hf^^^M^-^"^ 'jf-? '>, T ■ y ^^.T 'Shi -'HS..- ..;■/ >"*.*^' :ir*;:--y ,#H f5f. Cornell University Library SF 959.P6W72 Inhalation pneumonia. 3 1924 000 301 055 LIBRARY NEW YORK STATE VETERINARY COLLEGE ITHACA, NEW YORK THIS BOOK IS THE GIFT OF _ _ 11 II _ _Sijl22. INHALATION PNEUMONIA. By W. L. Williams, Professor of Surgery, and P. A. Fish, Professor of Thera- peutics AT THE New York State Veterinary College. A Paper read before the United States Veterinary Medical Association at Nashville, September 9, 1897. The inhalation of foreign bodies, whether mechanical, chem- ical or bacterial tend usually toward bacterial invasion of the bronchial mucosae, extending thence to the deeper parts, finally involving all tissues of the lungs, inducing suppuration, necrosis and death. The symptoms vary greatly in detail, though in general pre- sent the ordinary signs of bronchitis and pneumonia, along with expectoration of foetid bronchial secretions, with such variations in chest sounds as would result from the presence in the tubes of the- foreign bodies inhaled or of the products of disease. The , most common causes are the inhalation of medicines during their forced administration, of food particles during coma, as in parturient apoplexy of the cow, of pathogenic organisms and their products after arytenectomy for the cure of laryngis- mus paralyticus in horses or other operations involving the up- per air passages, by the inhalation of pus discharged into the fauces or upper air passages from abscesses, diseased teeth or tu- mors, "by animal parasites in the air passages, by the inhalation of irritant gases, or hot smoke, or of liquid chloroform during the production of anaesthesia and by a great variety of more rare accidents ending in the lodgment of irritant foreign bodies within the air passages. We might include also a highly important class of infections like diphtheria, in which there is a tendency for the extension of the lesions to the lungs, or of tuberculosis, actinomycosis and glanders, where there frequently occurs necrosis and softening of patches of lung tissue, which, discharging into, tl^ie,' bronchii, tend to pass upward, only to be in part carried, backward into neighboring bronchii, establishing there their typical patho- Z W. L. WILLIAMS AND P. A. FISH. logical processes in that manner commonly termed auto-infec- tion. The handling of these cases has, as a rule, proven ineffectual, and led practitioners to recoil from them with well founded dread. The plan of treatment usually adopted has consisted of the internal administration of expectorants and sedatives with some of the gum-resins possessing antiseptic properties and which are largely excreted by the lungs, and the inhalation of vapors, either simple or medicated. Intra-tracheal injections of vermicides have been success- fully employed in veriuinous bronchitis, and the bronchial mucosa has been used as a prompt and reliable absorbent sur- face for the administration of various drugs in solutions of small volume. The senior writer has attempted the administration of antiseptics in small volumes by intra-tracheal injection in cases of suppurative bronchitis, and has endeavored to aspirate suppu- rative areas of the lung and inject the cavities with antiseptics, but without noteworthy success. Beaumont Small (Handbook of Med. Sci. IX, 756) em- ployed a I to 500 solution of pyoktanin in the form of intrapul- monary injection of 8 to 16 minims in pulmonary tuberculosis, which was reported well borne, except that when reaching the bronchii it caused violent coughing, but was said to have les- sened the hectic condition and diminished the number of bacilli in the sputa. We have been unable to find record of any attempts to ad- minister per trachea for therapeutic purposes, large volumes of liquids either as mechanical detergents or as topical or general antiseptics, the filling of the lower air passages with liquids be- ing associated in the popular mind with drowning. Opposed to this fear existed the well-known fact that in par- tial drowning the water which had well filled the air passages was in many cases partly drained out, largely absorbed, and the patient left little worse for the experience beyond the physical shock. INHALATION PNEUMONIA. It had also been shown experimentally that large quantities of water could be slowly introduced into the lungs through the trachea and become absorbed without untoward results, while a like volume introduced rapidly and persistently would produce profound disturbance and eventually death. Notwithstanding that absorption occurs more rapidly in the lungs than elsewhere in the body, excess of fluid effects material changes not only in the respiratory epithelium, but also in the blood in which any change must necessarily affect all other tissues. In an experiment at L,yon, Prance, under the direction of Gohier, 30 litres ('j}4 gals.) of water were injected into the trachea of a horse without causing death. In another case it required 40 litres (10 gals.) to kill the animal by suffocation. Colin (1873, ^ol. 2, p. 109) experimenting along the same line introduced into the trachea of a horse by means of a special apparatus, 6 litres of water per hour at a temperature of 30 to 35 degrees C, which was continued for 3^ hours, making a total of 20 litres, after which the animal was immediately de- stroyed, the bronchii quickly opened, but found empty, all the water having been absorbed. In another horse he introduced into the trachea 25 litres of water in six hours, and bled him three times at intervals of two hours, obtaining 6 kilogrammes (i3xt 1^^.) of blood. The res- piratory mucosa absorbed all the water without apparent incon- venience to the animal. Intra-tracheal medication, though not in general use, has much to recommend it when rapid effects are desired, especially in those pulmonary diseases where antiseptics are indicated. Among the agents best adapted for this use, is hydrogen per- oxide, which is antiseptic, non-toxic, deodorant, styptic, and in dilute solution non-irritant. With these facts and suggestions before us, two cases were presented at the clinics of the New York State Veterinary Col- lege, which served to invite more radical attempts at intra- tracheal medication than had previously to our knowledge been undertaken, the results of which were to us at once so unex- W. L. WILLIAMS AND P. A. FISH. pected and instructive, that we felt ourselves warranted in com- municating them to the profession, though admitting that our experiments were preliminary and quite incomplete. Case I. was an adult roadster gelding, vigorous and sound so far as known except well marked laryngismus paralyticus, on which account he entered the clinic for the removal of the left arytenoid cartilage. After careful dieting he was cast for the operation on June 3d. General anaesthesia was omitted and cocaine used to produce local insensibility. A tracheotomy tube was inserted some twelve inches downwards from the larynx, after which the arytenoid cartilage was excised in the ordinary manner by the senior author of this paper. The patient fought viciously throughout the operation, and the day being warm he became very hot and bathed in profuse prespiration. The operation completed, the tampon trachea tube was in- serted and the operation field tamponaded with absorbent cotton and iodoform. When released, the patient required assistance to regain his feet, and was so greatly exhausted that he was placed in slings. On June 4th the tampon and canula were removed, the operation field carefully sponged with i-iooo sublimate solution, and the horse was permitted to drink a goodly quantity of milk, which he apparently relished. From this time until June loth the patient seemed bright, drank liquid food with avidity, tem- perature was normal, and all appeared well except an abundant and ever-increasing foetid purulent discharge from the nostrils and tracheal openings. On June loth he appeared weaker and had fallen down, but was quickly assisted to his feet, and the foetor of tracheal dis- charges still increasing, we injected small quantities of hydro- gen peroxide into the trachea, which caused the discharge of some froth. On the nth well-defined suppurative broncho-pneumonia was noted, the patient was rapidly failing, and the area of dis- ease was so great that the intra-tracheal injection of small vol- umes of antiseptics could promise no benefit. At this juncture INHALATION PNEUMONIA. Professor Law suggested that as an experiment on a hopeless case we might, in the light of the experiments noted above, at- tempt the administration of antiseptics by the intra-tracheal injection of large volumes of liquids and permit them to be ab- sorbed from the pulmonary mucosa. We prepared a tepid solution consisting of 5 litres of water, 30 grammes sod. chlor. and 60 c. c. of the commercial solution of hydrogen peroxide. Placing this in an irrigating reservoir at an elevation of ten feet above the animal, with the liquid gravitating downward through ^ inch rubber tubing and escaping through a J^-inch nozzle, the latter was inserted in the tracheal opening and the liquid allowed to flow into the trachea in a full stream until about one litre had entered, when by an expulsive effort the greater part was thrown out through the tracheal openings, mouth and nostrils, the liquid emerging frothy and carrying with it foetid discharges. As soon as that which had been thrown into the trachea was well out the process was quickly repeated until within 10 minutes the entire 5 litres of liquid had passed into the trachea, the greater part of it having been thrown out again, carrying with it much putrid material. This was accomplished without apparent distress to the patient, causing only a moderate amount of coughing with each expulsive effort, and leaving him at the conclusion of the ordeal apparently without additional fatigue and with the foetor of his breath very effectively diminished, his air passages clean and to all appearances the local conditions materially improved. The patient died on the following day without our having re- peated the treatment, and the autopsy showed extensive necrotic broncho-pneumonia. The only result gathered from the case was the facility with which large volumes of liquids could be rapidly introduced into the trachea without producing inconvenience to the animal worthy of remark, at the same time thoroughly flushing out the air passages and measurably deodorizing and disinfecting them. Case II. was in all material respects like I operated upon on June 4th this year, in the same manner as No. I. by student H. W. ,L. WILLIAMS AND P. A. FISH. The patient struggled less violently than I., and was less fatigued after the operation. Tampon and tampon canula applied as in I. and removed on following day. Deglutition very imperfect, almost all fluids taken into the pharnyx being expelled through the nostrils and tracheal open- ings. From June 6th to 12th the loss of power of deglutition con- tinued unabated, and there were no notable changes except that gradually increasing foetid discharges took place from' the nos- trils and tracheal and laryngeal openings. By the 13th of June the patient had become exceedingly weak, having been practi- cally without food, either solid or liquid, for nine days. At this stage the tracheotomy tube which had been removed on June 6th was replaced as a precautionary measure, and the patient allowed to eat succulent grass and soft bran and linseed mashes, of which he partook sparingly, much of it dropping out through the laryngeal opening. By June 17th the breath had become very foetid, which on the i8th had become excessively stinking. An examination of the tracheal wound revealed a necrotic piece of cartilage which was excised. We then introduced into the trachea 5 litres of tepid water, with 30 grammes sod. chlor. and 60 c. c. solution of hydrogen peroxide, which flowing in rapidly was largely expelled, flushing thoroughly the air pas- sages, pharynx and surgical wounds, cleansing and deodorizing the parts. On the 19th the foetor seemed so much less that the irriga- tion was omitted, but on the 20th the foetor had increased and the lungs were again flushed out like on the 1 8th without induc- ing any marked discomfort. The intra-tracheal treatment was now discontinued. After this the patient seemed to improve slowly if at all, in strength, appetite and power of deglutition, and was greatly har- assed by a persistent cough. The tracheotomy tube was re- moved on June 25th, as the power of deglutition now seemed restored, and by July 14th the tracheal and laryngeal wounds INHALATION PNEUMONIA. had closed, but the cough continued, the patient remained emaciated and weak, the appetite indifferent, the breath had again become foetid, especially evident during his fits of cough- ing, during which he expectorated through the mouth or ex- pelled through the nose dirty gray very foetid discharges. As there was evidently still some serious pathological condition present, we re-opened the laryngeal and tracheal wounds for ex- amination, finding each completely healed and all adjacent parts apparently normal. We had barely completed our physical examination of the parts when in a fit of coughing he expelled through the laryn- geal incision an excessively foetid dirty grayish tenacious mass which it could now be no longer doubted had emanated from low down within the bronchii and indicated local purulent broncho- pneumonia. We then began anew the irrigation of the bronchii, the vol- ume, composition and mode of administration of the fluid re- maining the same, and being repeated daily. On the 15th we began the internal administration of quin- ine sulphate, 3 i, nux vomica grs. xx, and arsenic grs. ii, twice daily. At the first expulsive effort during each irrigation, the pa- tient expelled with the water about 10 c. c. of a dirty gray very foetid tenacious discharge, and on July 1 7th, he expelled a piece of foetid necrotic tissue estimated to weigh 2 grammes. On July i8th, the volume of water was reduced to 3 litres, the sodium chloride correspondingly, leaving it at 6fo., while the volume of hydrogen peroxide was left unchanged. On July 19th, five days after the beginning of the regular daily irrigations, the foetor of the expectorated mass had greatly diminished, while its color had changed to almost that of ordi- nary mucous. July 20th no foetor could be detected in expectorate, nor in expired air. July 36th, the hydrogen peroxide was doubled, which caused more coughing and resulted in increased discharge of bronchial W. L. WILLIAMS AND P. A. FISH. secretion on the 27th and 28th, though the hydrogen peroxide had been reduced on the 27th to the original amount and was so continued thereafter. By July 31st the patient had markedly improved in every way, was gaining rapidly in flesh, the cough was less frequent, the bronchial discharge less, and seen practically only at times of irrigation, and the animal would run and play in the pad- dock. The use of the tracheotomy tube, through which injections were made, was dispensed with on July 30th and the nozzle of the injecting tube inserted directly in the trachea with an apparent advantage in causing less coughing. On August 2d the patient had so far recovered that treat- ment was discontinued and the tracheal wound permitted to close. August 7th he was hitched to a buggy and tested at a rapid pace up a steep hill, and found apparently much improved in wind. On August 12th he was driven home, a distance of twenty miles, without showing signs of fatigue. On August 31st the owner reported the patient much improved in flesh, practically free from cough, almost free from respiratory difficulty when driven rapidly, and taking exercise work daily without fatigue or other difficulty. While our experiments were very limited in extent, and can be regarded only as preliminary and suggestive, some facts have been established which appear to us of interest. It has been shown that large volumes of water can not only be introduced slowly into and absorbed from the lungs, but that such quantities can be introduced into the trachea and bronchi at a rapid rate, if the trachea is open, and be thrown back through trachea, larynx, pharynx, mouth and nostrils, thor- oughly flushing these parts, constituting thereby our most effi- cient cleansing procedure. We have shown that the air pas- sages tolerate quite well at least one antiseptic, hydrogen per- oxide. INHALATION PNEUMONIA Of great interest it appears to us, is the fact that on July 17th, during our irrigation we flushed out a large sized piece of necrotic tissue which must have been lodged low down in the bronchi. In each case we apparently cleared the bronchi, at least the larger ones, of any foreign matter, and we certainly are warranted in believing that the irrigation of the lungs exerted a very favorable influence on the course of the disease. Our efforts suggest a much wider range of usefulness. In accidental inhalation of drugs during drenching, it seems that irrigation may in safety be depended upon to wash out oils, to dilute and wash out such irritants as alcohol, turpentine, whiskey, chloral, etc., while in case of foreign bodies of consid- erable size, it offers us a means for their removal, quite worthy of a trial. It seems quite possible that good results might be had by this plan in such affections as pulmonary tuberculosis where large softening areas communicate with, and discharge into bronchi, and in all forms of suppurative broncho-pneumonia, and possibly also in extensive diphtheritic invasion of the air passages. Perhaps one of its most direct uses will be found in the pre- vention of inhalation pneumonia after arytenectomy, as it affords us not only a safe plan for thorough irrigation of the field of operation, but the fluid passing down the trachea into the bronchi flush out and destroy any pathogenic organisms which have been inhaled. We do not say that our plan, formula or rate of administra- tion is the best, other antiseptics may be better and other rate or details of administration may be far superior. We do not know if it is better to have a tracheal or laryn- geal opening or not, though the absence of a counter-opening might, it seems to us, lead to dangerous spasmodic closure of the larynx. The rate of administration can evidently be varied. We did not know at the beginning of our experiment the rate of ad- ministration by the experimenters quoted, and departed widely from their plan by introducing the liquid at a very rapid rate, 10 W. L. WILLIAMS AND P. A. FISH. quite too rapid to permit of total absorption, and in that way learned that we could, without discomfort or injury, have it quickly expelled, and thus we learned by comparison with Colin's and Gohier's experiments that we may at our option, by varying the rate of administration, either have the liquid absorbed or rejected, or partly absorbed and in part expelled. At some times we apparently had 50 per cent, or over absorbed, though always given rather rapidly, while in other cases nearly all appeared to be rejected. We have been led to hope that in spite of the meagre ex- perience upon which we have based our communication, the facts and suggestions will suffice to lead others to study the plan of treatment herein outlined, with a view to developing a successful method of therapeutics in this heretofore baffling group of affections. ^-s;:* ,.»v-. J*. V0H M* ,«fc<- ''■■^>^^jy . ■_«* xV^