(Abstract from the Medical News.) The Treatment of Affections of the Respiratory Passages and of Blood-Poisonings by Gaseous Enemata. A Clinical Demonstration before the Members of the Philadelphia County Medical Society, at the German Hospital of Philadelphia, March jo, 1887. J. SOLIS-COHEN, M.D., President of the Society. It is now some four years since Dr. L. Bergeon, lately Professor in the Medical School of Lyons, commenced a series of experiments in the treatment of pulmonary con- sumption, by injections of hydrogen sulphide in small quantities, propelled by currents of recently prepared carbon dioxide (carbonic acid gas of the old nomen- clature). On the 12th of July of last year, he communi- cated his results to the Academic des Sciences,* and on the 20th of August to the Congress of the French Asso- ciation for the Advancement of Sciences. On the 19th or October, Professor Cornil read a paper on the subject before the Parisian Academy of Medicine.f The bene- ficial results claimed therein have been confirmed by a number of French physicians, and have been favorably commented on by Dr. J. Henry Bennett, of Paris. A letter from Dr. Bennett in the British Medical fournal for December 18, 1886, so strongly impressed me that I * Comptes rendus, July 12, p. 176. f Bull, de I’acad., 2 me. ser. xvi. wrote to Paris at once for an apparatus, having previ- ously procured a pamphlet on the subject by his pupil, Dr. V. Morel, of Lyons, who devised the apparatus which will be used before you; and from whose pamphlet* I have obtained most of the information that I propose to communicate—much of it in his own phraseology. Mr Kyner, of the Polyclinic, has made for me and for some of my friends, a number of apparatus imitated from this one of Morel, which answer just as well, and which can be procured for $lO, less than one-half the cost of the imported one. I have them in use in this hospital, in St. Joseph’s Hospital, in the Home for Consumptives', in the Hos- pital of the Polyclinic, and in private practice. While unprepared, at this early date, to express a positive opinion as to the value of the method in curing con- sumption, I do not hesitate to state that sufficient evi- dence exists to demonstrate its value as a legitimate therapeutic measure; and I have invited you to a clin- ical demonstration because it is of importance that those of you who have not had access to the original sources of information should see how the administrations are made, in order that you should not submit yourselves to unnecessary disappointment should you feel disposed to give the method a trial, as I believe you should do. As you will see, the process is simple, but requires some precautions which necessitate the presence of the medi- cal attendant at the first few administrations. The principle upon which the treatment is based is that the disastrous results of pulmonary tuberculosis are due to septicEemia set up by absorption of the noxious products of suppuration in ulcerous lesions in contact with the atmospheric air; and that repeated prolonged bathings of the suppurating surfaces with a safe antisep- tic agent, controls the suppuration and gives the lesions an opportunity to undergo cicatrization. When an at- tempt is made to administer such an agent by inhala- * Nouveau traitement des affections des Voies Respiratoires et des Intoxications du Sang par les injections gazeuses, d’apres la Methods du Dr. L. Bergeon. Paris, 1886. tion, the quantity required to produce the desired effect is so large that it is poisonous to the individual. The same may be said of administrations by the stomach, or by the subcutaneous connective tissue. Dr. Bergeon, reasoning on some experiments reported by Claude Ber- nard in 1857,* has found that certain antiseptic agents, of which he has found hydrogen sulphide the best, can be administered in sufficient quantities by the rectum with impunity, provided that care is taken not to intro- duce too much at a time. Claude Bernard demonstrated that when a toxic or medicinal agent is introduced into an organ at a distance from the arterial system—the digestive tube, for example—it could not penetrate into the arterial system because it becomes eliminated be- fore it can reach that system. It has to traverse the portal system, the liver, the hepatic veins, and the pul- monary tissue ; during which transit it may be eliminated in the liver by the bile, or, if volatile, in the lungs by exhalation. To demonstrate this point, Bernard rapidly poisoned a bird by enclosing it in a bell glass contain- ing hydrogen sulphide ; and then he injected a syringe- ful of the gas into the veins of a dog with impunity ; and, with like impunity, a solution saturated with hy- drogen sulphide into the rectum of a dog. In both these instances the gas was detected in elimination within a few seconds by blackening a paper saturated with plumbic acetate and held before the muzzle of the animal, and elimination had ceased at the end of five minutes. Hence he came to the conclusion that this substance could be safely introduced into the digestive tube or into the veins, provided care be taken not to introduce too great a quantity at a time. The first experiments of Dr. Bergeon were made on animals with chlorine, turpentine, ether, ammonia, and bromine; but these agents had to be abandoned be- cause they soon produced a violent inflammation of the rectum, and even points of sphacelus in the mucous membrane. On the other hand, a mixture of carbon * Legons sur les substances toxiques et medicamenteuses. dioxide and sulphuretted hydrogen was thoroughly toler- ated when these two gases were pure and completely deprived of admixture with atmospheric air. In their union, the carbon dioxide plays somewhat the part of an inert agent, and attenuates the irritant properties of the hydrogen sulphide. Sulphur is well known as a powerful microbicide long recommended in pulmonary disease. Carbonic acid gas is likewise rapidly absorbed by the venous system, and rapidly eliminated by the lungs, provided it is injected slowly and in small quan- tity. The good effects of carbonic acid gas in pulmonary phthisis, in asthma, and in other affections, have long been known to the profession, as I had occasion to refer to it some twenty years ago in the first edition of my little Treatise on Inhalation, and in which I referred, like- wise, to some experiments made by Dr. James Collins and myself. In addition to this, the anaesthetic effect of carbonic acid gas may have some influence in prevent- ing colic of the intestine in the introduction of the gas, and in subduing irritation in the pulmonary tract in its elimination. Those of you who, like myself, have been practising medicine in Philadelphia some twenty-five years or more, may remember the experiments as to the anaesthetic effects of carbonic acid gas made by the late Dr. Demme, at that time Demonstrator of Anatomy in the Pennsylvania Medical College. Dr. Morel’s apparatus for administering gaseous enemata, is based on the principle that a current of carbon dioxide passing over certain gaseous or volatile substances produces a disassociation of the gaseous ele- ments, and drives them forward with it. It is necessary to produce a pure carbon dioxide; and then to pass it through a medicated liquid or over a volatile sub- stance, and to force this gaseous combination into the intestine without permitting any reflux into the reservoir of carbon dioxide. The carbon dioxide is prepared by dropping a solu- tion of dilute sulphuric acid (200 grammes of sulphuric acid to the litre of water) on sodium bicarbonate. Chlorohydric acid was used in the earlier experiments, but a portion always escaped with the carbon dioxide, and produced irritation of the rectum and kidneys. Fig. i. Carbon dioxide generator and reservoir. Glass tube, containing volatile medicament between two tampons of cotton. T. Medicament. V. D. Connections. The apparatus for generating the carbon dioxide (Fig. i) consists of a square bottle in which three table- spoonfuls of sodium bicarbonate are placed. The bottle is hermetically closed by a rubber cork with two aper- tures, through one of which a glass tube extends to the bottom of the bottle, the upper portion (G) being ex- panded into a funnel and reservoir for the dilute sul- phuric acid, beneath which is a glass stopcock (B) to regulate the descent of the liquid. The second aperture in the cork is filled with a curved glass tube (E) for the escape of the gas, and this exit tube is prolonged by a section of rubber tubing (F) for attachment to a rubber bag (I) of six litres capacity, in which the carbonic acid gas is to be collected. The mouth of this bag is furnished with a stopcock (H). The sodium bicarbonate being placed in the bottle, the cork is inserted, and the stop- cock of the sulphuric acid reservoir is closed. This re- servoir is then filled with the dilute sulphuric acid, say four ounces, and the stopcock is turned so as to allow the acid to drip on the soda. The carbonic acid gas is evolved immediately, the activity of the disengagement being controlled by the stopcock. A little gas is allowed to escape into the atmosphere, so as to drive off the at- mospheric air in the bottle. Meanwhile the reservoir is rolled tightly so as to drive out all the air it contains, as far as possible, and is then attached to the exit tube for the gas and allowed to become filled with the carbonic acid. It is then removed and its stopcock is closed. It must be removed before the stopcock is turned, in order that pent-up gas in the bottle shall not break the appa- ratus. This is one of the points to which the physician must direct the attention of his nurse, before entrusting the patient to the attendant. Another point upon which stress must be distinctly laid, is the rolling of the bag to prevent retention of atmospheric air. The gas is now ready for use. The reservoir (I) is Fig. 2. attached to a handball aspirator (J) with check valves at each end (Fig. 2). This is attached to a metallic T tube (D) passing through a cork which is intended to be placed in the neck of a bottle containing the medicated solution, preferably a highly charged natural sulphur water. The vertical portion of the tube is furnished with 6 a double valve (P) to prevent aspiration of the liquid through which the carbonic acid gas bubbles, and con- tains an orifice at top for the escape of the gas into the distal horizontal branch, to which is attached a tube (L) connected with a nozzle (N) for introduction into the rec- tum. As this tube could not be made here in time to supply me with the number of instruments I required, Mr. Kyner, Superintendent of the Polyclinic, has imitated the contrivance at my suggestion by two glass tubes placed in the cork just as in the cork of a modified Wolff bottle; the longer tube being supplied with a valve to prevent regurgitation. It answers equally well with the original. This T branch is placed in a bottle three-fourths filled with the sulphurous water— in this instance the Red Sulphur Spring water, of Vir- ginia—and the aspirator is worked two or three times to drive out the atmospheric air in the bottle, another point to which the physician must emphatically direct the attention of his nurse. The nozzle is then inserted into the rectum of the recumbent patient and the injec- tion made slowly. All clothing must be loose. With the hand on the abdomen, the amount of distention of the colon is noted, and when this is marked, or when pain is complained of, the process is suspended until absorption takes place, as manifested by relaxation of the tension ; and then the process is resumed. Fifteen to twenty minutes are consumed in the process of driving the six litres of carbon dioxide through the sulphur water. The sulphur salt—e.g., sodium sulphide—is decomposed, hydrogen sulphide being formed, a portion of the carbon dioxide taken up to form sodium carbonates. The only modification of the process I have per- mitted myself (for I deem it due in justice to Dr. Bergeon and Dr. Morel to test their method of administering the gas in their own way) is to place the mineral water bottle in a bath of warm water, which renders the injection more grateful. Within four minutes, sometimes within one, the sulphuretted hydrogen can be perceived in the breath, and be detected by paper saturated with plumbic acetate. It is prudent to have a bed-pan at hand in case there should be a call to stool. The injection should not be made upon the full stomach. This may produce emesis, it is said. You want all the room pos- sible in the abdomen to prevent pressure upon a distended stomach and upon the diaphragm. Three or four hours after a meal, or just before one, is the best time for injection. Two injections are given daily. I have found three hours after breakfast and three hours after supper the best periods. My patients have slept better after an injection just before bedtime, than after one three or four hours after the midday meal. At the first injections but half the contents of the reservoir of carbonic acid should be used, so that the parts and the system may be gradually accustomed to the process. If the bottle of sulphurous water remain strongly impregnated after the injection, it may be tightly corked for use a second time. It is not necessary to have the bowels moved before an injection. Haemoptysis and the presence of the menstrual period do not contraindicate the process. Indeed, Dr. Bergeon has seen amenor- rhoea relieved during this treatment, even when that condition had failed to yield to the ordinary methods of treatment for that special condition. When the pulmonary lesions are extensive, and, in consequence, elimination of the gas takes place slowly, the injections must be made very slowly, or they will produce sensations of fulness in the thorax and in the abdomen. Now, as to therapeutic results. All published observa- tions recount rapid amelioration of the suppurative phe- nomena; a marked diminution in cough, expectoration, dyspnoea, and night-sweats, being noted within two or three days. Similar prompt improvement, with reduc- tion of temperature, has been noted in some of my own cases, not in all. Some of his more than 200 patients Dr. Bergeon considers cured. These, he states, no longer expectorate, and present no other stethoscopic evidences than the dry sounds due to cicatrized or cicatrizing cavities, or to cicatricial bands consecutive 8 to old lesions. Some of them have been able to resume laborious occupations, and to ascend several flights of stairs many times a day without injury to their respiratory apparatus, or loss of the ameliorated condition which had been secured. Same who con- sidered themselves cured at the end of a few weeks, abandoned treatment, despite the advice of Dr. Bergeon, and underwent recurrence. It is, therefore, important that the treatment should be continued for some months, until all the pulmonary lesions have been cured, lest incompletely cicatrized surfaces undergo suppuration afresh, and reproduce septicaemia. They should be re- newed from time to time, even after apparent cure, and especially upon any reappearance of cough, expectora- tion, fever, or emaciation. Not only are pulmonary lesions said to be cured by these enemata, but pharyngeal and laryngeal tubercu- lous ulcerations are said to undergo cure likewise, and that without any topical applications whatever, simply from the contact of the gas in its elimination from the lungs. Of the cases treated under my own supervision I have as yet little positive to state. With a single excep- tion, they have done quite well so far, and some of them are very pronounced cases—cases that I have had no hope of benefiting very greatly by any treatment with which I am more familiar. One of my patients insists that she is well, but she is not. Some of these cases are here for the purpose of receiving the treatment in your presence. They will answer for themselves that they are better in several ways. Hope of recovery has much to do with this, but not all. I went through a similar ex- perience more than twenty years ago with inhalations of oxygen in phthisis. Hope buoyed the patients up until they found that oxygen had not the power of curing them, and then some of them, I fear, sank all the sooner for the disappointment. In the present instance the prospect is better, the treatment being more in accord with scientific principles, despite the awkwardness of the method. Try it, gentlemen, and within a few months 9 Philadelphia will be able to prove whether this treatment is to be regarded as a novelty of the moment, or whether it has the therapeutic value that has been claimed for it. In the one instance, it is hardly to be supposed that your patients will have been injured ; in the other, they will have had all the advantage of an early resort to a bene- ficial agent. Should it be desired to administer some volatile medicament, as iodoform, carbon sulphide, eucalyptol, or the like, the bottle of mineral water is replaced by a bottle of common or distilled water, and between the T- tube and the injection-pipe a glass tube is inserted, in which the volatile substance has been introduced between two tampons of cotton. (Fig. i, V, T, D.) In addition to pulmonary phthisis, the following dis- eases are said to be usefully treated by this method, the therapeutic principle being the same in all of them; asthma, whooping-cough, bronchitis, pulmonary catarrh, typhoid fever, the eruptive fevers, puerperal fever, and general septicaemia. If this be true, the list can be extended, as stated by Dr. Morel. The gas acts on the mass of infected blood in the right cavities of the heart, and upon its entire transit through the ramifica- tions of the pulmonary artery, so that the venous blood is disinfected in its course to the pulmonary alveoli and reenters the branches of the pulmonary veins in a purer condition. The Treatment of Pulmonary Diseases by Gaseous Enemata. A Preliminary Report. EDWARD T. BRUEN. M.D., Asst. Prof. Physical Diagnosis, University of Pennsylvania, and one of the Physicians to the Philadelphia Hospital. In the Philadelphia Hospital for the past seven weeks, the treatment of various forms of pulmonary disorders by the use of carbonic acid gas impregnated with sulphuretted hydrogen has been practised, accord- ing to the plan inaugurated by Dr. Bergeon, of Lyons, and described by Bennett.* In carrying out the treat- ment upon a considerable number of cases, much care and attention to detail have been necessary. Dr. McLaughlin, Resident Physician-in-Chief of the hospital, and Dr. Taylor, the Resident Physician in charge of my wards, have devoted a large share of their time to secure the proper administration of the gas, and owing to their valuable assistance it has been possible to give the atten- tion necessary to a careful trial of the treatment. The twenty-five cases of phthisis chosen on which to make a trial of the gas, included mostly patients suf- fering from advanced lesions, nearly all associated with cavities, marked bronchial catarrh, and some laryngeal lesions. At this time we are engaged in making a series of critical observations in reference to many essential * British Medical Journal, December 18, 1886. 11 features bearing upon the permanent value of the treat- ment, such as the best mode and frequency of the ad- ministration of the gas, the quantity and quality to be employed, and the effect upon the sputa, including the bacillus of tuberculosis. Our investigations into these subjects are still in progress; moreover, time is necessary to secure a proper estimate of the permanent beneficial effects of the treatment upon the lesions in the lungs. This report is, therefore, preliminary in character, and designed simply to record the results thus far secured. The histories of the cases under treatment have shown that the element of suppuration, as it occurs in the pulmonary cavities, and in the bronchial passages, has been positively and promptly antagonized. The temperature has been reduced in a few days, and within two weeks has frequently been brought to a normal point. In grave cases with advanced pulmonary lesions, the temperature has continued to rise a degree or so above the normal standard, but during the period of treatment in more than twenty cases, the temperature chart has always been positively modified. Together with the reduction in temperature has fol- fowed the cessation of night-sweats in most instances, and in all, this symptom has been markedly lessened. In cases in which evidences of'bronchial catarrh have been present, such as rales, and copious muco-purulent expectoration, the rales have disappeared, or have been decidedly decreased, and in nearly all instances the digestive system has been favorably affected, the tongue has become clean and natural, the appetite has increased, and also the ability to assimilate and appropriate food. In most cases the gain in weight has been progres- sive and considerable, and the nervous symptoms inci- dent to phthisis decidedly influenced for the better, and a more cheerful disposition secured. The immediate effect of the introduction of the gas upon the pulse, has been to lessen it by fifteen to twenty beats, and the respiration temporarily increased. The pulse-rate has subsequently been proportionate to the general condition of each individual case. 12 The effect of the treatment upon cases of bronchitis associated with emphysema has also been tried and the bronchitic element conspicuously modified, A woman set. forty, entered the Philadelphia Hos- pital February sth, with entire consolidation of the left lung of the variety frequently described as catarrhal or broncho-pneumonia. She had taken cold in December, 1886; had previously been a healthy, rather stout woman. The following symptoms, as abstracted from the clinical history, were present: Abundant muco-purulent expec- toration, more than a pint in twenty-four hours; profuse sweats; pulse 120, temperature ranging from ioo° to 103°; anorexia, with coated tongue, and inability to re- ceive and appropriate food. After treatment with the gas, administered twice daily since February 10th, she now seems to be convalescent. The temperature is normal, pulso 90, appetite excellent, and flesh increasing. The apparent beneficial effects were noticed within the first week, but it was four weeks before the patient was free from fever. The appetite improved within a few days from the first employment of the treatment, and simultaneously, the nervous symptoms, such as hysterical tendencies and excitement, disappeared. In this instance all treatment, except the gas, was suspended. At this date the physical signs of pulmonary lesions seem to be disappearing, and the lung seems to be approaching the normal condition once more. Four other cases among the group seem deserving of special mention. One of these is a case of basic cavity, involving almost the entire left lower lobe. In this case the effects of the gas treatment upon tem- perature, sweating, appetite, etc., were conspicuous, and the gain in flesh the first four weeks was two pounds per week, but during the last two weeks there has been a loss of two pounds, although the other symptoms continue to improve. Another case, also one of basic cavity, with marked pleural thickening, copious muco-purulent expectoration, but without other pulmonary lesions; in a word, a case suitable for treatment by the introduction of a drainage tube. The same good effects were noticed, yet although this case has been under treatment for several weeks, the temperature still remains somewhat above normal, and the secretion of pus in the cavity evidently continues, showing that some additional measures, such as those which may tend to secure perfect drainage, are still required. Another instance is one of pneumo-thorax localized to the lower zone of the chest by adhesions of the lung. In this case constant cough, entirely preventing rest, night-sweats, elevated temperature, anorexia, and loss of flesh, were all marked. The gas treatment has been employed four weeks. The patient’s condition has steadily improved, hectic and night-sweats and cough have ceased, and there has been a total gain of ten pounds. The patient takes daily exercise with freedom, and marked improvement in the pulmonary lesions can be recognized. Finally, in the most sadly diseased case of the group, a man forty-five years of age, five feet ten inches in height, with cavities in both lungs, profuse bronchial catarrh, and weight reduced to too pounds, the progress of the disease has apparently been arrested, and although the lesions are too advanced to make it possible for him ever to leave his bed, yet the relief of the distressing symptoms of fever, hectic, cough, and expectoration, have certainly been manifest. Summary.—i. In nearly all cases lasting effects have been secured in the reduction of temperature, suspension of night-sweats, lessened cough, and expec- toration, and in some, all physical signs of bronchial catarrh abolished. 2. Temporarily reduction of pulse-rate fifteen to twenty beats, and temperature one-half a degree to one degree during the administration of the gas. 3. The amount of gas introduced into the bowel has varied from three quarts to a gallon at each injection. It has been introduced very slowly, from fifteen minutes to half an hour being demanded by the operation. The 14 administration has been practised in most cases twice in the twenty-four hours. No injurious effects from the gas have as yet been observed. 4. Administration of the gas in different amounts and varying degrees of concentration is now being practised, and also investigations into the characteristics of the sputa. 5. In only one of the cases of phthisis the effects of the gas have been entirely negative. 6. In cases of phthisis complicated by intestinal lesions, experience is still insufficient to make it possible to state positive results. 7. The ultimate value of the treatment can cer- tainly only be established by time. The probable mode of action would seem to be antiseptic, and by reducing suppuration the relief of the attending serious symptoms, the patient is permitted to gain by food, exercise, and general treatment. Thus far, the value of the gas seems to be that of a useful therapeutic measure, rather than a curative plan of treatment. 8. The method of preparing the gas for use in the hospital is as follows: The carbonic acid gas is passed through a solution of chloride of sodium and sulphide of sodium in twenty-two onces of water. The proportion of the salts has been increased in some cases, and some trials of other combinations are being made. 15 Complete Apparatus For this New Treatment of Pulmonary Diseases. George B. 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