, the patient's strength justifies the
disturbance or the annoyance their frequent use may be.
  That the question  in any disease of the respiratory tract  is
not whether the atomized fluids can reach the seat of the mal-
ady, but whether they can do so in sufficient quantity, and in a
manner to become available as a therapeutic  means.
  That in estimating  the action of inhalations  of atomized
fluids,  we must accord due  value to the ready absorption  of 
41
many through the pulmonary structures,  and guard against
attributing to a local influence what may be due to the consti-
tutional effect of the remedy.
   That in any case, to be of service, they ought to be carried
on as a treatment with a distinct object, and not intermittingly
or spasmodically resorted to.
   These conclusions and the  remarks preceding  them  apply
exclusively to the treatment of the diseases of the respiratory
passages by atomized fluids, for though incidentally the inhala-
tion of gases or vapors has been  mentioned, it has purposely
been no more than alluded to, since this subject has been long
before the profession and has  been often  examined; whereas
that of inhalations by means of atomized fluids is a novel one,
and one which will require much unbiased investigation to
determine its true position.
   And, in conclusion, I wul point out what a wide range of
applicability atomization has beyond that to the treatment of
the diseases  of respiration.   By  atomizing salt or iodine in
rooms or in wards of hospitals, we can cause our  patients to
breathe  constantly  an atmosphere impregnated  with   these
agents, if such an atmosphere be thought desirable.  Perman-
ganate of potassa or chlorine may be used  in the same manner
as a disinfectant; and, as I have tested now in many cases, we
may obtain by atomization the constitutional effects of remedies
on the system.  In cases  in which the stomach cannot be re-
sorted to this will be a great aid.   It is scarcely necessary to
dwell  on its  value, for  instance,  in anasmia, with enfeebled
digestive powers.   The effect of remedies, too, thus adminis-
tered, is generally very prompt.  I have seen the pupils dilate
and a staggering gait produced by breathing for a  few minutes
a  pulverized solution of conium.   Of course it is incumbent
upon us not to avail ourselves of the respiratory mucous  mem-
brane needlessly; and if it be employed, it ought to be done so
with care, for it is not a membrane that will bear the slights
and rude usage the stomach receives.  But it is a  great  satis-
faction to know that, should we wish to make use of the lungs
to introduce medicines into the system, we possess now a means
more certain, more efficient and more susceptible of being regu*
lated than any that were formerly  available.
           4 
 
	
	
 
      .fim


    «cVc  r
   ccc<  *
   \r«rr  < /■

 <§L<CX~ <  < Q


 cccr cc <i
 CCCCcCcC*-
 cccc cc c
 <£CC CC.C«8
   {c.«:c ex < i
    C<CC_ «. * C
    c< tc  c c <
r_   <£cC  cc(

__Q  CC c
 <r cc c .
<c* / C
   <-. ^c c
  :  cccx
JjTTcC*
:CCC c
" cc c
>CCC C« C  -
 «t <i  «. c« <
 «t <s,  C <& C

  dCVc" CV C

 C« c«- C
 <C« cc. t
 <i:  c c. c
  _   C «  © C


■5i-  <C<£  |C^
    >-    c c <   ccc cc
  ^>    C u't   <f' <-'

.*%V*-  Ccc  <£LC( '
CC C tc «
<C C <i  c_
sN? c"
"~jc. c «
•fell  <

rs c cc  >^
 (fC!^'  L

 <* A<f   <.

COC  <

CCCC
£CC
 <> Tc  CTC -<-

 c%  CC £r

C cC OS  5"

- p Cc:  C c ;■*
  tec CC.-.-'
„C<^IC



  i^<C<i -.
  ■cCKCv-c


  'fcrc <
^?^-«C.
         cfc «r.«





  ^^cr%%

  ^-  cc  c<- c

  *r< cc  c<- ■ «

  ^ cc  Cci«  '
  <- cc  Cf  «
  T rc  cc tc/
   -  <c c « cs
   ? cc  c c C<
   r rc  C C C«c

   ' cc  C <  •«  -
   -  <   < C  '«.
  c  *   c cc ^tr

 V «  <  Cc  ^
-c<..cc  4


  CS  V-^v  ci
           c  CC

 <^<src < c
cccc c
— :ccc >c
  fccc-c
  «: cc<-v
     C«4' ^ C
 iiccc^^c
      c- <. c
_«rcc«r-

—<§L-«c  V-SV.

<TCG.

tCCC<t\C<  cc

C c ^_^
c c «-.
ss <^  «^
sec
 «c  c
 ccc  c
C C c^,
<C C<C«
c Cte '
C CC'*''

S ^^^ CC  *E5CCI" Ci Cg
c«*-c:
CC  '<<C  <^&°
cc  ccc  «^c<
Vc  C«C- <«"«
<ro CC CC'CCC
-y%W'