ON THE THERAPEUTICAL VALUE OF THE INHALATION OF OXYGEN GAS.
BY EDWARD MACKEY, M.B. LOND. ETC.
Joint Professor of Materia Medica and Therapeutics in Queen’s College, Birmingham.
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.
It is unfortunate that the application of these mighty remedies seems liable to degenerate into charlatanism: partly perhaps because they have the power—wrongfully claimed for quack medicines—of doing good in many apparently different forms of disease; partly because their use must at present be limited to the few, and does not admit of ready introduction into the practice of the many.
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,[[9]] 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.
Case I. Emphysema pulmonum (hereditary).—A lady of 55 had been for many years the subject of constant dyspnœa, increased on all movement, and often amounting to a sense of suffocation. A physical examination revealed sibilant râles with prolonged expiration heard all over the chest, which was of large capacity and more than normally resonant on percussion; the heart’s action was weak and the circulation embarrassed, as evidenced by œdema of the face and extremities.
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 dyspnœa, 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.
Case II. is of the same nature, and occurred in a gentleman of 24, who had had good health till twelve months before, when he noticed for the first time wheezing, and afterwards cough, traceable partly to the dusty nature of his business, partly to wearing damp clothes. The chest symptoms continued so bad as to confine him to the house for three or four months; afterwards, he seemed gradually to recover under the use of tonics and cod oil, and the influence of a warmer climate, and when he came to me in January 1869 for the first time, he looked well; however, he complained of debility, of constant dyspnœa on exertion, and of exaggerated attacks of it occurring suddenly at times, of some cough and of glutinous expectoration; if he attempted to live well, as he had been told to do—meaning especially the taking of wine—he usually got an attack of epistaxis.
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. lobeliæ 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.
Case III. Phthisis pulmonalis.—Mrs. W——, æt. 31, who had lost her father and sisters of consumption, consulted me in Dec. 1867. For the last six months had had cough, for the last three had emaciated, and at this time had the prostration, night sweats, diarrhœa, and hectic of the third stage of phthisis; hæmoptysis had occurred several times: the expectoration was generally purulent. There were violent pains, especially over left chest, and examination revealed a fine crepitus at apex of left lung. The patient was treated with ordinary medicines, and improved gradually. Opium in the form of an atomized spray was found to be the best medicine for relieving cough, and procuring sleep; tincture of steel and carbolic acid used in the same manner relieved, to a certain extent, the profuse expectoration; and although the case became complicated with a peri-uterine hæmatocele, in February 1868 she rallied from this also.
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 râle about the left apex (I examined the chest two days ago), the progress of the disease is arrested for a time at least.
Case IV. points precisely in the same direction. In May 1868 I was consulted by a gentleman of 19, whose father died of phthisis. He had been steward on board a packet plying between Liverpool and New York; got wet through on his last voyage, lung symptoms soon set in, and he considers that his present ones date from three months ago. He has constant cough, for which he can get no relief, profuse sweatings, hectic, and extreme emaciation; in short, all the ordinary signs of softening tubercle in the right apex, and had been sent home by medical men in Liverpool to Handsworth,—just to die. However, he too rallied under careful nursing, and with the help of ordinary medicinal agents, and by July was able to walk to my house, and begin inhalations of oxygen in proportion of 6 pints to 60. At this time the above-named symptoms were all better, and his principal complaint was of difficulty of breathing, and of pain in the side of the chest, and these did not yield to medicines or to liniments. He continued to inhale twice a week for two months, and at the end of that time was sufficiently recovered to seek for a situation. He is now in the employ of the London and North-Western Railway Company, has gained two stone, he says, and is 6 ft. 4 in. in height. I had an opportunity of examining his chest last week, and detected only dry and interrupted respiration in one apex. I should add that he continued the tinct. fer. perchlor. and cod oil during and after his treatment by gas; but he distinguished relief to the dyspnœa from the gas alone.
Case V.—Rev. W. M——, aged 34, lost father, brothers, and sisters from phthisis. In February 1868, when I first saw him, the prominent symptoms had lasted six months—the dyspepsia, the tight cough, the loss of voice, and the emaciation.
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 (being considerably longer than I had intended), 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 2½ 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 (October 8), 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 dyspnœa, 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 dyspnœa; 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.[[10]]
Case VI.—I adduce as an instance of another variety of dyspnœa a warehouse woman of 27, who had also lost several brothers and sisters of phthisis. Had been much depressed by nursing the last one through a long and painful illness; she came to me in June 1868, with symptoms of dyspepsia and history of attacks of urgent difficulty of breathing coming on generally at a fixed hour of 9 or 10 in the morning; occasionally after later meals; she kept constantly sighing deeply, and had various symptoms of hysterical temperament; had also cough and viscid expectoration; but a physical examination revealed nothing very definite—perhaps puerile respiration in one lung and diminished vesicular murmur in the other.
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 dyspnœa 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.
Case VII. Chlorosis.—Miss P——, æt. 21, had been employed for some years with very long hours of work in a small close room; was stunted in growth, with chlorotic complexion, drowsiness, headache, palpitation, dyspnœa, and great fulness of the thyroid gland. Menstruation still occurred, though scantily, and at intervals of six to ten weeks.
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.
November 8th.—Inhaled 6 pints diluted with 30 of air; pulse 96 before commencing, had same frequency at the end; the only special symptom felt was a sense of oppression at the chest, but the headache was not so bad as usual that night.
9th.—When she entered my room the headache was violent; she inhaled 12 pints in 60 of air, and before finishing, the headache had disappeared, and she felt better; this occurred on several though not on all occasions, but she continued the use of the gas for ten days only. She was then obliged to be away for a time, and the headaches returned shortly afterwards: relief had been given, but not permanently. Perseverance here might have shown good results, but an opportunity occurring soon afterwards of a residence in the country for some months, I recommended her to take advantage of it; she has recently returned much improved in health, and is following her occupation again.
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.
Case VIII.—Mrs. B——, æt. 40, mother of a large family, had been subject to bilious attacks for many years, and had several times been under my care. In May 1868 she had pain over hepatic region, depression, nausea, headache, and yellow conjunctivæ; the stools were frequent, loose, and pale; menstruation was profuse, and occurred oftener than normal.
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.
June 23d.—Inhalation of 4 pints in 60: there was not any marked effect.
25th.—6 pints in 60, and before the inhalation was over the headache was relieved, and all that day she felt “lighter” and better, though rather strange; to bed early, and slept and woke without headache, the first time for nearly twelve months, and was nearly free from her shoulder pain.
27th.—Dose repeated with similar good results, and no medicine taken; the diet was regulated as it had been before. To be brief, she took eight inhalations on alternate days, and at the end of that time was well enough to do without treatment: not that she was quite well, but restored to her ordinary health, and the improvement has up to this time continued.
Case IX.—A lady of 21, after a period of great mental anxiety and of close application to business, began to feel extreme depression, drowsiness, anorexia, headache, nausea, and interscapular pain; the pulse was slow, the face pale; there were palpitation and dyspnœa without signs of organic disease. The symptoms had lasted about two months, when I first saw her in July 1868. She took alkalies, aperients, and appropriate medicines, and on the 12th took inhalation, 7 pints in 60. Here again the same remarkable effect was produced, in relieving headache before the end of the quantity. She continued to inhale a little larger dose every third day for a fortnight, without taking any medicine for the latter part of the time. She has remained fairly well ever since, and voluntarily expressed the great benefit which she derived from the gas, especially as to relieving a sense of constriction across the chest and dyspnœa.
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.
Case X. was one of albuminuria in a lady of 57. The disease had commenced four years before, and her health had been markedly impaired for the last twelve months (dating from an attack of vertigo, and loss of consciousness). Last winter she had had bronchitis. She was a lady highly connected, and had been under the care of several eminent London physicians, who had concurred in advising her to go into the country for a time, and I was sent for to see her in November last, when she had already been at a country-house in this neighbourhood for some months.
She was feeble, with pallid face and injected cheeks; extremities œdematous; dyspnœa 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.
Case XI. resembled the last in the fact of there being organic disease. She was a delicate and refined lady, of the age of 34, unmarried. With a history of some years of spinal debility, and of congestive headache, at this time (September 1868) there was general prostration, numbness, and tingling in various parts, a sense of suffocation and of constriction, and partial loss of power over limbs; but worse than all, the attacks of headache of frightful intensity, attended with throbbing, flushing, and confusion of thought, and generally located over the left eye, which then protruded very much. Of these and other symptoms, some were explicable on the hypothesis of congestion of the spinal cord, and parts of the cerebrum, while some suggested a grave suspicion of ramollissement; others, again, of a chronic thickening of the membranes. My opinion was necessarily doubtful, but with regard to remedies oxygen offered a prospect of relieving at least some of these symptoms; it is said to have done so in recorded cases. Moreover, the patient had had the best obtainable advice in her own town of Wolverhampton and in the city of Cork, remedies prescribed by her physician had not benefited her, and for some months she had been under homoeopathic treatment at home and at Malvern. I recommended her to hire an apparatus for her own use; and on October 4 she began with 12 pints to 50 of air, the inhalation to be extended over the period of one hour. The necessary exertion tired her, and she felt no appreciable relief. I did not like to wait longer without attempting to relieve by some of our usual remedies, and I prescribed gr. viij pot. brom. with ♏︎viij. liq. ergotæ, as having a special influence in equalizing the spinal circulation.
Oct. 12.—Head bad, but not so bad as usual. On 15th, menstruation came on, and aggravated symptoms somewhat.
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.[[11]] 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.
Case XII. was one of general debility with irritable heart. A gentleman of 35, who had lost several brothers by phthisis, and had been subject to unusual harass and exertion, began to lose appetite, to grow thin, and to suffer from lassitude, dyspnœa, and palpitation. When he came to me in May 1868, the symptoms had lasted for two or three months, but I could detect no physical signs of disease. For some weeks he took quinine, aconite, and cod oil, and applied belladonna; still he did not improve much.
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.