A few Clinical Cases showing the 
value of Oxygen combined with 
Nitrogen Monoxide in the treat- 
ment of Pulmonary and other 
troubles. 
BY 
K. C. TITUS, M. U., 
NEW YORK. 
REPRINTED FROM 
©he 
October 5, 1889. A FEW CLINICAL CASES SHOWING THE 
VALUE OF OXYGEN COMBINED WITH NI- 
TROGEN MONOXIDE IN THE TREATMENT 
OF PULMONARY AND OTHER TROUBLES. 
By E. C. TITUS, M. D., 
NEW YORK. 
In The Medical Record of July 6th there appeared 
a very able article by Professor W. Gilman Thompson, 
showing a series of experiments with oxygen upon ani- 
mals, and the conclusions arrived at as a result of those 
experiments. The conclusions were in the main such as 
I have demonstrated repeatedly by clinical experience. 
In the treatment of pulmonary complaints the tendency 
at the present time is toward local medication. This 
arises principally from the general acceptation of the 
germ theory, which teaches in the main that diseases 
originate from micro-organisms, and the belief that from 
this it must follow, as a necessity, that these micro-organ- 
isms must be destroyed or rendered harmless to organized 
tissues, either as a means of cure, or as a prophylaxis to 
such a disease. For these reasons attention has been di- 
rected more particularly to the study of means whereby 
antiseptics or germicides may be made to reach disease- 
germs in the lungs more directly and safely than has 
hitherto been known. 
If tuberculosis depend upon the presence of infectious 
organisms in the tissues, then certainly the most rational 
mode of treatment in phthisis must include the adminis- 
tration of antiseptic agents. The most powerful anti- 
septic known to science is oxygen, for in an atmosphere 
of oxygen it is impossible for disease-germs to exist. 
It has been found by clinical experience that oxygen 
is less irritating and more readily absorbed when com- 4 
bined with a certain equivalent of nitrogen monoxide. 
The proportions that I have found most valuable are two 
parts pure oxygen and one part nitrogen monoxide. In 
order to obtain good results, it is of the utmost import- 
ance that these gases should be absolutely pure and prop- 
erly combined.* Pure oxygen I believe to be too power- 
ful an oxidizing agent when used alone ; especially when 
there exists inflammation in the air-passages. In cases of 
poisoning from hydrogen gas, however, it is better to use 
it undiluted. Nitrogen monoxide is valuable as a modi- 
fier of pure oxygen, and has a soothing effect upon the 
nervous system. It renders the oxygen with which it 
mingles more assimilable, and hence more promptly 
available in the general system. The discussion at the 
New York Academy of Medicine, following the reading 
of Professor Thompson's paper, was interesting in show- 
ing how generally this agent is now being used by the 
most advanced men in the profession. Its usefulness as 
a therapeutical agent may be shown by quoting the 
remarks of those gentlemen who engaged in the dis- 
cussion. Dr. J. West Roosevelt said that in the simple 
anaemia of girls he found patients do better under the use 
of oxygen in connection with administration of iron than 
under iron alone. That opinion was shared by Dr. Fran- 
cis Delafield, expressed some months ago at the Academy. 
Like Dr. Thompson, he had seen marked beneficial re- 
sults where the amount of breathing service was dimin- 
ished. Dr. George L. Peabody was of the opinion that 
oxygen inhalations were most useful in certain maladies 
attended by extreme dyspnoea, such as catarrhal bron- 
chitis, asthma, pleuritic effusions, etc. Dr. Beverly 
Robinson thought he had seen absolute proof of the di- 
rect, immediate therapeutic action of the inhalation of 
oxygen in anaemia, in conjunction with iron, and in a very 
large number of cases digestion and assimilation were 
* The agent that I have found to be the purest and the one that has given me 
the greatest satisfaction is that manufactured by the Walton Oxygen Works, 
380 Fourth Avenue, New York. 5 
improved, and in so far as it did that, it seemed to have a 
wide field of utility. In phthisis he believed it had no 
direct curative effect, but he thought it proper to use it, 
because, first, it forced patients to expand their lungs ; 
second, because there was reason to believe it might act 
in some degree as an antiseptic ; third, that it was useful 
in improving the nutrition. In cases of phthisis with 
partial consolidation, fever, night-sweats, and cough, 
the administration of oxygen will be followed by a decline 
of the daily temperature, subsidence of the night-sweats, 
improvement of appetite, and more perfect digestion and 
assimilation ; patients are taught to breathe more per- 
fectly, which is invariably followed by increased lung ex- 
pansion. The method of administration is important. 
The patient should be instructed to expel as completely 
as possible the air from the lungs, and then inhale deeply, 
and after fully inflating the lungs it should be held as long 
as is comfortable before being expired through the nose ; 
there should be an interval of two minutes between each 
inhalation ; this method is applicable to the treatment of 
phthisis and anaemia. In pneumonia it should be ad- 
ministered continuously from three to five minutes, and 
as frequently as the urgency of the case demands. 
I quote a few cases taken at random from my note- 
book, which will suffice to show the general action of 
this agent. 
Case I.-A gentleman, aged thirty, an actor by profes- 
sion, slight in stature, family history negative, was obliged 
to remain most of the time in the Northwest, because of 
pulmonary trouble. Whenever he returned to his home 
in the East his trouble was invariably aggravated. A 
physical examination revealed the following condition : 
Consolidation of the left apex anteriorly as far down as 
the nipple line ; also evidence of small cavity in the upper 
part, and moist rales throughout the lung; incessant 
cough, profuse expectoration of muco-purulent character, 
daily abnormal temperature, with profuse night-sweats 
and rapid emaciation. Began inhalations of oxygen 6 
for from fifteen to twenty minutes twice daily. At 
the end of one week the night-sweats had materially 
diminished, cough less severe, and general condition much 
improved. At the end of six weeks' treatment he had 
improved considerably in general condition and weight. 
An examination of the lungs showed that the induration 
had very much decreased, no evidence of cavity, and al- 
most an entire absence of rales. Physical examination at 
the end of ten weeks showed that the consolidation had 
entirely disappeared, no vestige of the former trouble re- 
maining, and he was apparently a well man. No return 
of his former symptoms have developed up to date, which 
is now more than a year ; the only treatment he received, 
other than the inhalations, was the iodide of iron. 
Case II.-A gentleman, aged thirty-two, by occupation 
a civil engineer, of phthisical family ; five years ago had 
an attack of pleurisy with effusion, which left a carnified 
condition of the upper part of the right lung. Three 
years later began to lose flesh ; a cough from which he 
had never entirely recovered became worse, accompanied 
by profuse expectoration, rapid loss of flesh ; daily tem- 
perature reaching as high in the afternoon as 103° F., 
followed at night by profuse sweating. Patient was ad- 
vised to go to Colorado ; after remaining there some 
months, without improving, he returned to New York 
thoroughly disheartened, having given up all hope of ever 
getting well. Placed him upon inhalations of oxygen and 
nitrogen monoxide, as in the former case. Its use was 
marked by an increase of the expectoration for the first 
week, after which time it gradually decreased ; the appe- 
tite, which was entirely gone, improved rapidly ; the 
afternoon fever and night-sweats disappeared at the end 
of the fifth week, with gradual improvement in the gen- 
eral health, and slight gain in weight. The breathing at 
the commencement of treatment, which under forced 
inspiration was very limited, painful, and accompanied by 
a disposition to cough, gave place to easier and painless 
respiration. Patient has been under constant treatment 7 
since November, 1888. The last two months he has been 
able to attend to his business daily, and has exposed him- 
self repeatedly to inclement weather without any return 
of his former symptoms. A slight cough remains, which, 
I believe, is due to the presence of pleuritic adhesions. 
One thing further I would mention, the chest expansion 
under forced inspiration was increased from one and a 
half to three and a half inches. 
Case III.-Young lady, aged twenty-three, suffering 
from an extreme form of simple anaemia, which had re- 
sisted a thorough employment of the usual remedies, 
combined with good food and plenty of fresh air ; was 
consulted because of amenorrhoea, loss of appetite, feeble 
digestion, and irregular action of the bowels ; could not 
take proper exercise without marked dyspnoea. A 
thorough examination excluded all organic causes. Hav- 
ing tried iron, arsenic, and strychnine with but slight and 
only temporary improvement, I concluded to employ in- 
halations of oxygen in conjunction with the above-men- 
tioned remedies. To my satisfaction, and to the patient's 
great delight, improvement began almost immediately in 
the appetite, digestion, and assimilation ; the pallor of 
the face gradually gave place to a healthful rosy com- 
plexion, with disappearance of the dyspncea, and at the 
end of three months' treatment the menses were perfectly 
re-established. 
In the treatment of pneumonia I have used the com- 
bination of oxygen and nitrogen monoxide with marked 
benefit. It quiets the action of the heart, greatly relieves 
the dyspnoea, enabling the patient to breathe more freely 
and deeply, and promotes free expectoration. The fol- 
lowing case, taken from a number so treated, and cited 
because of its extreme form, will suffice to demonstrate 
the beneficial effects of this mode of treatment. 
A gentleman, aged sixty-three, of robust habit, was 
taken ill with double pneumonia. Recognizing the case 
to be of extreme gravity, because of the rapid respiration 
and the early development of delirium, with a rapid, 8 
feeble, and irregular pulse, I immediately began the use 
of oxygen and nitrogen monoxide, with stimulants, and 
other remedies. At first the inhalations were given very 
frequently, as often as every fifteen or twenty minutes, 
and for a period of from three to five minutes at a time. 
After using a few times, the patient became more quiet, 
the breathing easier and less rapid, with clearing up of 
the cyanosis, abatement of the delirium, and free 
expectoration. The remedies were continued through the 
night. The following forenoon patient expressed himself 
better, and very much 'relieved by the inhalations. The in- 
halations were continued through the course of the disease, 
at either longer or shorter intervals, as the exigencies of 
the case demanded, and was always followed by an ameli- 
oration of the urgent symptoms. During the period of 
convalescence the patient seemed to gain strength more 
rapidly by a continuance of the inhalations, and made a 
perfect recovery. This case was seen with me in consulta- 
tion by Drs. Thomas E. Satterthwaite and W. A. Shufelt, 
who heartily endorsed the line of treatment. 
Sufficient has been said to show the efficacy of this 
agent in the class of cases above mentioned. Dr. Thomp- 
son cited in his paper the great benefit that was derived 
from the use of oxygen in the treatment of cholera, dur- 
ing the epidemic at Marseilles and Toulon in 1886. If 
such was the case, why should it not be a most excellent 
agent to be used in the treatment of cholera infantum, 
especially during the period of collapse ? I am convinced 
that oxygen as a therapeutic agent has not received the 
attention that it merits, and I agree with Professor 
Thompson, that no consideration of expense should weigh 
against it. 
153 West Tenth Street. 
Reprinted by permission of the Author.