CHAPTER V – CARBON DIOXIDE GAS IN THE TREATMENT OF DYSENTERY AND MEMBRANOUS ENTERITIS AND COLIC
Carbon dioxide gas, besides stimulating capillary circulation, has an anesthetizing influence, and this is especially remarkable when the gas is applied to painful ulcers—cancerous, for instance; and it was well made use of in gynecologic practise. There exists a large literature of the first half of the nineteenth century on this subject. On account of these two qualities, the stimulating and the anesthetizing, it is indeed an ideal remedy in old ulcers—irritable as well as indolent ulcers. As an antiseptic, it is of limited value. When antiseptic principles were first established in the treatment of wounds, all wound remedies were tried as to their germicidal powers. In regard to carbon dioxide, we know now that certain bacteria can live and thrive in it almost as well as in atmospheric air, that others develop imperfectly or slowly, and that a third-class grows in it only when the cultures are exposed to breeding temperature. Saprophytes, altho they do not thrive in it, do not perish in carbon dioxide. It does not affect the bacillus of typhoid fever, but it destroys the bacteria of anthrax and cholera. It interested me very much to learn from Dr. Alice Byram Condict, of Bombay, India, one of the matriculates of the New York Post-Graduate Medical School, while I was lecturing on carbon dioxide before the class, that the physicians in India—the home of cholera — insist strictly that people should drink no water except that charged with carbon dioxide.
In an old book, which is perhaps rarely consulted any more, Sobernheim’s “Arzneimittel lehre” —the last edition appeared in 1863—I found that Kuester and Perkin had treated ulcers of the rectum, especially in cases of dysentery, by inflation of the rectum with carbon dioxide gas. In no other books or papers on materia medica published since 1863—and I have consulted all I could find in the New York Academy of Medicine and the Surgeon General’s Library of Washington—have I seen this method mentioned. Theoretic reasoning and a reading of this recommendation of Kuester and Perkin made me apply the gas in dysentery. The first case thus treated by me was published in The Annals of Anatomy and Surgery, December, 1883, and, as it appears to me a specially instructive one, I may be permitted to give it in full as it was published in the said journal.
Mary R, 19½ years of age, born in Ireland, been four months in America; a domestic; fairly developed; and had been enjoying tolerably good health. She began to menstruate at seventeen years of age. Her menses appeared every two, sometimes every three, weeks, lasting from four to six days, and were painful at the beginning. On September 2, 1883, she was taken sick with fever and diarrhea characterized by tenesmus (cramping rectal pain). Was vomiting. The day following the stools contained matter and blood. I saw her first on September 5, and poured into the rectum both large and small quantities of warm water at varying intervals, while the patient occupied a recumbent position. I did this, as I had often found it successful in relieving tenesmus. None of the drugs employed, such as calomel cum opio, oleum ricini cum opio, tannin, bismuth, and plumbum aceticum, had any marked or lasting effect. The patient remained feverish and suffered greatly almost every night from frequent tenesmus, discharging blood and pus, sometimes with fecal matter resembling masses of blue clay. The little relief she obtained was more from ice or iced cloths to the abdomen than from any of the other means employed.
On September 19, Dr. Alfred Bessard anesthetized the patient, and I proceeded to make a thorough examination of the rectum in the way described by Dr. J. Gaillard Thomas. The mucous membrane, as far as it presented itself to view, was swollen, of a dark red color, and studded with deep ulcers, thickly covered with pus. After having cleansed the rectum with water from a Davidson’s syringe, I wrapped a piece of wet cotton around the end of a rod, having dipped the cotton in pure nitric acid, and lightly touched the swollen mucous membranes and all the ulcers in the manner practiced by Dr. Thomas. The first night after this procedure the patient slept well, did not suffer from tenesmus, and felt better in every way; but the night following she was, as she and her friends expressed themselves, ” as bad as ever. ” I then ordered suppositories of iodoform; they brought only temporary relief, and the same was the case with injections of chloral.
Almost from the commencement of her sickness the patient had been coughing. Physical examination showed slight dullness on percussion on the right side, below the axilla, between the third and fifth ribs, and, corresponding with this area, there were crackling sounds on inspiration. The patient being very much reduced by constant fever, restlessness, and pain, and presenting this probably metastatic affection of the lung, her case appeared indeed a desperate one.
In the forenoon of September 27, I inflated the rectum with carbon dioxide gas, and this one application, which caused no discomfort or tenesmus, was at once followed by a change for the better. There was no fever on that evening and very little tenesmus during the night; she slept well and improved, so to say, from hour to hour in every way. There were some matter and blood discharged, but only during the night following the first application; the next morning she had a natural evacuation from the bowels without either matter or blood, and never again discharged either. Tenesmus ceased gradually during the following nights. There was no more straining after October 1. For nearly five days the bowels moved as often as five or six times daily, very little at a time, the stools being in the shape of small, hard balls; and as long as this was the case, I had the carbon dioxide douche applied three times a day. The patient described the effect of such applications as being that of an agreeable sensation, and she asked for it. During the days immediately after the first inflation, tenderness and irritability of the stomach existed, which disappeared promptly after the patient had taken a few powders composed of ten grains each of subcarbonate of bismuth and bicarbonate of soda. The condition of the stomach having been corrected, the appetite improved rapidly. After October 2nd, the patient was able to be out of bed all day. The bowels after October 4th moved regularly and naturally once a day. There was still slight dulness on percussion on the right side and diminished breathing, but no more crackling sounds, and the cough almost ceased.
During the last twenty-two years, I have inflated the rectum with carbon dioxide in all cases of dysentery which have come under my treatment and invariably have noticed the prompt effect on the tenesmus. As a rule, patients have spoken with enthusiasm of the relief they obtained. Dr. R. E. Van Giesen, of Brooklyn, has informed me that he also knows the remedy, that he has made it a practice to inflate the rectum with carbon dioxide gas in cases of dysentery, and that his results have been most gratifying. In simple dysentery, we may use this topical application, dispense with administering medicine per os. Experience with this treatment in amebic dysentery, I have none. I should judge, however, that altho it might not destroy the ameba, it would be of service at least in alleviating the distressing tenesmus.
In July, 1900, I addressed a letter to the Surgeon-General of the United States Army, Washington, suggesting the carbon dioxide gas treatment of dysentery among our soldiers in the Philippines, among whom the death rate from this disease was exceedingly high at that time. In my letter, I stated the experience I had had and the theoretical reasons which prompted me to call attention to the method. I received the following reply:
WAR DEPARTMENT, SURGEON -GENERAL’S OFFICE,
Washington, July 18, 1900.
Dr. A. Rose, 126 East Twenty-ninth Street,
New York City, N. Y.
Sir: I have to acknowledge receipt of your communication of the 16th inst., with enclosures, calling attention to your discovery of a new method of using carbon dioxide gas in the treatment of dysentery, and to state that the matter will receive due consideration. Very respectfully,
Assistant Surgeon -General, U. S. A., Acting Surgeon -General.
Since the receipt of this letter, I have not heard any more from the Surgeon-General’s Office in regard to carbon dioxide gas. I do not wish to find fault with the War Department, except for branding the method as a new discovery of mine. Nothing can be further from my intention than such a claim. It is to be supposed that the War Department was overwhelmed with new discoveries and looked upon them with suspicion. It is simply a revival of an old therapeutic measure, which has, as the facts presented show, unjustly been forgotten.
The physiological effect of carbon dioxide gas inflation of the rectum suggests itself as a most rational remedy in cases of enteritis membranacea and colica mucosa. Both Dr. Robert C. Kemp and I have seen prompt relief from colic as well as from discharges of mucous strips in cases of several years’ standing. There is one case of Dr. Kemp, published in “International Clinic,” vol. iii., 13th series (1903), which is in so far valuable as the patient had been under observation for five years. This case is that of a woman of thirty-five years, who had been passing mucus from the bowels with the characteristic pains for seven years. During the last five years, she had been under observation. Here existed a complication of hyperchlorhydria and gastroptosia. I saw the patient on December 20, 1902. The treatment consisted of abdominal strapping, Illoway’s hyperchlorhydria diet, and inflation of the rectum with carbon dioxide gas. She improved from day to day. From January 2 to January 9, 1903, the day she was dismissed, she had passed no more mucous strips.
My own case, in which the effect of carbon dioxide gas inflation of the rectum could be demonstrated, was that of a lady of thirty-five years, who had been suffering for years from colica mucosa, for the relief of which morphin injection had been resorted to daily for two years. As much as sixteen grains of morphin had sometimes been administered on one single day. She had not been without morphin for more than twelve hours any day. On February 6, 1900, I began with inflation of the rectum with carbon dioxide gas. Since the administration of the gas—and no other treatment was given—the morphin injection was discontinued; patient found instant and permanent relief from the mucous colic and no desire for morphin any more. This lady had been attended for many years by many physicians. I will not enter into the details of this case, but confine myself to the fact that carbon dioxide gas inflation of the rectum brought prompt and permanent relief from mucous colic.
CHAPTER VI – CARBON DIOXIDE GAS IN THE TREATMENT OF WHOOPING COUGH
Since the year 1887 Bergeon has been using carbon dioxide gas in whooping cough. He inflates the rectum with it immediately after the attack, provided three hours have elapsed since the last meal. The child is allowed to eat at once after the inflation, as the digestion is not interfered with. If a fresh coughing spell sets in, the inflation is to be repeated as soon as four hours have elapsed since the one previously made. In very obstinate cases he inflates also during the night. According to Bergeon, even the severest forms require only a week of treatment. Bergeon has published and spoken in medical societies on this subject but has failed to make converts. One day it happened, at a dinner party of medical men, that he was sitting next to Professor Girod, who had been suffering for three months from whooping cough and had tried in vain a number of remedies. Bergeon interested Girod in his method. Girod tried it with excellent result on himself and his children, who were at the same time similarly afflicted.
I forget when and where I first read of the employment of carbon dioxide gas inflation in whooping cough, but I have been employing this method of treatment since May, 1894, and have had an opportunity to order it in quite a number of cases among my patients of St. Luke’s Society of Grace Parish. In all but a few cases, the reports I have received have been that the application of the gas has had an unmistakably good effect. Relief was observed in the first few days, and the patients were often cured entirely within, from eight days to two weeks. As a rule, the children coughed less frequently after the first application, and after four or five days’ treatment, they ceased coughing during the night, while in the day they would cough only after they had been running or had taken similar exercise. I attended a family in which the mother had two children suffering from pertussis while they sojourned at a fashionable seashore hotel. In the family, also, the mother’s sister, who remained in New York and had only occasionally visited her sister and the children at the seashore, became affected and was subjected to the carbon dioxide treatment as soon as I had made the diagnosis. In all these cases the result was most gratifying. I do not lay down rules, as Bergeon does, as to the frequency and the time of application. I only direct that the inflation be made at least two or three times a day. I have found that the result is better and more prompt the more frequent the inflations. In two out of about forty cases of children treated for St. Luke’s Association, the mothers had reported that there was no improvement. It is noteworthy that in both these cases the treatment with carbon dioxide was successful in children of the same families.
The following well-observed cases of pertussis treated by carbon dioxide inflation furnish conclusive evidence of the efficacy of this method of treatment in some instances:
Mr. D, a lawyer, had a wife and four children. He occupied four rooms on a second floor. His children were: Emily, aged seven years; Helen, aged five years and nine months; Agnes, aged four years; and Philip, aged two years. The three little girls slept in one room, which was well ventilated; the window was kept open all day long, even during cold weather. The three little girls were taken sick with whooping cough, while the youngest, the little boy, remained free from this disease.
Helen D, who goes to school, began to cough and sneeze on November 11 and grew worse daily. It was not until the 17th that she remained at home from school. summoned to see her on November 18. On the 17th she had had nine convulsive attacks during the day and twelve during the night from the 17th to the 18th of November. The face had the characteristic edematous swelling. On November 18 the carbon dioxide gas inflations of the rectum were done three times. The attacks on that day were much milder in character and only four in number; there were also only four mild coughing spells during the night from the 18th to the 19th. In this case, there was no epistaxis. The coughing spells assumed a milder and milder character under the carbon dioxide treatment until November 28, when the inflations were discontinued. During the days from November 28 to December 4, while no gas was given, the spells became more violent and were more frequent again, until they were equal in both respects to those which had been observed shortly before the gas was applied. Gas inflations were begun again on December 5, and were continued up to December 8. Again a most remarkable beneficial effect was noticed, gradual amelioration of the character of the attacks, and lessened frequency From December 8 to December 9 the child coughed only twice. During the night from December 10 to December 11 there was no cough at all. During the day, December it, she coughed three or four times, but very slightly.
Emily D, 7 years old, had slight cough and sneezing from November 18 to November 25. She stayed at home from school on the 25th, and had the inflations made from that day until December 4, like her sister, three times a day. The convulsive attacks were severer in this case and brought on epistaxis; the frequency, however, was less. She coughed four times during the day and six times during the night before the gas was administered. The first day on which the gas was given she coughed only once during the night and twice during the day. There was edema of the face also in this case. During the days on which the gas was not used the attacks reappeared with their former severity, but assumed at once a lighter character and were less frequent under renewed treatment. No more gas was administered on December 10. There was no cough at all on December 11.
Agnes D, 4 years old, began to cough simultaneously with Emily—i.e., on November 18. Treatment with carbon dioxide was begun on November 25. In this case the convulsive attacks were the severest, the most violent, the edematous swelling of the face more marked than in the two other cases. After the application of the gas the attacks were reduced in number from twelve to six during the day and from nine to four during the night. Epistaxis ceased after the first day’s treatment with gas. While the cough was less frequent, it was also less violent. This child was of a much more nervous disposition than either Emily or Helen.
Philip, the little boy, had only a light cough without any symptoms characteristic of pertussis. No treatment was given.
During the time of treatment the weather had been most unfavorable, so much so that the children had to remain in the house all the time; even as late as December 13 none of them had been outdoors.
In all these cases the appetite improved with the improvement of the symptoms of the affection.
After December 10 no more gas was applied. All the children were then doing well; they coughed once or twice a day, but only slightly.
In the spring of 1897 Dr. Joseph O’Dwyer gave the carbon dioxide treatment for whooping cough a trial in the New York Foundling Asylum. The result was published by Dr. Joseph O’Dwyer and Dr. Reed D. Norton in their treatise on whooping cough, which appeared in the fourteenth volume of the “Twentieth Century Practise.” During 1897 at this asylum one hundred and fifty cases of pertussis were treated by carbon dioxide inflation. Of the whole number, one hundred and forty three showed very marked benefit. The vomiting ceased even in the severest cases by the second or third day, the whoop disappeared, and the number of paroxysms was reduced to two or three daily. The seven remaining cases were apparently not benefited, one of the seven being well advanced in the disease before this treatment was instituted. The duration of the disease, so far as could be determined, was not influenced. Not the slightest ill effect of the treatment was observed. During the administration of the gas the faces flushed decidedly, and this effect lasted some fifteen minutes. The gas was given to the children three times daily, some two or three hours after meals. In infants the treatment lasted five minutes each time; in the “ runabouts,” ten minutes.
During the following year I treated a large number of children afflicted with whooping cough in the New York Foundling Asylum, but I have to confess that there could not be noted any effect either on the duration or on the severity of the disease in the cases treated by me. I had not witnessed the mode of application under Dr. Dwyer’s direction—I was absent from the city during the time—but I learned that the patients had been turned on their faces while the gas was administered. This fact accounts for the flushing of the face, of which the report speaks.
On the whole, I have found that, while the carbon dioxide gas inflation of the rectum will be of most marked benefit in some cases, it will have no effect in others.
Dr. N. R. Norton reported two series of cases of whooping cough occurring in two different years treated by rectal injections of carbon dioxide gas. Out of one hundred and fifty patients, one hundred and forty-three were benefited to a very noticeable extent. After the injections, vomiting ceased and the paroxysms of coughing were less frequent and less severe. The seven cases that were not benefited were of weakling children in advanced stages of the disease. The carbon dioxide was obtained from a mixture of bicarbonate of soda and crystals of tartaric acid. By this method, the gas is given off sufficiently slowly, so that its administration may be kept up continuously for the necessary length of time. In infants the injections were given for five minutes at a time; in older children for ten minutes. The administration of the carbon dioxide gas was followed by flushing of the skin, especially of the face. In a few of the patients mild diarrhea developed. This seemed to be produced by the irritation of the rectal tube. It ceased after a day or two when the injections were discontinued, and they could usually be resumed a day or two later without necessarily causing diarrhea. As children suffering from whooping cough frequently have diarrhea, it is doubtful whether the carbon dioxide or the method of administering it was the cause of the frequency of stools.
CHAPTER VII – CARBON DIOXIDE GAS IN IMPOTENCE AND IN SOME GYNECOLOGICAL AFFECTIONS
As we have seen, the first noticeable effect of carbon dioxide baths is a peculiar sensation of warmth and reddening of the skin. This effect is most marked on the inner surface of the thighs, the perineum, the scrotum, the labia, and on all parts which are especially well supplied with sensory nerves. As a rule, there is an increased desire to micturate, and afterward, the amount of urine voided is unusually large. The physiological effect, therefore, consists of congestion in the vascular system and irritation of the peripheral nerve- ends.
It has already been mentioned that carbon dioxide baths have been recommended in affections of the nervous system in general, as, for instance, hypochondria, hysteria, neuralgia, peripheral paralyses, and, in combination with gymnastics, in disorders of circulation. The rational application of carbon dioxide gas baths or douches can be of service in the treatment of some forms of impotence and in many gynecological affections.
Investigations have proved that the effect of carbon dioxide water baths does not essentially differ from that of carbon dioxide gas baths. The blood pressure is increased as well by the dry carbon dioxide gas bath as by the carbon dioxide water bath. In some cases, moreover, as much or more service may be rendered by the simple gas douche of carbon dioxide gas as with either water or gas bath.
Physicians in watering places are aware that men who are easily excited are apt to have erections during their stay in the carbon dioxide water bath, and that in many the libido becomes markedly stronger under treatment by such baths. It is the peripheral irritation near the sexual organs which increases sexual sensation. This effect may be noted when the rectum is inflated with carbon dioxide gas, evidently due to the innervation, discovered by Fellner, of the rectum by branches of the nervi erigentes.
It is self-evident that those forms of impotence which depend on malformation, congenital defects, diseases like diabetes, nephritis, cerebral lues, tabes, and other spinal diseases, and atrophy of the testicles are not amenable to treatment by carbon dioxide gas. Carbon dioxide gas may, however, be of service in neurasthenia sexualis, in nervous impotence caused by diminished utilization of the capability of the spinal center, or by disorders of their reflex conduits. It is a remedy also in cases which present a reduction of activity of the cerebral center of erethism in general, in forms in which we intend to create an excitement by means of peripheral irritation.
In cases of spermatorrhea, pollutiones diurnæ, ejaculatio præcox, in which the nervous weakness depends on morbid irritability of the spinal apparatus for ejaculation, carbon dioxide gas is not to be resorted to; in such cases hydrotherapeutics and electricity are more suitable measures because our object here must be to reduce the irritability and to improve the power of resistance. It may, however, happen that after the last-named remedies have done their work, carbon dioxide will be indicated. An exceptionally favorable field presents itself in impotentia senilis præcox.
In the female conditions of oppression, of atonia, or of torpor of the sexual organs, relief may be afforded by means of carbon dioxide gas douche, and sterility depending on anaphrodisia may be cured.
Continued use of the gas baths may produce metrorrhagia or even menstruation in cases of amenorrhea. Fellner observed menstruation occurring in isolated cases after a single gas bath.
It has been said that modern gynecology did not pay sufficient attention to the influence of the nervous system on diseases of women—that the effect of uterine diseases on the nervous system was made almost exclusively the subject of observation. We know of uterine dyspepsia, that is, gastric trouble brought on by uterine affections, and we can explain this reflex relation of the two organs since both are supplied with sympathetic fibers. The same is the case with uterine cough, a reflex symptom manifested in the organs of respiration. We know that the symptoms will disappear as soon as the corresponding uterine affections have been relieved. Most important are manifestations of sexual disorders in the nerve center or the peripheral nervous system, neuralgias, and neuroses dependent on uterine disease. In these cases, the pathogenesis of the reflex symptoms is easily explained, on account of the abundant innervation of the generative organs and their connection with the sympathetic through the plexus hypogastricus and also with the spinal nerves through the internal pudic nerves. These neuralgias are of frequent occurrence. Intercostal neuralgia is a common complaint, so much so that Bassereau said that there was almost always a metritis at the bottom of it. Facial neuralgia, infrequently lumboabdominal neuralgia with extension into the ramus femorocutaneus, mostly on the left side, may likewise be connected with uterine trouble. Simpson and Scanzoni mention in this direction also neuralgia of the serratus and coccygo dynia. Some cases of tachycardia may belong in this chapter, and, finally, all disorders of the nervous system collected under the name of hysterics.
In regard to the relation of the nervous system to gynecological affections, the following is to be considered: There can be no doubt that, as a rule, a much stronger irritation is required to excite sexual desire in woman than in man, and to bring on during coitus that orgasm with the sensation of ejaculation which gives the feeling of satisfaction. If this satisfaction is wanting, there will develop, in the course of time, a nervous condition which in some instances culminates into an invincible aversion to the approaches of the husband. Many physicians may be able to illustrate this painful example in this chapter. This aversion, sometimes associated with colpospasmus (sexual intercourse pain, barbarously called vaginismus), amenorrhea, and other anomalies of menstruation, many hysterical symptoms, reduction in flesh or the gaining of too much, are some of the manifestations of its nervous influence. When we have to deal with such conditions and find on gynecological examination no evident pathological condition, then carbon dioxide gas applications are highly to be recommended in order to improve the sexual sensation in woman, to aid menstruation, and to exert a beneficial influence on sexual neuralgias and neuroses.
Piéry, of Lyons, succeeded, in six out of seven cases of vaginal blennorrhea associated with colpospasmus, in obtaining complete relief by the application of carbon dioxide gas in a nascent form. This mode of treatment is correct in principle, but unnecessarily complicated in execution. Seven parts of bicarbonate of soda and six parts of tartaric acid rolled up in a piece of gauze are to be placed in the vagina, when the development of the gas takes place under the influence of the vaginal secretion.
In all cases of colpospasmus in recently married women who came under my treatment, I succeeded in giving relief by means of carbon dioxide gas douches in the vagina.
There can be no doubt that carbon dioxide gas baths or douches are effective in certain forms of menstrual disorders, as, for instance, dysmenorrhea, oligomenorrhea, and amenorrhea; also in cases of so-called frigidity and sterility depending on such frigidity. They may serve in case of chronic metritis with erosion at the vaginal portion. The direct effect of carbon dioxide on the uterus is manifested by intenser reddening of the portio vaginalis and a marked increase of secretion. After repeated application of the gas douche, the menses will appear in some cases somewhat earlier and in most instances more copious than is customary. In the systematic application of the gas douche we possess a very effective emmenagogue, which will prove beneficial in the cases mentioned. First of all, those cases will be amenable to this treatment in which there exists no anatomical change of the sexual organs and in which the ailment can be traced to disturbance of innervation or disorders of metabolism. The good results of carbon dioxide treatment in oligomenorrhea or amenorrhea of fat women are well known. But even in cases of endometritis with oligomenorrhea or amenorrhea, carbon dioxide douches may accomplish a cure after other methods of treatment have failed, and in such cases—that is, after other methods have been tried in vain—we should never omit to give carbon dioxide gas douches a trial.
An ingenious apparatus, devised by Mr. Thomas Warker of New York, for the purpose of imitating the douche of the Krähnchen spring at Ems, is described in the Medical Record, December 18, 1875. The spring in question, as well as one of similar composition at Plom bières, in the east of France, has long been noted for the value of its waters in the treatment of sterility and chronic uterine diseases. The mode of application of these waters at Ems is quite primitive, and consists simply of a bathtub, with a perforated bottom, through which the douche is conducted by means of a pipe. The patient sits in a straddling position when the douche finds its way into the vagina. The spring itself, being somewhat higher than the bath in question, supplies the force to the vaginal jet by means of hydrostatic pressure. Mr. Warker, in his apparatus, has very successfully fulfilled all the conditions necessary to insure the desired results of a local application of water of the Ems spring.
This water itself is made artificially and is contained in a glass fountain charged with carbon dioxide gas. To this receiver (as will be seen in the cut) a pipe is connected which passes through a water-bath and thence to the bath above, across which the patient sits. The amount and force of the jet is regulated by a valve in the receiver, while the alcohol lamp underneath the water-bath raises the temperature to the desired degree. The surplus water escapes in a vessel provided for the purpose. The extremity of the jet pipe is supplied with different kinds of nozzles to suit the different requirements of the volume and character of the stream. Theodore A. Demmé, of Philadelphia, describes a case of puerperal eclampsia in which the rigid and unyielding os dilated under the influence of the carbon dioxide gas douche, and other cases in which such douches relieved painful labor and seemed to aid the dilatation of the os. The following is his report, published in The Medical and Surgical Reporter, Philadelphia, February 18, 1871, entitled “On the Induction of Local Anesthesia in Labor by the Use of Carbon Dioxide Gas “:
CASE I. In December of last year, I received an urgent call to wait upon a lady who, it was stated, was in labor and had been in convulsions for several hours. Upon arriving at the house I was informed by the midwife having the patient in charge that she had been in labor over twenty hours; the bag of waters had ruptured almost at the commencement of labor, and, altho the pains were frequent and excessively severe, the mouth of the womb had scarcely dilated any during the last ten hours, and that she was about to request the attendance of a physician when convulsions dame on. I recognized at a glance that I had before me a terrible case of eclampsia or puerperal convulsions. The patient was lying in a totally unconscious condition, and at short intervals would be seized by a spasm, convulsing every muscle of the body, jerking violently the head to one side, and at the same time bending the body backward as if the head and heels were to approach one another; the features were distorted, the throat and face tumid and purple, and the eyes rolled up in the orbits-it seemed as if they would start from their sockets. Upon examination I found the os uteri dilated to about the size of a half-dollar piece, and extremely hard and rigid. This rigidity continued not only during the pain but in the intervals; there was, in fact, a constant spasmodic rigidity. The commencement of pain and the onset of a convulsion were almost simultaneous, it appears as if the pressure of the child’s head upon the irritable and sensitive os was the direct cause of the eclampsia.
The indication was undoubtedly to dilate the os and deliver, but every attempt at forcible dilatation aggravated the symptoms, and I, therefore, bled the patient freely from the arm, in the hope of promoting the relaxation of the spasmodically contracted muscles; but, altho I controlled the arterial circulation and reduced the volume and frequency of the pulse, I found that even excessive bloodletting had no effect upon the rigid os. The idea then flashed upon my mind of using the carbon dioxide gas. After a delay of fifteen minutes consumed in procuring the apparatus, I applied the gas to the uterus. When the douche had been continued for about five minutes, it was evident that some change had been produced, for the patient remained quiet and no convulsive movement took place. A few minutes more, and the anxious family, startled by the great change that had occurred in the behavior of the patient, imagined that she was dying, and only the regular beating of the pulse assured me that such was not the case. Fifteen minutes after the application of the gas there was a slight tremor of the body when I again carried the gas-tube into the vagina, and in so doing examined the womb, and to my astonishment and great satisfaction found the os not only no longer rigid but fully dilated, and the head about passing the superior strait. I immediately applied the forceps and delivered. The patient, after remaining unconscious for several hours, suddenly awoke as if from asleep and asked for a glass of water. Convalescence proceeded favorably.
In this case, we had a revelation of the power of carbon dioxide gas as an anesthetic agent over an extremely sensitive and irritable os uteri, controlling rigidity without any apparent interference with the contractile or expulsive efforts of the uterus.
CASE II. January 3, 1871, Mrs. D, primipara. When called to the patient, labor had been in progress for about two hours. The pains were excessively severe and frequent. The patient was nervous and extremely irritable, allowing neither herself nor those surrounding her any rest. Per vaginam examination gave little hope of speedy termination. The os uteri was dilated about one-half, the edges dry, hot- and cold-like. After waiting thirty minutes and perceiving little or no progress, I determined to use the carbon dioxide douche. The patient, having been assured that she would receive relief, offered no opposition to the application. After the gas had been allowed to act upon the mucous membranes for five minutes, the entire demeanor of the patient was changed. The demonstrations of suffering, impatience, and irritability were succeeded by a calm so complete that it seemed as if the labor had been suddenly arrested. The douche was repeated in ten minutes, and the observation made that, while the patient asserted that she felt no pain, the bag of waters was pressing firmly upon the now rapidly yielding os. In exactly fifteen minutes from the termination of the first douche, the dilatation being almost complete, I ruptured the bag of water and almost immediately perceived the head entering the pelvis. Five minutes after the escape of the waters the third application of the gas was made. The head had now entered the pelvic cavity and was pressing upon the perineum. The patient at this time, in answer to the questions, stated “that she felt no pain, “did not feel the head at all. “In fact, she did not believe she was to have a child. Very shortly after, however, the relief from suffering ceased and the passage of the inferior strait was accomplished with all the usual symptoms of pain. The further progress of the case presented no particular features.
CASE III. January 4, 1871, Mrs. D, aged 37; second confinement, thirteen years elapsing since the birth of the first child. When engaged to attend this lady I anticipated a difficult labor, in consequence of the great length of time that had passed since the birth of the first child. Such was, however, not the case. Being called to the patient at 9 A.M., I was enabled to leave the house at 11:15 A.M., the mother lying comfortably in bed and the nurse dressing the newborn babe.
In this case, I made four applications of the gas, at ten-minute intervals, during the first (or dilating) stage of the labor, with the effect of greatly ameliorating but not entirely relieving the sufferings, the patient complaining from the very commencement of labor of pain in the back and of cramps in the limbs.
CASE IV. January 21, 1871, Mrs. E, primipara. The gas douche applied every ten minutes, with the effect of relieving the pain in so marked a manner that it was with difficulty that I could convince the mother and nurse that I had not stopped the labor. Indeed, it was only when the sufferings became intensified, as the head pressed on the perineum, that they again had faith. In this case, the gas injection was applied four times, at intervals of ten minutes.
Dr. Demmé, in conclusion, says: “I would urge upon my medical brethren to give this agent a fair trial and to report their experience The number of cases in which I have used the gas is too limited to form a proper estimate of its value. Nevertheless, in cases of rigid, unyielding, irritable os uteri, I regard it as a boon, relieving the suffering and expediting the labor.”
The paper of Demmé in which these cases are given has been referred to in several of my publications on carbon dioxide treatment. I mentioned Demmé’s discovery before the Obstetrical Section of the New York Academy of Medicine, on the occasion when I reported a case of my own in which I had succeeded in producing anesthesia during labor by means of the carbon dioxide gas douche; but it seems, indeed, that a method discovered by an American physician has to be discovered by, or at least ascribed to, some European physician before the profession here will take the pains to notice it or give it a trial.
As far as my knowledge goes, Demmé was the first who wrote on this method of anesthesia in labor, and I have not seen a single notice in any journal of his paper; certain it is that it is not mentioned in any of the textbooks on obstetrics that I have examined.
When we ask why this apparently very valuable aid to suffering women has not been generally adopted in midwifery, we can find no other answer than that it was a certain fear which even Demmé helped to create when he said: “There are certain precautions to be observed in applying this agent. It must be remembered that one of the most powerful sedatives is being experimentally tried, and the condition of the mother must be carefully watched. The pulse and respiration should be frequently examined, and particular care given to furnish a free supply of air to the respiratory organs. The head of the patient somewhat elevated upon pillows, etc.” Fortunately, all these anxieties are superfluous since we have studied the physiological action of the carbon dioxide gas douche on the system.
But there exists another fear in regard to the application of the carbon dioxide gas douche, which has perhaps prevented its more general adoption in gynecological practice, but which fear is without foundation. This error has been spoken of already in the chapter on the history of carbon dioxide gas treatment. I will shortly recapitulate: Scanzoni, in the year 1857, recommended the carbon dioxide gas douche as a means of inducing premature birth. This recommendation, forming the title of a paper of Scanzoni, has been quoted since then without any commentary in all the writings on the therapeutic application of carbon dioxide gas. Whoever takes pains to peruse Scanzoni’s article will become convinced that carbon dioxide gas is perhaps the most unsuitable and ineffective means ever tried for the purpose in question. Scanzoni had the erroneous idea, and insisted upon it, that the carbon dioxide gas douche to the uterus would cause contractions of that organ. Even the demonstration of the prominent gynecologists, Simpson, Hohl, Guitar, and Carl Braun, to the contrary, did not move him. Gustav Braun tried to bring on premature delivery in a case of a deformed pelvis. For this purpose, he directed the carbon dioxide gas douche to the uterus and had such applications continued daily for thirteen days in succession. We may judge what an immense amount of gas he injected during these thirteen days when we learn that it took forty ounces of concentrated hydrochloric acid and a corresponding amount of marble to develop the gas for injection. A Woulfe’s bottle was used. Finally, a colpeurynter had to be placed into the vagina, the patient had to be brought into a sitz-bath, and, in addition to all this, was severely injured by accident with the hydrochloric acid. Gangrene of the labia, the vagina, and the cervix uteri was the consequence, and the patient finally died from peritonitis. Gustav Braun complains to Scanzoni that the procedure was too expensive, whereupon Scanzoni replies that he had successfully attained the end in twenty sittings and that only one florin and fifty kreutzer (about sixty cents) were spent by him for chalk and hydrochloric acid in such a case.
Carl Braun tried to induce premature delivery by means of carbon dioxide gas douches in one case. He had ten sittings, each of half an hour’s duration, but, as the case required quick action, he finally introduced an oiled elastic catheter into the uterine cavity. His opinion was that this gas douche was much more unreliable than the plain water douche and the colpeurynter and the introduction of the elastic catheter into the uterine cavity, and that it was the most expensive method, which alone would interfere with its being generally adopted. Hohl says that carbon dioxide gas introduced into the vagina would be as little apt to cause contractions of the uterus as if it were applied to the abdominal wall. All this demonstration of plain and indisputable facts only excited Scanzoni to violent polemics. Scanzoni himself is dead, but his error haunts us yet.
Early in the year 1884, I was called to a neighboring city as consulting physician in a case of incessant vomiting in pregnancy. All the usual remedies had been employed in vain. I for the first time suggested the introduction of carbon dioxide gas into the vagina and exhibited my simple apparatus. My idea was to make use of the anesthetizing effect of the gas on the womb, especially on the os. I assumed that the vomiting in this case might be a reflex action, originating in neurosis of the uterus. My suggestion was not accepted. It happened that my colleague had in mind the title of Scanzoni’s paper above mentioned, and feared contractions of the uterus and abortion.
A well-known German gynecologist, Adrian Schücking, arrived at the same conclusions as myself in 1885. It is possible that the curative effect of carbon dioxide gas in vomitus gravidarum has been known before Schücking and myself made use of it, but no reference of this kind is found in Schücking’s paper, nor have I found it mentioned in literature. He published in the Centralblatt für Gynäkologie an article, entitled “Zur Therapie des Vomitus gravidarum,” in which he describes a case of incessant vomiting of pregnancy and in which, other measures having failed, he irrigated the rectum with the carbonated water from the Pyrmont Spring. This water is highly charged with the gas. After the first application of this water, vomiting ceased. In the same paper he recounts a case of incessant vomiting in a girl with an ovarian tumor, in which, as in the preceding one, the vomiting was controlled by irrigation of the rectum with carbon dioxide water.
I have confined myself to inflation of the rectum with gas and have never applied the gaseous water in cases of vomiting of pregnancy. The results have been invariably gratifying. I have not met with another case of so-called incessant vomiting. Perhaps by applying the carbon dioxide early graver symptoms have been prevented in one other case I attended.