Part 3

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.

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

BY ROBERT S. OGLESBY, _Assistant Demonstrator of Anatomy in the Leeds School of Medicine._

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 (which are as a rule weak in such children) 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 fæces 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.