Carbon Dioxide in Medicine Part II – Dr. Achilles Rose

CHAPTER III – INFLATION OF THE LARGE INTESTINE WITH CARBON DIOXIDE GAS FOR DIAGNOSTIC PURPOSES

H. v. ZIEMSSEN, in the year 1883, was the first to describe and publish experiments to establish the value for diagnostic purposes of artificial inflation of the large intestines. It may be admitted, however, that other investi­gators, those of the Berlin Medical Clinic, for instance, and other places, made experiments in the same direction, employing various methods, and were, as well as v. Ziemssen, aware of the significance of this diagnostic aid.

All that v. Ziemssen has said of the utility of carbon dioxide gas inflation for diagnostic purposes may be said of inflation with air, pure and simple. His method is to develop the gas within the intestine, by introducing through a rectal tube, first bicarbonate of soda, then water, and finally tartaric acid. Having the large intestine inflated, he found he was enabled to diagnosticate situs inversus viscerum, to demonstrate an acquired pathological position of the colon. He recommends this method to ascertain the relative posi­tion of the large intestine to a floating kidney and ovarian and other abdominal tumors. Using such inflation he discovered com­munication between the colon and stomach and between the small intestine and stomach. It also enabled him to study the relations of a fistula of the cecum, extending through the abdominal wall, and of a carcinomatous vesico-rectal fistula. Inflation was most of all serviceable in cases of stricture of the large intestine. In several such cases, the exact location of the stricture could be ascertained, the surgeon is guided to the very point where to enter upon the gut.

V. Ziemssen used a solution of from 10 to 12 gm. of bicarbonate of soda and somewhat less tartaric acid to expand the large intestine. He found the method of inflation preferable to that of pouring in water for the purpose of ren­dering passable stenoses and strictures of the colon.

He most emphatically advocates sudden ex­pansion using carbon dioxide to reduce abnormal positions, strangulations, intussuscep­tions, and twistings of the colon, as they are caused by perityphlitis, pericolitis, or periproctitis. Thus v. Ziemssen employed carbon dioxide gas as a mechanica] agent.

Rosenbach has published a series of experi­ments made on the living, and also the results of experiments on the cadaver, by inflating the large intestine with liquefied carbon dioxide. The selection of liquefied carbon dioxide in place of the effervescent mixture offers a number of advantages:

1.   It allows an exact dosage.

2.   The introduction of the gas is absolutely uniform and constant.

3.   The inflation may be interrupted at any desired moment and be continued again at will, so that much larger quantities of gas may be introduced.

4.   There is no liquid applied together with the gas.

5.   The pressure under which the gas enters is a much higher one.

6.   There is no apprehension of those accidents which are apt to happen when the two components for the development of the gas are introduced separately, which accidents may interfere with the success of the proceeding.

It must be conceded that inflation with air, as practiced by Ewald, Runeberg, Oser, etc., using a rectal tube and spray apparatus, renders essentially the same good service; but carbon dioxide gas has been held preferable as being safer than the introduction of large quan­tities of unfiltered air.

The carbon dioxide gas is taken from an iron balloon, in which it is contained in the liquefied form; a double stop-cock is attached, to regulate exactly the flow of the gas from the balloon, in which it is natural enough under high pressure. The carbon dioxide, on escaping from the balloon, at once assumes the gaseous form. From the balloon, it passes first into a bottle filled with water. This contrivance to have the gas pass through water is to enable us to observe and to control the celerity of its escape. From this bottle, it enters into an elastic tube terminating in a nozzle for the rectum. With the nozzle having been inserted into the rectum, the stop-cock is opened to so limited an extent that we are ena­bled to count the gas bubbles passing through the water.

In a few seconds after the gas enters the rectum there is produced a sensation of warmth in the anus, then a slight desire to stool is felt for a moment but soon passes away. In pa­tients who avoid pressure, control the levator, there is no voiding of gas, the muscular closure sufficing to retain it; in some cases, it is advis­able to secure closure using a rubber valve fastened to the rectal tube, which valve is pressed against the anal opening. If even this means should fail securely to close the opening, we may simply increase the amount of gas that enters by opening the stop-cock some­what wider, when a satisfactory filling up of the intestine takes place. We soon notice now that the abdomen gradually becomes expanded, and when the patient begins to complain of tension we have to discontinue the introduction. It will be well to inflate the rectum empty in order to avoid obstruction of the tube by fecal masses. The presence of the latter, however, so long as they do not directly obstruct the lu­men of the nozzle, is no hindrance; the gas passes alongside them while the intestine is stretching. The amount of the gas entering the intestine may be judged from the size and the number of bubbles that are seen in the water of the bottle spoken of or may be calculated exactly using a manometer that can easily be inserted. For practical purposes, however, it is of no importance to know the exact amount.

Rosenbach has given a very thorough and exact description of the behavior of the intesti­nal tract when inflated with carbon dioxide gas, and his observations are of great value for diag­nostic purposes; it does not, however, come within the scope of this treatise to enter into all the details of this useful investigation, since the results obtained are by no means character­istic of carbon dioxide gas introduction, but may be arrived at as well by inflation with atmos­pheric air. They are, notwithstanding, of great importance to us, in so far as they fur­nish conclusive evidence that carbon dioxide gas may be employed with perfect impunity.

Errors about carbon dioxide gas have been transmitted from book to book, from generation to generation. One of the grossest errors we find in the latest edition of Eulenburg’s “Real­encyclopadie”: “When carbon dioxide has been introduced in large quantities into cavities of the body – as, for instance, the uterus – the intoxication produced thereby may become fatal by asphyxiation.” A. patient of mine, a lady suffering from dysmenorrhea, kept up in­troducing carbon dioxide gas into the vagina for hours at a time, because it gave her relief from pain. There was no asphyxia, and the idea of such a danger did not even enter my mind. When the inflation is carried out ad maximum, the lower part of the abdomen becomes ex­panded and the abdominal walls are under great tension, but, notwithstanding this, the liver is not at all or only very slightly pushed upward, for on percussion over this organ the dulness remains about as before, there is no rising of the diaphragm, and consequently no retraction of the lungs and no dyspnea is observed. All that may be noticed is a very slight accelera­tion of respiration and pulse, as will be men­tioned presently. There is no cyanosis. The subjective symptoms of patients or persons ex­perimented on are due to the disagreeable ten­sion of the abdominal walls and the difficulty of expiration caused thereby, but even this unpleasantness disappears more and more as the patient becomes accustomed to inflation.

Rosenbach’s experiments confirm the well known fact that we can not, by way of the rectum, inflate the small intestine; especially conclusive in this respect are his experiments on the cadaver. The inflation can not be carried out beyond a certain limit, which limits corresponds exactly to that noticed in the living. In attempting to force introduction beyond this limit he did not succeed; the gas would escape through the anus or it would encounter such strong resistance that no more could enter. He carefully opened the abdomi­nal wall without injuring the intestine and was then able to convince himself that, notwith­standing the considerable meteorism, the infla­tion did not extend beyond the ileocecal valve. The diaphragm was not pushed up nor was the liver displaced.

All experiments thus far have demonstrated that neither in the living nor in the cadaver can we force gas or liquid up through the ileo­cecal valve so long as the abdominal wall is intact; and even if the wall is opened the entrance into the lumen in question can only be forced when the injection is made close to the valve, so that from the anus, even while the abdominal wall is wide open, we can not at all, or only imperfectly, fill the ileum. From these facts, we can be absolutely certain that the valve not only prevents regur­gitation but that there must exist other me­chanical conditions causing the closure to be of great firmness. Among these factors are mentioned by Rosenbach, and by others before him, the physical and physiological behavior of the abdominal muscles or the abdominal walls in toto, the action of the diaphragm which tends to reduce the capacity of the abdominal cavity, the difference in the width of the lumina of ileum and colon on the opposite sides of the valve, as well as the muscular communication of the two intestinal segments, the axes of which are placed almost vertically to each other.

CHAPTER IV – THE THERAPEUTIC EFFECT OF CARBON DIOXIDE GAS IN ANEMIA, ASTHMA, AND EMPHYSEMA OF THE LUNGS

Carbon dioxide is absorbed by the mucous membranes, especially by the mucous membranes of the intestine, to a higher degree and with more facility than by the skin. The rapidity of this process may be judged from the shortness of time it takes for an artificial carbon dioxide meteorism to become reduced while there is no way for the gas to escape except through its channel of absorption.

The physiology and chemistry of respiration teach us that the carbon dioxide of the blood exists as a constituent of combinations partly in the blood- corpuscles, partly in the plasma, and partly in the serum. Whether a change in the composition of blood results where large masses of carbon dioxide gas have been introduced into the rectum and from there have found their way into the veins, is not known, no investigations in this direction have been published. The amount of the chemically bound carbon dioxide in the serum of the blood is proportional to the amount of carbonate of potassium therein, and similar relations exist likewise in the blood- corpuscles and the plasma.

Therefore, whether any and how much carbon dioxide may be absorbed in the blood remains as yet an open question. Symptoms of intoxication have never been noted. Röhrig has made experiments on rabbits in this direction. He found that very considerable masses of carbon dioxide gas might be introduced into the veins without producing symptoms of intoxication, though such symptoms doubtless would occur if these masses had no opportunity to be eliminated by the lungs. Conclusive experiments on this point of venous injections were made by Nysten and Demarquay.

Nysten made a number of experiments that showed that carbon dioxide gas may be injected into the jugular vein and even into the carotid without causing serious accidents, provided the gas is introduced in small doses and slowly. If, however, the operation is performed forcibly, if the gas is introduced into the blood too rapidly and in too large a quantity, death will ensue through distention of the cavities of the heart.

Against the experiments of injecting the gas into the jugularis, the objection has been made that the gas could not have time for action on the blood, because it would be transported at once to the lungs, whence it would be exhaled immediately. Demarquay, in repeating the experiments of Nysten and desiring that the gas should remain for a longer time in contact with the blood, selected the crural vein. The result corresponded exactly with the results formulated by Nysten. He injected into the cruralis of a good-sized dog, within forty minutes, 1 liter of carbon dioxide, taking care not to inject more than from 5 to 6 centiliters at the time. After the operation, the animal did not appear sensibly affected. The next day after this experiment he injected into the same dog, again into the cruralis, another liter of the gas, but this time it was introduced within nine minutes, and 20 centiliters at a time. The animal made three or four inspirations and died. The necropsy was performed immediately. The cavities of the right heart were found to be very much distended. In beating slightly with the finger upon the right heart, a resistance was felt and a very well pronounced elasticity. The aorta incised, issued only blood at first, and then quite numerous bubbles escaped. The left heart was filled with rather spumous blood, a little less red than normal. The right heart was incised. With effervescence, a blackish foam spouted out, followed by very black blood. No clots were found in the heart. The vena cava was distended by the gas, which gushed out when pressure was made on this vein. 

The lungs presented externally a reddish slate coloration. On the periphery of the right lung, there was a good-sized ecchymosis. The surface of the kidneys was very brown. 

In these two experiments, Demarquay found, on auscultation of the heart, a very strong noise every time while forcing the gas into the vein; this noise was quite analogous to the dabble produced in a cavity of the phthisic. These experiments confirm those of Nysten and speak in favor of the harmlessness of the gas. 

Brown-Séquard, judging from facts of quite another character, thought he could demonstrate that carbon dioxide gas had decidedly a toxic effect. Continuing the experiments made by Bichat to this end, he studied the action of the blood charged with carbon dioxide injected into the vessels, and he arrived at a conclusion which, in fact, is the best refutation which we could offer against his experiments. When we compare the phenomena of complete asphyxia with those which present themselves after an injection of blood charged with carbon dioxide gas, we find that they are similar except that they are more violent in case of such transfusion when compared with those in asphyxia. It appears that in both instances the phenomena under consideration depend certainly on poisoning by carbon dioxide. The fact of the transfusion adds a new element to the question. It is not unlikely to cause the carbon dioxide to penetrate into the blood in the form of a gaseous injection or by process of transfusion, and, since Brown-Séquard has stated that even in performing transfusion serious accidents will happen only when a certain quantity of blood is introduced rapidly, he admits, the phenomena apparently toxic which he has observed, are in a great measure to be attributed to the mode of operation. 

The whole mass of gas introduced into the blood is carried to the lungs. From the lungs, it is eliminated in a manner corresponding to the elimination of carbon dioxide under normal conditions. The route which the carbon dioxide pursues through the system is decided by the peculiarity of traveling in the direction in which it meets the least tension. On this law depends likewise its transmission from the tissues into the blood, as also its normal evaporation from the blood into the alveoli of the lungs. Altho we know that this evaporation is limited, and is for one thing dependent on the celerity of the blood circulation, i.e., upon the length of time during which the gas remains in the lungs, we may take for granted that at this point large masses are eliminated. 

It is, therefore, evident that the carbon dioxide gas injected into the rectum and passing through the venous current causes no noticeable effect whatsoever in the system. Some of its therapeutic effects begin with its elimination from the lungs. 

The acts of inspiration and expiration exert a direct influence on the contents of the upper air- passages, but not on the lower, especially not on the air in the alveoli, which latter is, to a certain degree, independent of the phases of respiration. The changes in this air required for the arterialization of the blood take place by diffusion. From the alveoli of the lungs, carbon dioxie finds its way toward the atmospheric air, and oxygen in the opposite direction enters into the alveoli. This exchange of gases is favored, as mentioned by Landois, by the so-called cardio-pneumatic movement — that is, the shaking of the respiratory air with every contraction and every dilatation of the heart and every pulsation of the pulmonary arteries. Landois shows that this cardio-pneumatic movement depends on the sustenance of life during hibernation and during catalepsy.

Ephraim interested himself and extensively tried rectal injections of carbon dioxide gas on patients. He reasoned as follows: The large amount of carbon dioxide gas introduced into the rectum passes through the veins, enters into the alveoli, and from there, obeying the physical law, is diffused in an upward direction, whereby an excess over the normal process of the diffusion of the gases takes place; that is, more than the normal amount of oxygen descends, the ventilation of the air- passages being thus increased. In making this assumption, that the alveoli with this increased afflux of carbon dioxide receive an increased amount of oxygen, he had in view the law, according to which gases interpenetrate other gases without causing pressure or expulsion—a law which in general governs the sustaining of respiration. 

Experiments made by Speck have shown that increased ventilation of the lungs brought on by increased respiratory activity, that is, more profound inspirations, causes a large amount of oxygen to be retained in the body; but only a small part of this extra amount of oxygen enters the blood, by far the greater part, of it entering into the composition of the residual air and enriching it in oxygen. With the increased activity of the respiratory organs the body uses up a larger amount of oxygen than normally, and the small extra amount in the residual air is needed to cover the deficit, whence there is not enough left to add noticeably to the oxygen of the blood. 

Ephraim leaves the correctness of this explanation undisputed but adds that no application of it can be made to the manner of increasing the oxygen under consideration, for, while the conditions bear some resemblance to one another, they differ in essential points. He mentions the experiments of Pflüger on animals upon which tracheotomy had been performed as being more applicable. Here the conditions correspond with those presented by rectal inflation with carbon dioxide. Pflüger found that with tracheal breathing continued for some length of time, the amount of oxygen would increase in the blood. This increase was due to facilitated and augmented lung ventilation taking place after tracheotomy had caused the shortening of the distance between the alveoli of the lungs and the atmospheric air, thereby facilitating the intrabronchial diffusion of gases. 

The increased lung ventilation in animals with the trachea cut open corresponds with the better lung ventilation under consideration, to the extent that the oxygen in both instances is full gain, not being required for increased respiratory activity, but, according to Ephraim, the conditions for the increased influx of oxygen into the blood are still more favorable when carbon dioxide is introduced by way of rectal inflation than in the case of animals with open trachea. Just as the rising of the extra amount of carbon dioxide through the veins causes an increased diffusion of gases within the respiratory passages, so will the gas diffusion between the blood and the alveolar air, which renders exchange of gases possible, be improved. 

The result is not only an increase in the amount of oxygen contained in the alveoli, but also an augmented exchange of gases between it and the blood. The entrance of an extra amount of carbon dioxide through the capillaries into the alveoli brings about increased diffusion, and a larger quantity of oxygen to the blood. The question of whether this increased diffusion is followed by increased absorption, Ephraim thinks he can decidedly answer in the affirmative. 

Summing up, Ephraim’s view is that the carbon dioxide taken up by the digestive tract enters the venous system, is then eliminated by the lungs, and thereby brings on an improvement in the ventilation of the lungs, resulting in an increased accumulation of oxygen in the blood, and that this is the main factor in the curative effects thus far observed. 

Ephraim administered carbon dioxide gas by the rectum, the cases being exclusively those of outdoor patients, and he gave, as a rule, one, and in exceptional cases on account of special circumstances two, sittings daily. He employed the liquefied gas in the following manner: The carbon dioxide gas was taken from an iron balloon in which it was contained in the liquefied form; a double stopcock was attached to regulate exactly the flow of the gas from the balloon in which it was, naturally enough, under high pressure. The carbon dioxide, on escaping from the balloon, at once assumed the gaseous form. From the balloon, it passed first into a bottle filled with water. This contrivance to have the gas pass through water was for the purpose of enabling us to observe and to control the celerity of its escape. From this bottle, it entered into an elastic tube terminating in a nozzle for the rectum. The nozzle having been inserted into the rectum, the stopcock was opened to so limited an extent that he was enabled to count the gas bubbles passing through the water. I have simplified the apparatus he used, or rather reduced the size of the cylinder, so as to make it more convenient.

Fig. 1 – Small Cylinder for Liquefied Carbon Dioxide. Mode of application to nasal cavity.

The patients treated by Ephraim were suffering from anemia, tuberculosis, and asthma. There could have been no objection to more frequent application of the gas than one or two inflations per diem, but for his complicated and cumbersome method. These cases treated and described by him were as mentioned:

1. Anemia. Eleven girls, varying in age from sixteen to twenty years. The circumstances surrounding them were most unfavorable in regard to health. All these patients belonged to the poorer classes. They were obliged to earn their living by working in factories. Their fare was consequently a very poor one. In order to secure the results of the carbon dioxide treatment pure and simple, nothing was altered in regard to their occupation and mode of living while under treatment. The cases selected were all of a severe form of anemia, and, except in one instance, were all of long-standing and had been under treatment, some having been treated by Ephraim himself. 

One of these cases was not benefited by the carbon dioxide, in two cases there was a marked improvement, and in seven a complete cure ensued. An examination of the blood was made in nine out of the eleven cases but was confined to estimating the number of red blood cells, erythrocytes. An unmistakable and in most instances a considerable increase in the number of red blood cells was noted, altho there was no examination made in regard to the amount of hemoglobin. Ephraim thinks that judging from the improved general condition of the patients, there must have been an improvement in this direction. He admits that the improved condition of the patients may to some extent be due to the fact that the administration of gas regulated the stools. 

Even with these favorable results before us, it would not be warrantable to speak of the introduction of carbon dioxide gas as an especially effective means for the treatment of anemia, but it may safely be said that it appears to be an excellent auxiliary in the treatment of this affection. 

The result of the examinations of the blood supports the theory of Ephraim that the healing effect is due to an increased introduction of oxygen into the blood. While I myself was treating a large number of children suffering from whooping cough with carbon dioxide gas inflation of the rectum, I observed that those who were anemically improved markedly in regard to this condition under the treatment. 

2. Asthma. Altogether there were twenty cases treated, ten of which were suffering from true bronchial asthma, five from neurasthenic asthma, three from emphysema of the lungs, associated with bronchitis and asthma, the nature of which could not be exactly defined. All the ten cases suffering from bronchial asthma were relieved from these difficulties for a longer or shorter period of time. The result, which was a surprise, considering that the affection is, as a rule, intractable to all sorts of treatment, induced him to publish the cases in detail. None of the patients was given any medicine, nor was any change in the mode of living ordered. 

I. Flora S, 32 years of age, had suffered for seven or eight years from chronic bronchial asthma and slight shortness of breath. For one year she had attacks of dyspnea, which at first occurred in long intervals, but then became more frequent. During the previous four weeks, she had an asthmatic attack lasting about half an hour every evening, which was accompanied by wheezing and blowing in the chest. During the night the patient slept little and was obliged to sit up in bed. 

Status præsens: Moderate emphysema of the lungs, diffuse and numerous rhonchi (sound from the lungs). In the sputum were a very large number of asthma crystals. The heart was normal. The patient could not go up more than one flight of stairs without resting. Treatment: Every afternoon she received one injection of carbon dioxide gas. After the second injection, there were no more asthmatic attacks. After the fourth, the patient slept through the whole night without waking, and at the same time, the cough began to diminish. After the eighth injection, there were no more asthma crystals found in the sputum. After the eleventh the cough was much diminished, rhonchi had disappeared, the patient climbed three flights of stairs without resting, and the treatment was discontinued. During the next six weeks, the patient remained free from attacks and from shortness of breath, but then the symptoms reappeared. 

II. Josefa S, 37 years of age, had suffered for a year from slight attacks of bronchial asthma, which lately made their appearance at intervals of from two to three days and lasted a few minutes. Percussion sound over the lungs was normal, and within normal boundaries, there were numerous sibilant râles (high sounds). In the sputum, spirals and asthma crystals were in large numbers. After the first inflation came one more attack, but none afterward. At the same time, coughs and expectoration became less and râles were scarcer. The patient now climbs two flights of stairs in succession, while formerly she could not climb more than one without taking a rest. The treatment was discontinued after the eleventh inflation. No further observation was made. 

III. Clara E, 21 years old, for nine years had suffered from coughing, and occasionally dyspnea appeared. In the last few years, the latter came on more frequently and during the last two years almost every night. After August 10, 1889, the attacks were very severe and lasted from one to two hours. During the day there was slight shortness of breath, cough, and abundant expectoration. 

Status præsens: Here we had well-pronounced emphysema of the lungs, diffuse sibilant râles, in the sputum numerous spirals, and a very large number of asthma crystals. Treatment with carbon dioxide gas began on August 15. During the following seventeen days, one injection being given daily, the attacks appeared in undiminished frequency, but their severity was lessened soon after the commencement of treatment. This was noticed by the patient as well as by the mother. The amelioration made progress continually so that after the seventeenth inflation there were no more attacks; the cough was, however, only little improved, and the râles could still be noticed. On the whole, twenty-eight inflations were made and the patient was dismissed. Iodide of potassium with apomorphine was ordered. During the treatment, the patient gained remarkably, probably because her sleep was so much better, that is, undisturbed. After fourteen days the catarrhal symptoms became less (catarrh = inflammation of the airways). During the following three months the patient remained entirely free from attacks, but subsequently, from time to time a slight difficulty in breathing appeared, which has repeated itself often since the middle of April 1890.

From this time on occurred from eight to ten attacks weekly; they were, however, milder than the former ones. On May 2, 1890, the carbon dioxide treatment was resumed. The result was about the same as before. The attacks assumed, even after the first inflation, the character of a passing oppression, and disappeared entirely after the nineteenth inflation. After seven more inflations had been given, the treatment was discontinued. Catarrh as well as shortness of breath were much improved. Climbing of stairs was much easier than before. Five months after the discontinuance of the treatment the attacks had not returned. 

IV. John P, 66 years old, for two years had asthmatic attacks, appearing only during the night and lasting from one to two hours; during a few months they appeared every night, and during the day there was shortness of breath. Very slight emphysema of lungs and few râles were observed. With the beginning of the carbon dioxide treatment the attacks became shorter and lighter, and with the seventeenth inflation ceased entirely. During the following days, once in a while, there was a little oppression, “as if I entered a smoky room,” said the patient. After the twenty-second inflation, even these ceased. After treatment, the patient slept regularly the whole night through. At the same time, his continual shortness of breath was remarkably relieved. After having received the thirty-second inflation the patient was dismissed, being in an essentially better condition. During the next three months, he remained free from attacks, but then they began again, tho in a mild form and at long intervals. 

V. E. H, 62 years old, had a barrel-shaped thorax, considerable emphysema of lungs, and chronic bronchitis. He had had a severe asthmatic attack every evening for from five to six months. After the second inflation, the attacks ceased; under continued treatment, the catarrh improved considerably; patient slept all night long without, as was formerly the case, being disturbed by coughing. He was dismissed after having been given the seventeenth inflation. Four weeks later the patient presented symptoms of insufficiency of the heart, under which he died after a few days. In the meantime, he had had no recurrence of the attacks. 

VI. Elizabeth P, 25 years old, had pronounced sclerosis. She had often suffered from cough; the least exertion, climbing of stairs, etc., brought on dyspnea. For five weeks bronchial catarrh and severe asthmatic attacks occurred every night. These latter ceased after the fifth inflation, and the patient slept every night uninterruptedly until morning from this time on. Eventually, the catarrh disappeared. The patient was dismissed after having had the thirteenth inflation; the bronchi were entirely free. One year later the attacks had not returned. 

VII. Clara W, 14 years of age, had suffered since her eighth year from attacks of difficulty of breathing, which at first appeared at intervals of several months, but for a few years had appeared at intervals of from three to four weeks; they lasted from two to three days and ended with abundant expectoration. The patient came under treatment fourteen days after such an attack. She received twenty-five inflations. During this treatment, the patient had still, once in a while, a slight oppression with cough, but no real attack. Six weeks afterward came a mild attack lasting three hours. Again seven inflations of carbon dioxide gas were made. During this renewed treatment slight oppressions reappeared from time to time when treatment was again discontinued. From this time on the patient had no attack for seven and a half months, when again a spell of the former intensity and of two days’ duration occurred. 

VIII. Anna W, 22 years old, had suffered for one year every night from light and short attacks of difficult breathing. After the second inflation, they ceased. The patient had received only four inflations when for external reasons she did not present herself anymore for treatment. 

IX. Bianca J, 23 years old, had suffered for one and a quarter years from difficulty of breathing, which made itself noticeable during fast walking and climbing of stairs, and was more marked in the evening. For the previous twelve days every evening, an asthmatic attack came on, lasting one or more hours. There was slight emphysema. Auscultation, except during the attack, revealed nothing abnormal. After the second inflation, there were no more attacks; with the seventh inflation, treatment was discontinued. There were, however, symptoms of dry bronchitis, but eight weeks later no new attack had appeared. 

X. Mrs. A, 50 years old, for four years had been subject to asthmatic attacks, which over time happened more and more frequently. During four weeks there had been daily attacks of from three to four hours’ duration, occurring mostly during the night, seldom during the day. 

Status præsens: Emphysema pulmonum with numerous sibilant râles. In the sputum were many spirals and crystals. During the first four days of carbon dioxide treatment, there was little change, but after the fifth day, the attacks disappeared. After two more inflations, the patient declared herself cured and stayed away from treatment. The cough had decidedly improved, râles were considerably reduced, and the patient remained perfectly free from attacks during the following eight weeks; then they reappeared, but less frequently and in a lighter form. 

In the cases enumerated the effect of the carbon dioxide was noticeable after various lengths of time; the chances of cure were better the shorter the time the evil under treatment had existed. But even in the chronic cases subjective and objective improvement was noticeable almost from the commencement of treatment; that is, improvement in regard to either duration or severity or both. Amelioration of the shortness of breath was noted, not only during the attacks but during the intervals; and bodily exertions, such as climbing of stairs, could be executed with greater facility. Simultaneously with the relief of dyspnea and asthmatic difficulty, there was experienced a most beneficial influence on the bronchial catarrh. Only in one case (No. III), no change was noticed during treatment, and in another case, the improvement took place after treatment had been discontinued. 

In all other cases the cough improved, the râles became less or disappeared completely. Especially noteworthy are three cases of emphysema of the lungs, which Ephraim treated with carbon dioxide gas. The history of all three is essentially the same. There were considerable emphysema, chronic bronchial catarrh, cough, and shortness of breath, which, naturally enough, increased under bodily exertion. In all three cases relief was secured after a comparatively small number of inflations (seven, nine, and eleven respectively), the dyspnea improved considerably, the catarrhal symptoms disappeared completely in two cases, and in one almost completely. The volume of the lungs, however, underwent no alteration. 

Résumé: The results of the carbon dioxide gas treatment of asthma are shown in improvement of shortness of breathing and of the bronchial asthmatic attacks, which improvement sometimes lasts for a certain period, while at others it is permanent. 

It is to be mentioned again that in all these cases only a limited number of inflations were given. Ephraim observed in some cases that nightly attacks would be prevented when inflations were made during the afternoon, but would come on when the inflations were given during the forenoon. 

My own experience in treating asthma by means of carbon dioxide gas inflation of the rectum confirms fully all that Ephraim has observed. My patients—outdoor patients of the dispensary—made the inflations themselves by means of my simple gas generator (see Fig. 2 ).

Being enabled to apply the gas at any time, they secured, without exception, as far as I know from reports they gave, freedom from attacks during the night; they enjoyed, sooner or later, complete rest at night, and all were relieved from bronchitis. Two cases I had under observation for about two years and saw lasting benefit in regard to bronchitis and asthma. Both patients made use of the gas with more or fewer interruptions—according to their statement—for many months.

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