Read Ebook: The Practitioner. May 1869. A Monthly Journal of Therapeutics by Various Anstie Francis Edmund Editor Lawson H Henry Editor

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On the 23d, "injected gr. j of morphia twice daily since the last entry, and with decided benefit, and she is much less excited. Sleeps well, and the suicidal tendency seems to have passed away."

On July 15th the entry is as follows:--"Has improved uninterruptedly ever since the last entry, and is now tolerably sane."

She was discharged recovered on 7th December, 1868, and has continued sane to this date, although in such a case another relapse is most probable.

ON THE THERAPEUTICAL VALUE OF THE INHALATION OF OXYGEN GAS.

BY EDWARD MACKEY, M.B. LOND. ETC.

Our ordinary medicinal agents are substances from the animal, the vegetable, and the mineral kingdoms: the one here to be treated of is of that class of remedies which includes the great elements or forces of nature: such are water, in all the varied forms of bath; electricity, in its different developments; air, in all its modifications of pressure or composition.

Nevertheless, the truthful study of these agents offers scope for the highest science, and promises therapeutical results of the highest value. The following cases are offered as data for judging of the value of one of them. I do not propose to treat here of the chemistry of oxygen, nor of its physiological effects, nor even of the objections which have been urged against its use--but simply to state facts which have come under my own observation.

She was subject to attacks of bronchitis occasionally, but, at the time of treatment, the general health was in fair condition; the prominent complaint was the difficulty of breathing.

On July 5, 1868, she inhaled a mixture of 3 pints of oxygen with 30 of air: the results were favourable. Within a few days the dose was doubled, 6 pints to 60: soon the proportion of 8 to 60 was used: and later, 12 to 60, and with this dose we seemed to obtain such good effects that I did not think it necessary to increase it. The inhalations were taken at intervals of three or four days for a space of six weeks; after each one, the lady experienced marked relief, which she expressed as being able to take a deep breath and get sufficient air--a feeling not known for years; as being able to move with comparative ease, feeling buoyant, and more like healthy persons should feel, than she ever remembered.

The only definite effect upon secretion was a more copious and facile expectoration, always produced, and lasting for a day or two; the effect upon the circulation was not marked at the time, but some palpitation occurred, generally in the nights which followed the taking of the larger doses; no other unpleasant symptoms whatever.

In attacks of exaggerated dyspnoea, as they occur sometimes in the emphysematous, and in those peculiar, nervous, irritable states apt to be induced by mental causes in the subjects of weak hearts, I have known her come into my consulting-room, inhale for half an hour, and express herself cheerful and composed. Nor was this the effect of fancy; for, at first, the lady had a prejudice against the plan; now she esteems it highly, nor has she ever found relief at all comparable to this, from the many medicines prescribed at various times by various practitioners.

Physical examination revealed a sibilus at the end of inspiration, and a rhonchus with expiration over all the right lung, except the apex; the chest was very fully developed and abnormally resonant.

I prescribed for him inhalations of oxygen in the proportion of 12 pints to 60 of air, and he took these twice in the week for five weeks; after each one he expressed himself in much the same manner as the last patient, was conscious of a general feeling of renewed health, of a greater power of breathing, and of facility of expectoration; great improvement took place in his condition, and I think it must be credited principally to the gas; for, although I ordered him 10 to 20 drops of tinct. lobeliae at night-time, and later on tinct. fer. acetatis and frictions with the linim. tereb. acet., yet it is to be borne in mind that he had previously had a fair trial of expectorants, tonics, and even change of air, without anything like equivalent relief.

It was July 1868 before she could walk as far as my house. Her principal symptoms then were debility, pains in the chest, cough, and copious muco-purulent sputum. At this time she began inhalations of oxygen in the proportion of 6 pints to 60 of air, increasing by degrees to 12 pints. She took eight inhalations at intervals of two days, and then found the above symptoms so much relieved as to be able to omit all treatment for a time. She herself attributed great benefit to the gas, and was taking no other special medicine at the time. Since then she has borne fairly well the cares of a large family. She has gained flesh, and though there is still a frequent cough, and sputum, and a mucous r?le about the left apex , the progress of the disease is arrested for a time at least.

In March the physical signs of phthisis were evident in the left apex, as was ascertained by Dr. Russell, who saw the patient with me at that time. I need not detail symptoms or treatment, as they did not differ from what is usual; suffice it to say that improvement took place, but was temporary, and in April we recommended him to visit Jersey. He was there for three months , and at that time he thought that he found benefit from the sulphurous acid spray. However, he returned as bad, if not worse, than when he went, with night sweats, extreme prostration, cough, difficulty of breathing, and purulent expectoration. It was in this condition, and when he had had a trial of almost every other remedy, including a prolonged course of cod oil, that I proposed oxygen to him, and he began it July 24, 1868, in proportion of 6 pints to 60, increasing gradually up to 10 to 60, and taking this two or three times a week up to October 8, a period of 2 1/2 months; during the whole course of the time, he had expressed himself as much relieved, both as to breathing power, cough, character of expectoration, appetite, and strength. He had gained weight, and the malady was quiescent. He had been accustomed to come from the country by train, and to ride back in a cab. On one unfortunate day , which was cold and very wet, he got into a cab the window of which was broken, drove six miles in the night air, in the course of that night got a sudden pain in the side, and dyspnoea, and when I saw him next day pneumonia had attacked the right lung, and he was desperately ill.

Now the point of the case is this. It has been said that the inhalation of oxygen is liable to cause inflammation of the lung. Did it do so in this patient? That must be a question to be decided on the evidence, but I cannot think that it did. The dilution of the gas was great; the same quantity had been inhaled for weeks before without any injury, and the other exciting cause was such a probable one. At the end of a month's time he was convalescent, and urgently requested the resumption of his inhalations. I consented, and he again expressed relief from them, especially as to the dyspnoea; but effusion in the right pleura came on gradually, but too surely; for some time we saw the end approaching, and he died last month. Almost to the last he expressed benefit from the gas, and he certainly suffered less than any consumptive patient whom I have ever seen.

She was treated for some weeks with various stomachic and tonic medicines, and went into the country for a fortnight; but the symptoms remained more or less.

It was during an attack of this spasmodic or hysterical dyspnoea that I first administered oxygen to her, in proportion of 5 pints to 30 of air, and again in a double dose, only on three or four occasions.

It is possible that these doses were not large enough for a fair trial; but, however, I wish to record that relief was given, but it was slight and not permanent. Eventually the patient recovered under the use of bromide of potassium and quinine. She has since married, and is well.

She came under my care in January 1868, and after regulating her hours and her food as far as possible I prescribed various preparations of iron, of magnesia, of aloes and myrrh, baths, and liniments, &c.

There was a gradual improvement in her condition with occasional relapses, which obliged her to remain under treatment for many months. In October 1868 the prominent symptom was headache, violent and pulsating, and it was for this that I prescribed oxygen, after the failure of many medicines.

The two following cases are somewhat allied to the last, in being disorders of secretion or excretion, and are examples of that so common complaint in town people, hepatic congestion; the results were exceptionally favourable, and although under ordinary medicines patients generally improve in a satisfactory manner, yet the malady sometimes shows such a disposition to return, that one really scruples about prescribing over and over again rhubarb, magnesia, nux vomica, acids, or blue pill.

She took at first dilute acids with tinct. rhei co. and improved, but relapsed at the end of June, and it was then that I recommended the gas to her; the prominent symptoms being headache, depression, complete loss of appetite, and a constriction about the chest "as if she could not get air enough:" menorrhagia had been going on for two days.

Both these cases were tolerably acute, and occurred in persons of naturally "sanguine" temperament, but it is necessary to record that another case which I have treated more recently,--a young lady of "bilious" temperament, who suffered from hepatic congestion in a more chronic form,--found no special effect whatever from inhalations taken on alternate days, for a fortnight.

She was feeble, with pallid face and injected cheeks; extremities oedematous; dyspnoea to a great extent on the slightest exertion; tendency to fainting and giddiness; urine deposited urates, and gave a cloud of albumen with the usual tests. Almost the only remedy which had not been given to her was this gas. I requested her to write and ask her physician if he concurred in its use; he wrote back to say "by all means," and on November 18 she began with 14 pints in 60 of air. The pulse was 78 at commencing, and did not vary. She took it six times at intervals of three days. I had anticipated good from it, but there was really no marked effect. She thought, in fact, that her headache was rather worse afterwards, but I think that was better accounted for by the carriage drive to my house and the extra excitement.

Treatment was omitted for a time, and in the interval she got an attack of subacute bronchitis; on recovery she hired an apparatus of her own, and began, on December 12, 16 pints to 60. I consider that she had a week's fair trial, but at the end of that time, what with leakage in the machine and non-arrival of gas, the lady's patience failed, and the treatment was not persevered with. I mention these matters as an instance of one of the difficulties that an unusual mode of treatment must necessarily contend with. However, the result of this treatment, such as it was, gave no encouragement to persevere.

I directed inhalations to be increased in strength every day, until I reached equal proportions of air and oxygen--as much as 30 pints of each.

On October 21 had an attack of prostration to a more extreme degree than ever known before; she seemed, in fact, at the point of death from sheer exhaustion. And here again we are met by the important question--Was this due to oxygen? for experience recorded of its effects seems to warrant this apparent paradox, that although in many cases a stimulant, in some it is a depressant; that although it will increase the vital powers when only moderately depressed, it will tend to lower them when they are already very much lowered. Or, again, was the prostration due to the bromide of potassium?

Candidly, I do not think that it was due to these causes, partly because she had had no inhalation for two days before, and no medicine for three days, and partly because a depression similar, though less in degree, has followed menstruation on other occasions, and this had been more profuse than usual.

For the time I gave her quinine and brandy and a little morphia, and on the 23d permitted her to resume inhalation, beginning at 12 to 60; she again gradually increased the dose to 30 pints in the day. For the bromide of potassium I substituted small doses of strychnia. The administration of the gas in varying doses was persevered with till November 4--a full month altogether--then I recommended her to discontinue it. The effect was certainly not marked; if there was any, it might be in relieving the sense of suffocation, which was not so bad during that month as it had been before and since; but on the whole the gas must be considered to have failed in this case. However, it will be remembered that many other remedies had failed also, and the further progress of the case has convinced me of the presence of serious organic disease; it is in fact two months since I have ceased to entertain or give any hope whatever of this lady's recovery.

On June 21, he inhaled 4 pints mixed with 30 of air, and felt a "greater lightness"--no increase of palpitation. After four days of treatment, he got an opportunity of spending a fortnight in the Highlands, and I recommended him to try the breathing of oxygen there. He returned home, however, in July, not so much improved as we had hoped, and still complaining much of soreness about the chest, and oppressed breathing. From this time to September he took an inhalation every third or fourth day, and with perceptible benefit. It is true that he took, for some weeks of the time, the hypophosphate of lime and cod oil, but still the effect of the inhalation in improving breathing power, and appetite especially, was immediate enough to convince us that it had a large share in his recovery. He has remained fairly well since.

To resume: 12 cases are here related; 2 of the 12 are of organic, and in all probability incurable disease, and these 2 derived little or no benefit from the inhalation of oxygen; the other 10 found benefit as recorded, some more, some less, but all of a kind which I have not seen given by medicine alone. It remains to ask--Is there any common character by which we may connect together this series of cases, and which may enable us to say, oxygen is good for such and such a class of cases, as we say iodide of potassium or quinine is good for such and such a class?

I think that we may find some such common character in the presence of congestion, especially venous congestion, whether of the liver, the lungs, or the uterus: more than this I will not say at present; the classification of carefully-observed cases, and a rational theory of this "modus medendi," are points that require special study, and cannot be dogmatised upon until we have a wider basis of facts.

ON THE HERPETIC FORM OF STRUMOUS OPHTHALMIA, AND ITS TREATMENT BY ARSENIC.

Strumous Ophthalmia, associated with herpes of the face, or as it may be termed the herpetic form of strumous ophthalmia, is a disease so often met with in general practice, and one so little amenable to local treatment, that I venture to say a few words regarding its treatment constitutionally. I should hesitate to occupy valuable time and space with what appears to be a trivial subject, on which much has already been written, did I not believe that by so doing additional light might be thrown upon the subject. For several years past I have been collecting evidence, carefully sifting and placing all well-marked cases aside for special treatment. The results obtained in the earlier batches of cases thus treated, decided me to continue such treatment for a lengthened period. The evidence thus obtained being highly satisfactory, other treatment formerly employed was abandoned.

During the time that has since elapsed, I have continued to employ the same remedy with the same good results.

This form of the disease generally presents itself in fat, red-faced children who have the appearance of robust health. On questioning the parents, they will perhaps inform you that the child was but small and puny at birth, and for the first few months of its life it was sickly and delicate, and not until lately had it become so stout and healthy. They attribute the change to the purer air the child now breathes, for they have removed from a populous and unhealthy district to one less crowded and decidedly more healthy.

In such a child we find traces of constitutional defect in enlarged and rickety joints, a head big and ill-shapen, and an anterior fontanelle not completely closed. We find a thick and prominent lip, conspicuous for the extent of mucous membrane it shows.

The intolerance of light is so intense that the child cannot bear even a moderate degree, but persists in burying its face in its hands, or hiding from the light in some dark corner. But what strikes us so forcibly, and what really is so characteristic of the case, is the fact that the patient's face is disfigured with patches of herpes,--a fact which makes us hopeful, as these cases are as a rule the most amenable to treatment. To cure the disease of the skin is to cure the disease of the eye in the most rapid and satisfactory manner.

In the majority of the cases which have come under my care, the eruption was confined to one-half of the face below the brow. In a small proportion the side of the nose was not affected, and in several the skin of the upper lip and chin escaped altogether. The vesicles in most of the cases appeared to follow the course taken by those branches of the infra-orbital nerve which supply the skin of the face.

My notes do not supply me with any case where the eruption invaded the brow, although I may have overlooked some such case in my earlier investigations on the subject. The eruption was often accompanied by a febrile condition more intense than I have ever met with in the other forms of strumous ophthalmia.

Before proceeding to active treatment, instructions regarding diet, regulation of the bowels, &c. should be given. The diet should be plentiful, simple, and nutritious; and all articles of food likely to unduly tax the digestive powers should be carefully avoided. Strict attention should be paid to the bowels, which ought to be opened at least once during each day, but oftener if the appetite be faulty, the tongue loaded, and the faeces light coloured and of bad odour. These preliminary instructions having been attended to, special treatment may be adopted.

It is well to begin with small doses of the arsenic in form of Fowler's solution. Two drops may be given thrice daily, in some bitter infusion, to a child between one and two years of age, and gradually increased to four drops. Seldom is it requisite to further increase the dose. Arsenic appears to exercise a marked control over the febrile symptoms of this disease. As the herpetic eruption diminishes, the child ceases to shun the light, and as the rash fades the pustule on the eye heals. The benefit of fresh air in the more obstinate forms of the disease is well known; but it is often difficult to convince parents that exercise in the fresh air will benefit the child. They imagine that it is rather hurtful than otherwise, because the intolerance of light is then a distressing symptom, proper means not having been taken to shade the eyes. A ready method is to place over each eye a pad of cotton wool, and over the pads a bandage, which should encircle the head, and tie on the occiput. The pads should be frequently renewed and the eyelids washed with warm water.

In a future paper I hope to bring forward additional facts on the subject, and conclude by giving the history of a number of cases.

Reviews.

Another matter which deserves notice, and had escaped ours, is the experience of M. de Beaufort as to the efficacy of iodide of potassium in diseases of the lachrymal apparatus. This observer began by applying the treatment to comparatively recent and slight cases of obstruction of the sac and nasal duct, the result of coryza, chronic conjunctivitis, &c. Obtaining a speedy cure in several such cases, he proceeded to try it even in instances where a tough fibrous stricture had existed for a long time. Even in such apparently unlikely circumstances, he has twice obtained success by the treatment. Where there is lachrymal fistula, following an abscess of the sac, the iodide is also very useful, but its employment should be accompanied by applications of tincture of iodine.

POTION NO. 1.

Extrait gommeux d'opium 1/3 grain. Tincture of digitalis 7 1/2 minims. Syrup 1 ounce. Distilled water 5 ounces.

POTION NO. 2.

Extrait gommeux d'opium 2/3 grain. Tincture of digitalis 15 minims. Syrup 1 ounce. Distilled water 5 ounces.

We have no wish, however, to leave an unfavourable impression of M. Ferrand's very able pamphlet on our readers' minds. On the contrary, we refer them with confidence to the work as a repository of a large amount of accurate and careful thought and observation on the nature and the remedies of the pyrexial state.

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