VACiMvU>i. lIBHtlMf^ PT O./A. Z M NLfl D511DflEtD M NATIONAL LIBRARY OF MEDICINE I 4NBBX Surgeon General's Office im a. JLJi^.JL NLM051108264 RETURN TO NATIONAL LIBRARY OF MEDICINE BEFORE LAST DATE SHOWN _ ' SEP 02 1980 r\) 0CTY7 1985 Skptembkk ON ASTHMA: ITS PATHOLOGY AND TREATMENT BY HENRY HYDE SALTER, M.D., F.R.S. m FELLOW OP THE ROYAL COLLEGE OF PHYSICIANS ; PHYSICIAN TO CHARING CROSS HOSPITAL, AND LECTURER ON THE PRINCIPLES AND PRACTICE OP MEDICINE AT THE CHARING CROSS HOSPITAL MEDICAL SCHOOL NEW YORK WILLIAM WOOD & COMPANY 56 & 58 Lafayette Place 1882 X s Trow's Printing and Bookbinding Company 201-213 East Twelfth Street New York TO MY RELATIVE, THOMAS BELL, ESQ., F.R.S., OF SELBORNE, HAMPSHIRE, THIS WORK IS INSCRIBED, LN ADMIRATION OF HIS LEARNING, HIS CHARACTER, AND HIS TALENTS; BUT MORE IN ACKNO'WLEDGMENT OF OBLIGATIONS THAT CAN NEVER BE REPAID, AND AS A SMALL TRIBUTE OF A GREAT AFFECTION. PREFACE TO THE SECOND EDITION. In preparing the present Edition I have had but few alterations to make in the views which I expressed in the former one. My chief work has been that of adding fresh matter, the result of an enlarged experience. The principal additions are in the therapeutical part of the work—on the treatment of the asthmatic paroxysm by Alcoholic Stimulants, the value of Iodide of Potassium as a remedy, the thera- peutical effects of Chloroform, etc. I have also added some interest- ing cases of Uterine Asthma, and Asthma dependent on Animal Emanations. The number of Tabulated Cases has been raised from forty-four to two hundred and twenty-three, and represents a mass of facts from which large and safe conclusions may be drawn, and which constitute, in my opinion, one of the most valuable parts of the book. I must not omit to express my obligations to my friend Dr. Halley, for the pains he has taken in helping me to revise the proof-sheets as they have passed through the press. CONTENTS. CHAPTEE L Preliminary Inquiry into the Tenabllity of the Theories of Asthma. Theory 1. That bronchial spasm is not necessarily present in asthma ; Laennec's "Asthma, with puerile breathing;" Copland's "Nervous asthma;" Walshe's " Haemic asthma." These dyspnoeas not true asthma.—2. Dr. Bree's theory of a specific irritating mucus. —3. That asthma is the dyspnoea of bronchitis; the " Bronchite a rales vibrants" of M. Beau.—4. The "Humoral" theory.—5. Dr. Todd's theory of a poisoning of certain portions of the nervous centres, or nerves, of respiration, by a specific materies morbi. —6. That asthma is nothing but the dyspnoea of emphysema.—7. That the phenomena of asthma are due to spasm or paralysis of the respiratory muscles.—8. That asthma is paralysis of the bronchial tubes.—9. That there is no such thing as asthma, as a substantive dis- ease .............................................,................pp. 1-12 CHAPTER It The Pathology of Asthma.—Its Absolute Nature. Asthma essentially a nervous disease.—The phenomena of asthma immediately de- pendent upon spastic contraction of the organic muscle of the bronchial tubes.— Evidence derived from the dyspnoea and sounds of asthma.—The four ways in which the bronchiae may be narrowed.—The phenomena of asthma mostly excito- motory or reflex.—The portion of the nervous system involved differs in different cases, being sometimes restricted to that of the lungs themselves.—Different de- grees of remoteness of irritant.—Irritant sometimes humoral ; a contaminate pul- monary blood.—Physiological argument: Spasm-theory confirmed by the purposes of the bronchial muscle in health...................................pp. 13-31 CHAPTER HI Clinical History of Asthma.—Phenomena of the Paroxysm. Premonitory and initiatory symptoms.—Drowsiness, dyspeptic symptoms; headache, excitability, profuse diuresis, neuralgic pains. —Time of attack, the early morn- ing; why?—Description of access of paroxysm.—Appearance of the asthmatic in the height of the paroxysm.—Pulse.—Itching under the chin.—Muscular phenom- ena.—Enlargement of capacity of chest.—Modification of respiratory rhythm.— Auscultatory signs. —Conclusions.—Length of paroxysm. —Necessity of starving during the attack.—Expectoration.—Its physical and microscopical characters.— Haemoptysis............'..........................................PP • 32-46 X CONTENTS. CHAPTER IV. Clinical History of Asthma (continued).—Phenomena of the Intervals. Periodicity. A characteristic but not constant symptom.—Diurnal periodicity that of organic asthma; weekly; monthly; annual, as in winter, hay, and aestival asthma.—Intrinsic and extrinsic periodicity. Tendency to habitude. Cases.— Change of type.— Capriciousness.—Caprice of the disease in general; caprice of individual cases.—Physiognomy.—Time of life of first access.—Influence of sex : its implication.—Is asthma hereditary ?............................. PP- 47-01 CHAPTER V. Varieties of Asthma. Idiopathic or uncomplicated asthma (" spasmodic "), and symptomatic or complicated asthma ("organic").—Intrinsic asthma; ipecacuan, hay, toxaemic asthma, etc. — Excito-motory ; peptic, organic nervous, cerebro-spinal nervous. — Central asthma.—Asthma depending on bronchitis and heart-disease..........pp. 62-69 CHAPTER VI The ^Etiology of Asthma. Two kinds of causes of asthma.—I. Causes of the paroxysms; respiratory causes; alimentary causes; nervous causes; psychical causes.—II. Causes of the dis- ease : a. Organic and acquired ; p. Constitutional and inherited.—Organic disease not necessarily at the root of the asthmatic tendency.—Is asthma in its essence a systemic or a local affection ?—Conclusion___....................... pp. 70-81 CHAPTER VH. Consequences of Asthma. Tendency of asthma to disorganize.—The consequences of asthma fourfold: 1. Its direct results on the bronchial tubes: hypertrophy of the bronchial muscle; per- manent bronchial contraction.—2. Results of obstructed pulmonary circulation : o. In the lungs (congestion, oedema, etc.); 0. In the heart (hypertrophy, dilata- tion) ; y. In the systemic venous system (venous stasis, oedema, etc.).—3. Emphy- sema : is pure asthma capable of generating it ?—4. Acquisition of the asthmatic physique ; its distinctiveness ; its characteristic, gait, physiognomy, and configu- ration : rationale of the asthmatic spinal curvature ; pigeon-chest of young asth- matics........................................................... pp. 82-90 CHAPTER VHI. Treatment of the Asthmatic Paroxysm.—Treatment by Depressants. Preliminary measures.—Ipecacuanha.—Tobacco.—Tartar-emetic.—Their modus ope- randi.—Their relative value and methods of administration.—Cases.—Value of tobacco in hay asthma.—Cases.—Caution with regard to tobacco.—Importance of the early administration of these remedies.—Practical observations... pp. 97-104 CONTENTS. XI CHAPTER IX. Treatment of the Asthmatic Paroxysm (continued).—Treatment by Stimu- lants. Theory of the modus operandi of stimulants.—Illustrated by coffee.—Alcohol.—Cura- tive influence of violent emotion.—Its action analogous to that of stimulants.— Its acts also as a " nervous derivative."—Cases....................pp. 105-113 CHAPTER X. Treatment of the Asthmatic Paroxysm (continued).—Treatment by Seda- tives. Their number and value.—Tobacco.—Chloroform: its varying efficacy.—Caution with regard to its use.—Opium.—The objections to it.—Stramonium : its unequal value.—Cases.—Its various preparations and modes of exhibition.—Practical rules.—Lobelia.—Indian hemp.—Ether...........................pp. 114-128 CHAPTER XI. Treatment of the Asthmatic Paroxysm (continued). Treatment of asthma by the inhalation of the fumes of burning nitre-paper.—Cases. —Practical remarks............................................. pp. 129-134 CHAPTER XH. Dietetic and Regiminal Treatment of Asthma. Facts showing the connection between the stomach and asthma; illustrative cases.— Practical rules as to the quantity and quality of food, and time of taking it.— Special vitanda.—Summary.....................................pp. 135-142 CHAPTER XLH. On the Therapeutical Influence of Locality. Special curative influence of London air. —The air of great cities in general curative of asthma.—Exceptional cases.—Caprice of asthma in respect to the effect of local influences.—Subtle and inappreciable character of such influences.—The asthmatic tendency not eradicated by them.—Adequacy of locality to develop asthma.— Change of air, per se, prejudicial.................................pp. 143-159 CHAPTER XIV. Treatment of Asthma by Iodide of Potassium.—Hygienic Treatment of Asthma. Relative value of iodide of potassium as a remedy.—Illustrative cases.—Theory of its action.—Beneficial influence of sustained bodily exertion.—Cold shower-bath.— Value of tonics.—Avoidance of cold.—Regularity of life.—Inhalation of powdered alum; of nitro-hydrochloric acid vapors; of oxygen gas; of compressed air.— Galvanism.....................................................pp. 160-167 xii CONTENTS. CHAPTER XV. Prognosis of Asthma. 1. Indications derived from the actual condition.—The influence of age in determin- ing prognosis.—Presence or absence of organic complications.—2. Indications derived from past history, e.g., a. Length of attacks, b. Frequency of attacks. c. Completeness of recovery, d. Persistence of expectoration, e. Cough. /. In- dications derived from exciting causes.—General conclusions........ pp. 168-172 APPENDIX A. Narrative Cases................................................. PP- 173-222 APPENDIX B. Tabulated Cases................................................. pp. 223-279 ON ASTHMA. CHAPTER I. PRELIMINARY INQUIRY INTO THE TENABILITY OF THE THEORIES OP ASTHMA. Theory 1. That bronchial spasm is not necessarily present in asthma; Laennec's "asthma, with puerile breathing;" Copland's "nervous asthma;" Walshe's " haemic asthma." These dyspnoeas not true asthma.—2. Dr. Bree's theory of a specific irritating mucus.—3. That asthma is the dyspnoea of bronchitis; the " bronchite a rales vibrants". of M. Beau.—4. The "humoral" theoiy.—5. Dr. Todd's theory of a poisoning of certain portions of the nervous centres, or nerves, of respiration, by a specific materies morbi.—6. That asthma is nothing but the dyspnoea of emphysema.—7. That the phenomena of asthma are due to spasm or paralysis of the respiratory muscles.—8. That asthma is paralysis of the bronchial tubes.—9. That there is no such thing as asthma, as a substantive disease. Spasmodic asthma—paroxysmal dyspnoea of a peculiar character, gener- ally periodic, with intervals of healthy respiration between the attacks— although not a very common disease, cannot, in this country, be said to be by any means rare, and I believe that all who direct their attention to it will find it to be much commoner than is imagined. Cases of perfectly pure asthma, that is, without the slightest organic complication, are, how- ever, rare, unless they have existed a very short time, and for this reason— that asthma, if it is at all severe and its attacks frequent, cannot long exist without inflicting permanent injury on the lungs, and even on the heart. If in asthma of long standing the lungs and heart remain healthy and un- injured, we may be sure either that the attacks are very mild, so as to pro- duce but little disturbance in the lung, or that they are very rare, so as to allow ample time for the recovery of the injury produced by one attack before the occurrence of another. But asthma is not the less asthma be- cause it has produced certain organic changes which complicate it; and many cases are primarily and essentially asthma that ultimately become, and are called, emphysema and heart disease. But not only is asthma not an uncommon disease, but it is one of the \ direst suffering; the horrors of the asthmatic paroxysm far exceed any acute bodily pain ; the sense of impending suffocation, the agonizing struggle for the breath of life, are so terrible, that they cannot even be witnessed without sharing in the sufferer's distress. With a face expressive of the intensest anxiety, unable to move, speak, or even make signs, the chest distended and fixed, the head thrown back between the elevated shoulders, the muscles of respiration rigid and tightened like cords, and 2 ON ASTHMA : tugging and straining for every breath that is drawn, the surface pallid or livid, cold and sweating—such are the signs by which this dreadful suffer- ing manifests itself. And even in the intervals of health the asthmatic s sufferings do not cease : he seems well, he goes about like his fellows and among them, but he knows that he is altogether different from them ; he bears about his disease within him wherever he goes ; he knows he is struck—" hceret lateri lethalis arundo ; " he is conscious that he is not sound —he cannot be warranted ; he is not certain of a day's, perhaps not of an hour's health ; he only knows that a certain percentage of his future life must be dedicated to suffering; he cannot make an engagement except with a proviso, and from many of the occupations of life he is cut off; the recreations, the enjoyments, the indulgences of others are not for him ; his usefulness is crippled, his life is marred ; and if he knows anything of the nature of his complaint, he knows that his sufferings may terminate in a closing scene worse only than the present. And not only is asthma thus comparatively common and superlatively distressing, but it is peculiarly and proverbially intractable. The asthma- tic is generally looked upon as an asthmatic for life, as one who, though he should suffer many things of many physicians, would be nothing bettered, but rather grow worse, and the treatment is regarded as palliativerC It must be admitted that the remedies for asthma are of very irregular and uncertain operation ; that probably there is no single remedy that is not inoperative in a large number of cases ; that that which is useful in one is valueless in another, while there are many cases that resist all remedies. If this intractability of asthma were doubtful, the large number of remedies that have been suggested would be a sufficient proof of it. ,J__ But, besides this, asthma is a disease about whose pathology more vari- ous and discrepant ideas prevail than about any other disease that could be named, and to this day, if we appeal to the written opinions of living authors, its absolute nature must be considered as still subjudice. I think, then, I shall not be undertaking a useless task if I attempt to throw some light upon the pathology, and lay down some rules for the treatment, of a disease so comparatively common, so distressing, so intract- able, and so obscure. Before attempting to enunciate or enforce any views respecting the nature of asthma that have, either in themselves or in the arguments ad- duced in their support, anything of novelty, or against which commonly received opinions are ranged, it seems to me desirable to pass in review pre-existing theories, and test their tenability by the standard of a recent physiology and pathology, that so, if any of them abide this scrutiny and prove irrefragable, they may contest the exclusive claims of the new theory, or if, on the other hand, they are found to be untenable, they may be swept away and the ground that they occupied left clear for something more true and enduring. And especially is such a preliminary inquiry desirable in the case of asthma, from the great number and variety of the theories that have been suggested in explanation of its phenomena, from the primd facie reason- ableness of many of those theories, and from the high names by which they have been endorsed. Doubtless there are many circumstances peculiar to asthma that go far to explain why such vague and, as I think I shall show, erroneous notions should be entertained with regard to its absolute nature, such as the rarity of death in cases of uncomplicated asthma, the slightness and unconspicu- ous character of the post-mortem appearances in such cases, or the total ITS PATHOLOGY AND TREATMENT. 3 absence of any applicable morbid change, and the remoteness of the actual pathological condition from the manifest phenomena of the disease. Let me, then, as the first step in the inquiry into the absolute nature of asthma, analyze in order, and see if they bear investigation, the many theories respecting it which are current, and which have either been in- herited from past authority or coined in the present generation. The first of these theories is, that contraction of the bronchial tubes is not necessary to constitute asthma—that asthma may exist without it. Laennec abandoned the principle of the necessity of bronchial spasm as the only possible cause of asthma, inasmuch as he divided asthma into two varieties: one, asthma attended with puerile respiration, in which the vital expansibility of the lungs is increased from a temporary augmentation of the respiratory necessities of the system, occasioned by some unknown modifi- cation of the nervous influence ; the other, spasmodic asthma, from a spas- modic contraction of the air-tubes. Dr. Copland adopts the same view, and describes Laennec's "asthma, with puerile respiration," as nervous asthma, defining it thus: "anhelation from a feeling of want of a more complete respiration than the patient enjoys, the pulmonary expansion dis- tinctly taking place with promptitude, completeness, and uniformity, so as to furnish a general puerile sound on auscultation." Dr. Walshe describes just the same thing under the name of "hsemic asthma," believing the dif- ficult breathing to depend upon morbid conditions of the blood which prob- ably interfere with its ready oxygenation, directly or indirectly, the breath- ing being instinctively increased in frequency to make up for the deficient amount of oxygen supplied to the system by each separate inspiration. The dyspnoea, he correctly remarks, has much the character of the breath- lessness following over-exertion in health, is not frequent in the ratio of its apparent labor, and is unaccompanied by any physical signs, cardiac or pulmonary, to explain the morbid state of the breathing. Now, that you may have a dyspnoea characterized by laborious respira- tory action and. an exaltation of the sense of want of breath, and, at the same time, accompanied by a free inflation of the lungs, is not to be doubted ; but it is no more asthma than bronchitis is asthma ; it has not one character in common with asthma that would justify such an alliance. In the circumstances under which it occurs, in the kind of dyspnoea, in its whole clinical history, it presents the strongest contrariety to asthma ; and it would be strange, indeed, if two kinds of dyspnoea, so unlike in character, had anything in common in their essential pathology. There is an ab- sence of the distress, of the characteristic wheeze, of the intolerance of the recumbent posture, of the evidence of deficient oxygenation, of the repeti- tion of the attacks, of the periodicity, of the exciting causes, indeed of every feature characteristic of asthma. It certainly is dyspnoea, and so is asthma, and that is just what they have in common, and nothing more ; but to make that the warrant for calling them both asthma would be to call all forms of dyspnoea asthma—bronchitic, emphysematous, cardiac— indeed, it would be to make asthma and dyspnoea synonymous terms. It may be said that this is a mere dispute about names, and that it is not of any consequence whether this kind of dyspnoea is called asthma or not. But I contend that it is ; because the adopting of such a nomencla- ture involves the confounding of things utterly dissimilar, and the sur- render of the essential pathology of the disease. Besides, it is not in tire interest of correct nosology, or rational treatment, that such errors in no- menclature should be allowed to stand. I am perfectly familiar with this variety of dyspnoea, and have been 4 on asthma: accustomed to call it "subjective dyspnoea ;" because I conceived there was no objective cause for it, nothing wrong in the condition of the lungs that could give rise to it—nothing to produce such arrears in the respira- tory changes as would legitimately account for such deep and accelerated breathing—but that it arose from some perversion of the perceptive en- dowments of the respiratory nervous system, or of the centres, inducing a spurious kind of stimulation to respiratory effort. The cases in which I have seen the best marked specimens of it have been in narcotic poisoning, uraemia, and ansemia. The resemblance of the dyspnoea in cases of dia- betes terminating in suppression of urine to that of chlorosis, and of both of them to common out-of-breathness from exertion, long ago struck me. I see no objection to calling this form of breathlessness " hsemic dysp- noea," instead of " subjective dyspnoea ;" indeed, I think it a better name, because I think it very likely that there is an objective cause for it—an im- perfection, namely, in the respiratory changes going on in the rungs ; and that that consists in a diminished oxygenation and decarbonization of the blood, in consequence of its peculiar constitution in these respective cases. In the hypothesis which he has thrown out to this effect, Dr. Walshe is probably quite correct, and it offers a rational solution of what, to my mind, was always a difficulty. I have often been puzzled at the panting dyspnoea of a chlorotic girl, not only on exertion, but when at rest, and have never before been able to give myself a satisfactory explanation of it. But, adopting Liebig's view of the part which the red globules play as the oxygen carriers, we see at once how ansemia would suspend the due oxy- genation of the blood, inasmuch as it would directly diminish the agents concerned in that process ; if there were half the blood-globules, for exam- ple, half the oxygenation would go on ; and we can easily understand how such arrears in the respiratory changes would give rise to instinctive res- piratory efforts, with the object of re-establishing the balance. The dysp- noea of anaemia thus becomes at once intelligible, and furnishes, in my opinion, a most interesting confirmation of the correctness of Liebig's views as to the relation of the red globule to blood-oxygenation. The fact is, the dyspnoea, in these cases of chlorosis, is as much an integral part of the diseased condition as any other symptom—the panting shortness of breath is as characteristic as the pallor of the complexion. If, then, this dyspnoea is no asthma at all, the free lung-expansion that characterizes it in no way invalidates the belief in the universal presence of bronchial stricture in true asthma. Many years ago an original and ingenious view of the pathology of asthma was advanced by Dr. Bree, in a work entitled "A Practical In- quiry into Disordered Respiration, distinguishing the Species of Convul- sive Asthma." He endeavors to show that the asthmatic paroxysm, and all the excessive muscular action that attends it, is merely an extraordi- nary effort to get rid of some peccant and irritating matter existing in the air- tubes, in the same way as tenesmus and spasmodic contraction of the bladder are extraordinary efforts to get rid of some source of irritation in the rectum and bladder respectively—faeces of a particularly irritating character, or a stone ; that this irritating matter exists in the lungs ante" cedently to the attack ; and that the asthmatic paroxysm is the means and mechanism of its discharge. And this view he founds on the argument of analogy, on the fact that in continued asthma there is some permanent and immovable source of irritation in the lungs, and that in the great majoritv of cases of spasmodic asthma there is a copious secretion of pituita to- ward the end of the paroxysm, with the discharge of which the attack ITS PATHOLOGY AND TREATMENT. 0 passes off. Dr. Bree maintains his argument with a great deal of ingenu- ity, and presses many facts into the service of his theory; but the most superficial reflection would suffice nowadays to show that it is utterly un- tenable ; and had Dr. Bree enjoyed the light that now shines on us from those two important points, the stethoscope and our acquaintance with excito-motory action, he would never have broached the doctrine he did : the one would have shown him the fallacy of his views, the other would have opened to him a solution of his difficulty—the stethoscope would have shown him that the conditions of an extraordinary discharging power are not present in an asthmatic attack ; indeed, that the power of getting rid of anything in the lungs is very much diminished by it ; and the knowl- edge of reflex nervous action would, in connection with anatomy, have dis- played the true nature of the disease, and made all its discrepant and scat- tered phenomena conspire to the production of its true and simple theory. A word or two will suffice to show the fallacy of Dr. Bree's views, and where his error lay. Was this peccant matter, that Dr. Bree supposed to be the exciting cause of an asthmatic paroxysm, thrown off and got rid of by expiration merely, as the carbonic acid and some of the constituents of the expired air are ; or was coughing necessary for its expulsion ? In either case, asthmatic breathing, so far from affording additional excretory power, would indicate a very great reduction of it—a reduction below the most moderate standard of the equable and tranquil respiration of health. For if the air simply breathed, without any assistance from coughing, be the medium of its discharge, of course extraordinary discharging power can only be obtained by an extraordinary amount of air respired. Now, any one who listens to the chest of an asthmatic during a fit of his disease will see that the amount of air respired is very small, indeed, much below the natural standard ; that the vesicular murmur, even when not drowned by rhonchus and sibilus, is either inaudible or very feeble, and he will see that the amount of movement of the parietes of the chest, in spite of the vio- lent muscular efforts and its great distention, is very slight. If a person \ suffering from asthma tries to blow his nose he finds he cannot make a j sufficiently full inspiration, or get enough air into his chest, to perform j that act efficiently : he makes a little, short, and soundless blow that drives nothing from his nostrils; the same with coughing. A case so clearly illustrative of this once came under my observation that I cannot for- bear relating it. A great sufferer from asthma had a double polypus in his nose, which so blocked up his nostrils that he could not, in health, breathe with his mouth shut without making a loud, sniffing, snoring noise, both at expiration and inspiration, and, indeed, could not breathe at all for any length of time without opening his mouth. But when his asthma was on him he could breathe with his mouth shut without producing any of the sniffing sound, and without increasing the embarrassment of his breathing—in fact, as well as with it open. The fact was, the amount of air respired was so small that the narrow chinks between the polypi and the walls of the nares were sufficient for its transmission. Supposing, on the other hand, coughing to be necessary to the expul- sion of this irritating material, as some of Dr. Bree's observations indicate, a similar extraordinary respiratory power would be necessary, for an extra- ordinary inspiration must precede an extraordinary coughing effort. But we find asthmatic dyspnoea destroys the power of efficient cough. .We find, too, that in the majority of asthmatics the greater part of the par- oxysm is free from cough—it is dry ; the wheezing dyspnoea is the only 6 on asthma: thing that troubles the patient. How, then, can the coughing and spitting explain the antecedent dyspnce'a? or how, if the coughing is necessary for the expulsion of the offending pituita, can the preceding labored breath- ing be an excretory act at all? The fact is, Dr. Bree mistook the effect for the cause. The inordinate mucous secretion, the expulsion of which gives so much relief at the termination of a paroxysm of asthma, is the re- sult of the congestion into which the capillaries have been thrown by the long-continued imperfect respiration, and the secretion, by unloading these congested capillaries, relieves one of the most pressing causes of the dysp- noea ;' the expectorated matter exists not in the first part of the attack of which Dr. Bree considers it the exciting cause. This accumulated mucus is, no doubt, an additional source of dyspnoea, by blocking up the bron- chial tubes ; when the bronchial spasm ceases this is the only source of dyspnoea that is left, and its expectoration is therefore attended with im- mediate and complete relief. This expectoration never takes place without a marked abatement of the dyspnoea, for the simple reason that until the dyspnoea does abate, until the bronchial spasm is passing off sufficiently to allow the chest to be freely filled with air, efficient cough, adequate to the free discharge of this accumulated mucus, cannot be effected. Expectora- tion cannot take place till the intensity of the dyspnoea is already subsid- \ ing. The order of events, then, is this : Air shut off from the lungs by bronchial stricture ; consequent pulmonary congestion—in fact a state of partial asphyxia ; an abundant mucous exudation ; inability to expectorate this material, in consequence of not being able to get sufficient ah' into the lungs to cough efficiently ; abatement of spasm ; consequent recovery of i coughing power ; free expectoration, and complete relief. > A great deal more might be advanced in demolition of Dr. Bree's theory, but what has been said is, I think, quite sufficient; indeed, I should not have been at such pains to notice and disprove his views as I have, were it not that his book is so well known, and caused some sensation and made many converts when it came out. It is so well written, however, the arguments, as far as the author's knowledge went, so well and ably supported, and, in spite of the theoretical errors, there is so much sound practical advice in it, that it really forms a valuable addition to the medical literature of this subject. Some authors have asserted that asthma is nothing more or less than the dyspnoea of bronchitis. Of these, some have attributed the dyspnoea and wheezing to plugging of the tubes by bronchitic mucus, while others, re- cognizing in the occasional entire absence of mucus in asthma, and other facts, an insuperable objection to this explanation, have attributed the symptoms to inflammatory thickening of the bronchial mucous membrane. The former of these views, analogous to Dr. Bree's in so far as it attri- butes the phenomena of asthma to a mucous exudation, but differing in-as- much as it does not assign to that mucus the character of a specific irri- tating humor, nor consider the muscular phenomena of asthma convulsive efforts for its discharge, was advocated by M. Beau, some fifteen years ago, in a memoir on "A Distinction of Two Forms of Bronchitis." He con- siders asthma to be a phenomenon of a particular form of bronchitis which he calls " bronchite d rdles vibrants," and that the wheezing and the dysp- noea alike depend on the obstruction of the air-tubes by the inflammatory products of this bronchitis. Speaking of the spasm theory of asthma, he says: "This opinion, adopted by many conscientious physicians from respect for medical traditions, is no longer capable of being maintained, since aus- ITS PATHOLOGY AND TREATMENT. 7 cultation and percussion have given us the means of seeing (so to speak) what occurs in the chest. It has, in fact, been ascertained, with the assist- ance of these two methods of inquiry, and in a manner the most positive, that'there is no asthmatic dyspnoea without an obstruction of the bronchial tubes, which causes vibrating rdles, and which, producing an obstacle to the exit of the inspired air, forces it to react on the vesicles and to dilate them." ' I quote the above from an able review on this subject by Dr. W. T. Gairdner,2 who, in commenting on this very passage of M. Beau, so hap- pily exposes the untenability of the bronchitis theory of asthma, and so exactly expresses the objections to it that have struck my own mind, that, although I have elsewhere shown the entire independence and distinctness of the two affections, I cannot forbear quoting his words: " We had thought that the experiments of Williams, of Longet, and of Volkmann, which are, or ought to be, well known in France, might have saved the spasm theory of asthma from being consigned so very coolly, as it is in the first sentence of the above paragraph, to the limbo of medical tradition ; more especially as there never has been any doubt, even among the most hazy and ' traditional' of the spasm theorists, as to the existence of an obstruction in the bronchial tubes. The wheezing and ' vibrating rales' were too evident a portion of the asthmatic paroxysm to be over- looked, even before auscultation and percussion were introduced. M. Beau has entirely missed the real point of the controversy, and has not of- fered the shadow of a proof on the real matter at issue—viz., whether the vibrating rides, the obstruction of the tubes, and the consequent dyspnoea, are caused by mucous secretions, as he himself maintains, by sudden in- flammatory engorgement of the mucous membrane, as others have sup- posed, or by spasmodic narrowing of the tubes generally or locally, as is the common opinion in this country. " On the part of the mucous theorists, it is alleged that the paroxysm of asthma is almost always terminated by expectoration of a thick, semi- transparent mucus, and that its accumulation was in all probability the cause of the paroxysm. We admit the fact to be true, but doubt very much the correctness of the inference ; at least it is certain that, in ordi- nary bronchitis, enormously greater accumulations of mucus take place with comparatively few signs of general obstruction. We think this posi- tion must be admitted by every unbiassed observer; and it is, in our opinion, fatal to this theory. Nor can we find more probability in the theory of inflammatory or congestive thickening of the bronchial mucous membrane. That such a lesion should become the source of most serious dyspnoea in ten minutes (an incident of frequent occurrence in the violent forms of asthma) ; that it should subside with almost equal rapidity ; that it should almost never produce a directly fatal result by asphyxia, and very rarely issue in the expectoration of pus, while, on the other hand, far more severe forms of inflammatory bronchitis often produce comparatively little evident dyspnoea—these are, in our opinion, ample reasons for re- jecting the congestion theory of asthma, and maintaining the spasmodic as probable, even had the power of the bronchial fibres to produce sudden and rapid obstruction not been positively ascertained." There is another school of pathologists who maintain that the essence of asthma is humoral; that each attack depends on the development of 1 Archives Generates, vol. lxxviii., p. 155. 2 Med.-Chir. Review, vol. xi., p. 476. 8 ON ASTHMA : some specific humoral disturbance ; that without that particular humoral disturbance you cannot have the asthma; that the difference between the asthmatic and one who is not so lies in the disposition or indisposition to produce this specific humoral condition. Now I do not deny that in some cases the exciting cause of the attack is humoral; but what I would deny is, that the humoral derangement has any higher place than that of an ex- citing cause, and what I would insist upon is, that the heart and core of < the disease is nervous, that the essential peculiarity of the asthmatic is a vice in his nervous system, a peculiar morbid irritability of it, whereby a certain portion of it is thrown into a state of excitement from the applica- tion of stimuli which in another person would produce no effect at all, or \ a very different effect. Take an example. Two men make a hearty sup- per—one wakes with asthma, the other with vomiting; two men get drunk—one wakes with asthma, the other with a violent headache. These I consider to be instances of the production of different results from the application of identical sources of irritation to constitutions of different diseased tendencies. There is probably a humoral disturbance in both cases, in both the blood is contaminated with the products of deranged digestion; but there is no reason to believe that in the asthmatic the humoral disturbance is speoific, or that it differs from that of the other case. A general expression, like that of a theory of a disease, should ful- fil all conditions and explain all cases. But how will the humoral theory of the disease explain an attack of asthma brought on within one minute after drinking a glass of wine ? WTiat will be said of the humoral nature of an attack of asthma instantaneously brought on by a fit of laughter ? What will be said of the humoral nature of an attack of asthma brought on by lying lower at head than usual by the amount of one pillow ? What will be said of the humoral nature of an attack of asthma brought on in a . minute or two by walking near a hayfield ? No ; the essential pathological condition in asthma consists, as I shall endeavor to show,' in the irritabil- ity oi the part irritated, and not in the production of any specific irritator. In an interesting clinical lecture, published in The Medical Gazette for December, 1850, Dr. Todd advanced the opinion that asthma depends upon a poisoning of the nerves of respiration, or those portions of the nervous centres with which they are connected, by a particular materies morbi, by which their function is so perverted that a spurious and morbid sense of want of breath is engendered; that this central or subjective breathlessness is the first step in- the morbid phenomena; that it need have no real objective cause in the lungs themselves ; that bronchial spasm is an accompaniment, not a cause, of the dyspnoea of asthma; and that you may have asthma without any bronchial contraction whatever. Dr. Todd's argument is this: In many points asthma resembles gout; gout is humoral; therefore asthma is humoral. Again: You may have asthma with puerile breathing ; with puerile breathing the bronchi cannot be contracted ; therefore asthma may coexist with uncontracted bronchial tubes. But let me give, in his own words, the views of one whose opinions always carried with them so much weight. " Like asthma," said Dr. Todd, " gout comes on quite suddenly__there is no warning. A man may go to bed quite or nearly well, and may wake up early in the morning with a fit of the gout in his great toe. There is another disease, epilepsy, in which we have exactly the same phenomenon. 1 Chapter IL ITS PATHOLOGY AND TREATMENT. 9 A patient, with or without warning, falls down foaming, livid, and con- vulsed ; the paroxysm goes off and leaves him in his ordinary good health, and he may go on for years and not have another. Again, we know a fit of the gout leaves no organic lesion if it occurs once or twice, but if it is often repeated it leaves permanent injury in the joints it attacks. The same of asthma ; the organic changes are all secondary, and a few attacks leave no traces behind them. " The theory at present most in favor with regard to gout is, that it is a disease of assimilation, and that this defective or vitiated assimilation gives rise to some materies morbi. When this matter is eliminated from the system the attack passes off; when it accumulates the attack comes on. In asthma defective assimilative power is a frequent coincident. Gout, too, and rheumatism, and all humoral diseases, resemble asthma in being inherited. " When the materies morbi of asthma has been generated, its effect is to irritate the nervous system, not generally, but certain parts of it, those parts being the nerves concerned in the function of respiration, viz., the pneumogastric, and the nerves that supply the respiratory muscles, either at their peripheral extremities or at their central termination in the me- dulla oblongata and spinal cord ; extreme difficulty of breathing is the result, and, as a consequence of this, ultimate disease of the lungs. "Many pathologists ascribe all the phenomena of asthma to spasm of the circular muscular fibres of the bronchi. The first link in the chain of effects of the immediate exciting cause of asthma would be, according to them, spasm of the bronchial tubes, then dyspnoea. Undoubtedly, a state of spasm of the bronchial tubes would produce a great deal of dyspnoea ; but what I want to point out to you is, that this state of spasm of the bronchial tubes ought rather to be regarded as one of the accompani- ments, one of the phenomena, of asthma, than as its cause. The feeling of breathlessness, or, in other words, a peculiar state of certain nerves, or of a certain nervous centre, the centre of respiration, is the first link in this chain of asthmatic phenomena. The spasm of the bronchi follows sooner or later upon this, and often it follows so quickly upon it as to ap- pear to come simultaneously with it. Does it ever precede it ? I doubt this. "Undoubtedly you may have severe asthma without severe spasms of the bronchial tubes. I remember a well-marked instance of this in a gentleman whom I attended for a chronic disease—cancer, as I thought, of the liver. For nearly a week before his death he suffered from the most frightfully distressing asthma, which nothing could control, and which lasted without interruption till he died. I examined his chest repeatedly at all parts, and could hear nothing but the most perfect, loud, and puerile breathing, which is quite inconsistent with a state of spasm. " Again, a section of the vagi nerves of animals produces phenomena exactly like those of asthma. Whatever be the cause of the dyspnoea in these cases, it is clear it cannot be bronchial spasm, as the muscles of the bronchi would be paralyzed after a section of their nerves." With regard to the first part of Dr. Todd's theory, founded on the supposed analogy of asthma to gout—that you have in asthma a specific materies morbi—I do not think that the existence of points of analogy in the clinical history of the two diseases in any way implies identity of pathology. To how many diseases are headache, sliivering, loss of appetite, thirst, an accelerated pulse, and loaded tongue common, be- tween the pathology of which there is no affinity whatever. With regard to the second part of his theory—the coexistence of asthma with un- 10 on asthma: contracted bronchial tubes—I believe that the case that he quotes is one of that subjective dyspnoea, not asthma at all, to which I have already referred. In the anhelitus consequent upon the division of the vagi I can see nothing resembling asthma. Altogether, I cannot but think that the arguments brought forward by Dr. Todd are inadequate to meet the mass of evidence that can be adduced in proof of the necessity of bronchial spasm and the non-necessity of humoral disturbance in asthma. In the twenty-third volume of the " Medico-Chirurgical Transactions," Dr. Budd, after controverting both the necessity and the existence of muscular elements in the bronchial tubes, offers the following theory of the pathology of asthma : " The idea of spasm was suggested by Cullen, and has been generally adopted, from inability to explain in any other way the symptoms of asthma. The necessity of such a supposition has, however, in great measure ceased, in consequence of modern discoveries in morbid anatomy. Corvisart first pointed out diseases of the heart and large vessels as an occasional cause of fits of dyspnoea, formerly regarded as nervous, and confounded under the name of asthma. Laennec, and more recently Louis, have shown that emphysema of the lungs is the most common cause of this group of symptoms ; and the physical signs of dilatation of the air-cells may be discovered during life in most persons who present the symptoms of asthma. " Many of these persons can vary the capacity of their chests to a de- gree only just sufficient to supply them with the requisite quantity of oxygen in favorable circumstances. Whenever their circulation is quick- ened by exciting passions or by exercise—or their power of expanding the chest is a little diminished by the obstacle which a distended stomach offers to the descent of the diaphragm—or ah' is prevented from freely entering the air-cells in consequence of secretions in the bronchial tubes—or the proportion of oxygen in a given volume of air is diminished, whether by increased temperature as in heated apartments, or by diminished pressure as in elevated situations, and in those states of the atmosphere which precede storms—in fact, whenever, from any cause, their need of oxygen increases, or their means of inhaling it diminishes, these persons experience difficulty of breathing or a fit of asthma. " There still, however, remain some cases, which at present we can only explain by supposing the dyspnoea to be nervous. It seems probable that the number of such cases will be still further diminished, that many of those fits of asthma which we are now forced to consider nervous will be discovered to depend on some organic change which has as yet escaped our observation, perhaps on some morbid condition of the blood itself. " In fits of asthma really nervous, the difficulty of breathing must re- sult from spasm, or from suspension of the normal action, of the diaphragm and other muscles of inspiration." It will be seen, then, that Dr. Budd recognizes two forms of asthma, in neither of which does he admit bronchial spasm ; in one the asthma is nothing but the dyspnoea of emphysema ; in the other it is a spasm or suspension of the normal action of the muscles of inspiration. Is either of these theories tenable ? If asthma is but the dyspnoea of emphysema, or heart disease, it can never occur without them. Now we know that in numberless cases of asthma there is not only no emphysema or heart disease, but no appreciable organic disease whatever__that asthma may invade health without a flaw, and lapse again into health without a flaw. To assume organic disease in such a case would be ITS PATHOLOGY AND TREATMENT. 11 purely gratuitous. I know that the dyspnoea of emphysema has been called asthma ; but what form of dyspnoea is there that has not been called asthma ? According to Dr. Budd's second theory, the muscular phenomena of asthma are primary. Now, all asthmatics tell us that they are preceded by an intolerable sense of want of breath, to which they are secondary, which enforces them, and to which they are always proportionate. More- over the action of the inspiratory muscles in asthma has nothing of spasm or paralysis about it ; it is rhythmical, symmetrical, and forceful. Why, in spite of such effort, the inspiratory movements are at such a dead-lock, I shall endeavor to explain in a succeeding chapter. Yet another theory has been suggested for asthma, a theoiy for the suggestion of which it would be difficult to offer any explanation, except that pathologists were resolved that no conceivable hypothesis should want an advocate. It is that asthma depends not upon spasm, but upon paralysis of the bronchial tubes. Now this theory would not be for a moment tenable except on the supposition that the bronchial tubes were engaged as active agents in respiration ; if they are not concerned in respiration it is manifest that the loss of their muscular power would be immaterial, and would leave respiratory phenomena unaffected. Supposing they were a part of the ac- tive machinery of respiration, they. could be engaged in earpiration only, and would assist by their contraction in emptying the lungs. And it must be admitted that there are two phenomena of asthma that such a paralysis of expiratory force would very conveniently and readily explain, and which might possibly have suggested this very theory. One is the extreme difficulty and prolongation of expiration ; the other, the permanent state of distention at which the chest is kept during the asthmatic paroxysm— its girth increased, the ribs elevated, the intercostal spaces wide—as if it could not be emptied of its air. There can be no doubt that the difficulty of getting air out of the chest in asthma is much greater than that of getting it in, and supposing the bronchial tubes engaged in expiration, this is exactly what would result from their paralysis.1 But I think it is now admitted on all hands that they are not, because they can not be, agents of respiration. There is one reason that, independent of many other con- siderations, forbids the possibility of it: it is that respiration is under the 1 Dr. Walshe, in his work on Diseases of the Lungs and Heart, p. 337, adopts this paralysis theory as explanatory of some, though not all, cases of asthma. He says : " Bronchial asthma may depend on a plus or a minus state of the contractility of the muscular fibres of the bronchial tubes ; in the former case it is spasmodic, in the latter paralytic. '" Laennec ascribed the peculiar air-distention of the lungs, found in persona asphyxiated by the mephitic erases of cesspools, to paralysis of the vagi nerves ; Mr. Swan noticed similar distention in animals whose eighth pair had been divided in the neck. In both cases, the contractile force of the bronchial muscles concerned in expira- tion is more or less completely annulled. " If then, as we have seen, there be motive to believe that nervous asthma com- monly depends on spasmodic action of the bronchial muscular apparatus, here are speculative reasons for presuming that paralysis of the apparatus may cause a variety of the affection. Clinically, too, we meet with examples of asthma in which the comparative facility of inspiration, and difficulty of expiration, svggest of themselves tlie probability of a minus rather than a plus state of power in bronchial contractibilityZ It is clear from the above that Dr. Walshe believes in bronchial muscular contrac- tion as an efficient expiratory power ; the first sentence that I have italicized asserts it, the last implies it—it is the inevitable third element of his syllogism. For what I believe to be the true explanation of the distended thoracic cavity and prolonged expiration of asthma, I must refer the reader to Chapter III. 12 on asthma: influence of the will, that it may be varied at pleasure—quick or slow, superficial or deep—while the contraction of the bronchial tubes, like that of all organic muscles, is essentiaUy involuntary. This conclusive argu- ment is so well urged by Dr. Budd, in his paper on Emphysema and Asthma in the " Medico-Chirurgical Transactions," to which I just now referred, that I cannot do better than quote his words : "It can be shown," he says, speaking of the circular muscular fibres of the bronchi, " that these fibres are not muscles performing a part in the ordinary acts of breathing. Supposing them to be muscular, it is evident, from their arrangement and microscopic characters, that they belong to the muscles of organic life, or that they are involuntary muscles. But all the external muscles of respiration are voluntary muscles. Hence we should have engaged, to accomplish the act of breathing, a voluntary and an involuntary power. The function would be easily performed as long as these powers acted in unison—that is, as long as the involuntary muscles contracted only during expiration. But, by varying the rapidity of our breathing, we should soon have two powers opposed to each other—the involuntary muscles acting to close the bronchial tubes, while the volun- tary muscles acted to expand them. We should then be able to dilate the chest only when we adjusted the inspiratoiy movements to the actions of the involuntary muscles. But we never perceive any necessity for such an adjustment. The test which this circumstance affords us is one of extreme delicacy. For, if the two powers were not exactly in unison, there would occur intervals, like the beats in music, when they would coincide with or be opposed to each other. The inspiratory acts would be alternately easy and difficult, according as the voluntary and involuntary muscles were in the same or opposite phases. But however rapid we make our breathing, we per- ceive no difference in the ease with which successive acts of inspiration are performed. This circumstance is a proof the most decisive that the fibres of the bronchi have no independent rhythmical motions of contraction." Discarding, then, the theory of bronchial expiration, the theory of bronchial paralysis, as a cause of asthma, falls to the ground. Finally, I may mention, but I need hardly attempt to refute, the views of those—and they are not a few—who deny the existence of asthma alto- gether as a substantive disease, who hold it to lae a generic and not a spe- cific condition, and that it and dyspnoea are convertible terms. In the above resume I have not alluded to those authors who have ad- vocated what I believe to be the only true theory of asthma—the spasm theory—because my purpose has been simply to clear away the obstruc- tion of erroneous notions ; and if this chapter asserts anything of the true pathology of asthma it is strictly in a negative and exhaustive way. But there is one author, Dr. W. T. Gairdner, to whose writings' I feel bound to refer, not so much on account of the correctness of his views and the conclusiveness of his reasoning, as to do an act of justice both to him and to myself—to him, that I may admit, which I do entirely, that in some of my writings I have been anticipated by Dr. Gairdner, not only in my sub- stantial opinions, but in the arguments I have adduced and the very phra- seology I have employed - to myself, that I may state that it is only with- in the last few months, after the principal part of this work was in type, that I became acquainted with Dr. Gairdner's admirable papers. I would fain hope that our unconscious coincidence of views depends upon our both having read Nature sincerely and successfully. 1 Edinburgh Monthly Medical Journal for 1851. Med.-Chir. Review, 1853. ITS PATHOLOGY AND TREATMENT. 13 CHAPTER II. THE PATHOLOGY OF ASTHMA.—ITS ABSOLUTE NATURE. Asthma essentially a nervous disease.—The phenomena of asthma immediately de- pendent upon spastic contraction of the organic muscle of the bronchial tabes.—■ Evidence derived from the dyspnoea and sounds of asthma. —The four ways in which the bronchia? may be narrowed.—The phenomena of asthma mostly excito- motory or reflex.—The portion of the nervous system involved differs in different cases, being sometimes restricted to that of the lungs themselves. —Different de- grees of remoteness of irritant.—Irritant sometimes humoral; a contaminate pul- monary blood.—Physiological argument: Spasm theory confirmed by the pur- poses of the bronchial muscle in health. Having endeavored in the preceding chapter to give a fair summary of the various theories that are entertained with regard to the nature of asthma, and to inquire if those theories are such as are fairly borne out by the phenomena of the disease, I purpose in the present one to develop what I believe to be its true pathology. What I shall endeavor to show is this : First.—That asthma is essentially, and, with perhaps the exception of a single class of cases, exclusively, a nervous disease: that the nervous system is the seat of the essential pathological condition. Second.—That the phenomena of asthma—the distressing sensation and the demand for extraordinary respiratory efforts—immediately depend upon a spastic contraction of the fibre-cells of organic or unstriped muscle which minute anatomy has demonstrated to exist in the bronchial tubes. Third.—That these phenomena are those of excito-motory or reflex action. Fourth.—That the extent to which the nervous system is involved differs very much in different cases, being in some cases restricted to the nervous system of the air-passages themselves. Fifth.—That in a large number of cases the pneumogastric nerve, both in its gastric and pulmonary portions, is the seat of the disease. Sixth.—That there is a large class of cases in which the nervous circuit between the source of irritation and the seat of the resulting muscular phenomena involves other portions of the nervous system besides the pneumogastric. Seventh.—That there are other cases in which the source of irritation, giving rise to the asthmatic paroxysm, appears to be central—in the brain; consequently in which the action, though excito-motory, is not reflex. Eighth.—That there is yet a class of cases in which the exciting cause of the paroxysms appears to be essentially humoral. Let us now examine these propositions in the order in which I have stated them, and see what proofs can be brought to their support. First.—The reasons that force upon one's mind the conviction that asthma is essentially a nervous disease are very numerous, and not less 14 on asthma: forcible and convincing; but I shall here be able only briefly to indicate them, as their fuller consideration would involve too great space, iney are principally derived from the following considerations : a. Ine causes of asthma ; b. its remedies; c. its associated and precursory symptoms; d. its periodicity / e. the absence of organic change; f. the circumstance that the phenomena of the disease are muscular. a. We see, in the first place, that the causes of asthma are such as af- fect the nervous system, and such as give rise to other diseases acknowl- edged on all hands to be nervous. Thus, fatigue and physical exhaustion, and sudden or violent mental emotion, will bring on an attack. I was in- formed, some short time since, by my friend, the late Dr. Theophilus Thompson, of a casein which, on two occasions, severe asthma was brought on in a gentleman by sudden fear, from his having, as he imagined, admin- istered accidentally an over-dose of belladonna to his wife. I knew the case of an asthmatic boy, some years ago, who used constantly to be warned by his parents not to over-excite himself, as if he did he would be sure to have the asthma the next day ; and lately I met with another case, in which I was told that when the asthmatic was a little boy he found in his disease a convenient immunity from correction. "Don't scold me," he Would say, if he had incurred his father's displeasure, " or I shall have the asthma;" and so he would; his fears were as correct as they were convenient. Venereal excitement will bring on asthma ; a gentleman once told me that one of the severest attacks he ever had in his life was brought on in this way. Moreover, many well-known and recognized causes of asthma can only act on the lungs through the intervention of certain parts of the nervous system; thus, gastric irritation can produce spasm of the bronchial tubes only through the intervention of the pneumogastric nerve —it is the only connecting link between the two organs, either physiologi- cally or anatomically. b. Again, the remedies of asthma are such as appeal to the nervous sys- tem—as antispasmodics, sedatives, direct nervous depressants, etc.; to- bacco, for example, stramonium, antimony, chloroform. Perhaps the ef- fect of chloroform is, of all remedies, the most striking, and at the same time the most illustrative of the purely nervous nature of the affection—a few whiffs, and the asthma is gone ; a dyspnoea that a few seconds before seemed to threaten life is replaced by a breathing calm and tranquil. Now, remembering the action of the drug, that it is the nervous system to which it appeals, it is impossible to help seeing in this the most conclusive proof that the symptoms are due to a nervous cause. And besides these ordi- nary remedies there are other circumstances that will put a stop to the par- oxysm, that eminently prove its nervous nature ; one of these is mental emotion—any strong or sudden passion, such as fear, fright, or surprise. It is a curious thing that mental emotion should have the effect both of inducing and relieving asthma, but so it is; and there are not wanting facts analogous to this—e.g., shock will bring on chorea and shock will cure it. I think the immediate effect of emotion is always to cut short asthmatic spasm, if it exists, by a sort of nervous revulsion ;' whereas its tendency to induce it is remote, and only shown after some time, as the next day ; and it acts, I think, by producing an exaltation of nervous impressibility__and thus facilitating the induction of excito-motory action. Nothing indeed in the whole range of pathological phenomena is to my mind more remark- able than the effect of emotion upon asthma. Dr. Todd has told me that he has had patients come to him who have lost their asthma the moment they have entered his house ; suddenly, and without any apparent cause ITS PATHOLOGY AND TREATMENT. 15 except the mental perturbation at being within the precincts of the physi- cian, the difficulty of breathing has vanished. We see just the same thing in toothache—the sight of the dentist's house is enough to cure it. I witnessed once myself so striking an example of this sudden disappearance of asthma under the influence of alarm that I cannot forbear relating it. A gentleman, a confirmed asthmatic, was suffering an unusually bad attack of his complaint, so bad that he was unable to move from his chair, or speak even, except in catchy monosyllables. He had been suffering all day, and in the evening his sister was going to give him an emetic of ipeca- cuanha, when she suddenly fell down in an hysterical fit, to the occurrence of which she was subject. The suddenness of her attack and the severity of her sufferings so alarmed him that he sprang from his chair and ran to her relief, and as soon as he had placed her in a position of safety ran down two flights of stairs to procure the restoratives that were usually adminis- tered. Having run up-stairs again with the same speed, and applied the remedies, he found to his surprise that his asthma was gone, and indeed it was its sudden departure under the influence of alarm that had alone en- abled him to perform such a feat; a man who, two minutes before, was unable to speak or move, had, under the influence of an absorbing alarm, ran down two flights of stairs and up again, and found himself after his exertion breathing with perfect freedom. The asthma gradually returned, and within an hour he was as bad as ever. I do not think it possible to adduce a stronger proof than this of the purely nervous nature of asthma. I might cite many such cases.1 c. Again, the periodicity of asthma implies its nervous nature, that is, such a periodicity as characterizes asthma. There are three kinds of pe- riodicity in disease. One, in which it is produced by the periodical return of its cause, as in the recurrence of hay fever every summer, the morning* expectoration after a night's rest, indigestion every day at a certain time after dinner. Another, in which the periodicity seems to depend upon that rhythmical impress which is stamped on the functions, that sort of diurnal oscillation in which the body is swung by the constant recurrence, at one unvarying daily interval, of the habitual actions and passions of the body ; I think that hectic and ague acquire their periodicity from this diurnal beat into which the body falls. But there are other diseases whose rhythmical recurrence cannot be explained on either of these suppositions, whose pe- riodicity has no relation either to the diurnal interval or to the renewal of the cause, but which must be intrinsically periodic ; such are epilepsy and asthma. In these the interval is long and of no certain standard—that is, though tolerably constant in the same individual, it differs veiy widely in different cases—the period is peculiar to each case, is an integral part of the pathological condition. It is this last kind of periodicity, and this alone, that points at all to the nervous nature of the disease. d. Furthermore, the associated and precursory symptoms of an asth- matic attack are such as point to its nervous character. The quantity of limpid water passed in the early part of the paroxysm, white as pump-water, like the nervous water passed in the students' " funking room," or like the urine of hysteria, or that of nervous headache ; the neuralgia, which I have often noticed ; the frontal headache ; the drowsiness and languor of the previous day by which the approach of the attack is foreknown ; or, on 1 A remarkable exception to this curative power of excitement once came under my observation, in the case of a woman who suffered from a, violent attack of asthma the whole of the time she was in labor. 16 ON ASTHMA : the other hand, a peculiar and unwonted hilarity and animation and sense of health—all these are just such symptoms as we meet with in various diseases of the nervous system, such, for example, as hysteria and epilepsy. e. Another circumstance in favor of the view that asthma is essentially nervous, in fact consistent with no other, is the possible absence of appre- ciable organic change, as shown by post-mortem examination in cases where the disease has not been of long standing. A man may have been known during his life to have had attacks of asthma, he may have seemed over and over again almost in articulo mortis from want of breath; and yet if death from some other cause1 gives an opportunity of examining his lungs they may be found apparently in every way healthy—no trace of in- flammation or its products, the vesicular structure perfectly normal, the pas- sages leading to it lined by a healthy and unchanged membrane, the cavities of the pleura free from all abnormal contents, their surfaces smooth and apposed, the heart sound. The disease shows no cause, and has left no trace, either in the respiratory or circulatory systems—in fact, no trace anywhere. Where, then, shall we locate it ? What is its starting-point ? We may, I think, lay it down as a rule, that all those diseases that leave no organic trace of their existence produce their symptoms through the ner- vous system. f. Lastly, the phenomena of the disease are muscular, the proximate diseased condition is situated in the muscular system, and whenever the proximate derangement is muscular, we may always, with one or two ex- ceptions, safely affirm that the primary disease is nervous. In epilepsy, tetanus, chorea, paralysis agitans, hemiplegia, child-crowing—in all these the obvious departure from health is in the muscular system \ bat the es- sence of the disease is nervous. The only exceptions that I know of are the cases in which the muscles are either poisoned by some material pres- ent in them, as, for example, in the paralysis of lead-palsy, the cramps of cholera, or disorganized by fatty degeneration, as we see in the heart, the muscles of disused limbs, etc. In these cases the disease is radically and primarily muscular. In all other cases muscular disturbance is but the index of nervous disease. Hence the very fact that the phenomena of asthma are muscular is all but proof positive that the nervous system is the seat of the primary derangement. Second.—That the phenomena of asthma—the distressing sensation and the demand for extraordinary respiratory efforts—immediately depend upon a spastic contraction of the fibre-cells of organic muscle which minute anatomy has demonstrated to exist in the bronchial tubes. Although this is a proposition that many perhaps might think it hardly worth while to set about proving, yet I think it will be well not to assume it, partly for the reasons I have already mentioned (the general absence, namely, of precise pathological views on the subject), partly because it is a necessary stepping-stone to the succeeding propositions, and partly be- cause I think its proof will be the best way of expressing my notions of the ultimate pathology of the disease and my reasons for them. It will certainly be an advantage if it can be shown beyond cavil that spasmodic stricture of the bronchial tubes is the only possible cause of asthma, that it is adequate to the production of all the phenomena, that it is a form of perverted physiology that may exist pure and uncomplicated with any or- ganic disease, and that the view that would assign it as the sole essential 1 I say from some other cause, because if asthma kills it always does so by produ/ cing organic change in the heart or lungs, or both. ITS PATHOLOGY AND TREATMENT. 17 condition in asthma is—what all pathological views should be—physiolog- ical and rational. I think perhaps the eliminative or exhaustive method of proof will be as good as any. I will suppose a case of severe uncomplicated asthma, such as we some- times see. Now, what have we here ? We have, as the sole constituent symptom, dyspnoea—dyspnoea of a peculiar kind—sudden in its access, in- tense and agonizing, following a state of perfect apparent health and ease, and relapsing as suddenly, perhaps speedily, and, it may be, without any expectoration, into ease and tranquillity again. What, then, can give rise to such phenomena as these ? We know that the only way in which such an arrear in the respiratory changes as produces a sense of dyspnoea can be brought about is by a derangement of the supply of one or both of the two fluids, the air or the blood, or by a disorganization of the functioning portion of the lung. On what recognized diseases, then, can we fall back, as supplying in such an instance the necessary conditions? On heart dis- ease possibly, bronchitis, and emphysema. But if we examine the heart we find it, in the case supposed (that is, in a case of uncomplicated asthma), perfectly healthy—it cannot then' be that. The mucous membrane of the air-passages could not assume and relinquish a condition of inflammation so suddenly; and moreover, to produce such dyspnoea the inflammation must be intense, and could not fail to give rise to the results of inflammation, yet none such are thrown out. There is not necessarily any mucous exudation; crepitation or expectoration may both be absent. Besides, it would be impossible for bronchitis to exist to such an extent as to give rise to the amount of dyspnoea, without produ- cing the constitutional signs of inflammation ; but none such are present— the patient is not ill, he is wheezing and laboring—he passes from a state of health to a state, not of illness, but of dyspnoea, and back again from dyspnoea to health : there are no sequela?, there is no convalescence. It cannot therefore be bronchitis. Emphysema we know it is not, for the dyspnoea of emphysema is constant and unvarying, and, moreover, we listen to the breathing before and after the attack, and find evidence that the spongy structure of the lung is perfectly healthy. We see, then, that in none of the three ways in which dyspnoea is ordinarily produced—on the side of blood-supply, on that of air-supply, or on that of injured func- tioning structure—by heart disease, emphysema, or bronchitis respectively —can the symptoms of asthma be explained. Moreover, the character of the dyspnoea is altogether peculiar ; it is utterly unlike either of the three dyspnoeas that have been mentioned. Heart dyspnoea is intolerant of the slightest exertion, or of the recumbent position, and sitting up, or stillness, may cure in two minutes the most violent paroxysm. The breathing, too, has rather a panting and gasping than the wheezing, laboring character of asthma. Bronchitic dyspnoea is short, crepitous, and accompanied with cough ; asthma, often long-drawn, dry, and without cough. In pure em- physema the dyspnoea is abiding, varies but little and has no wheeze. But the dyspnoea of asthma tells a plainer tale than this; it tells us not only what it is not, but what it is. It gives the most positive evidence of narrowing of the air-passages. The asthmatic's breathing is what our forefathers called "strait," what we call "tight;" he feels as if a weight were on his sternum, as if his chest were compressed, as if a cord bound him, as if it would be the greatest relief to him if some one would cut his breast open and allow it to expand. He rushes to the window to get air; he cannot tolerate people or curtains about him; his clothes are loosened, and all the muscles of respiration tug and strain their utmost to 2 18 on asthma: fill his chest. But he can neither get air in nor out, he can neither in- spire nor expire—his respiration is almost at a dead-lock ; he cannot blow his nose, can hardly cough or sneeze, cannot smoke a pipe, and if his fire is failing, cannot blow it up; he has hardly air enough to produce the laryngeal vibrations of speech. The chest is distended, indeed, to its greatest possible limit, the cavity of the thorax is enlarged both in the costal and diaphragmatic directions ; the costal distention is shown by the fact that the clothes that ordinarily fit will not meet over the chest by from one to two inches, while the descent of the diaphragm is shown by the increased girth of the abdomen and by the heart being drawn down to the scrobiculus, where it is seen beating plainly ; such are the violent instinc- tive efforts of the respiratory muscles to overcome the obstruction to the access of air. But they are unavailing; the air that is without cannot get in and that which is within is locked up. In spite of the violent muscular effort there is hardly any respiratory movement, the parietes of the chest cannot follow the action of the muscles : on listening to the chest the respiratory murmur is inaudible, even when not drowned by the wheezing ; respiration is almost nil. Where, then, can this obstruction to the intro- duction and exit of air be ? It must be in some part of the air-passages— the larynx, trachea, or bronchial tubes. In the larynx and trachea we know, from the symptoms, it is not. The fact of bronchial stricture, then, is certain. The very intensity of the dyspnoea, too, its agonizing and laborious character, implies that the seat of the mischief is in the air-passages. Dyspnoea is essentially remedial, and tends directly, both by its sensory and muscular phenomena, to diminish and relieve its cause. As soon as respiration is not going on satisfactorily the sense of dyspnoea, or want of breath, at once prompts to more violent respiratory efforts, which tend to relieve it. The distressful sensation is an essential link in the chain—it gives warning of the condition to be remedied and is the irresistible stimu- lus to the remedial efforts. But this sense of dyspnoea, being in its nature remedial, would be likely to be felt only in those cases in which the con- dition giving rise to it could be remedied by those extraordinary respira- tory efforts to which it irresistibly prompts. Now, consistently with this new, I think I have noticed a very curious law with regard to dyspnoea— it is this, that it is proportionate not to the amount of injury done to the organ, but to the amount of relief that the condition admits of by extraor- dinary respiratory efforts. If the parenchyma of the lung, its functioning structure, is injured, no amount of respiratory effort will better the con- dition, and accordingly violent dyspnoea is not induced. Thus, half the lung may be destroyed by phthisis or solidified by pneumonia, and the tranquillity of the respiration be hardly interfered with : a little hurried, perhaps, but with no distress or violent effort. But if, while the lung- substance is healthy, the free access of air is prevented, violent and distress- ing dyspnoea is immediately induced—as in croup, laryngitis, the sudden infarction of a large bronchus. For here, if the air could only be got in sufficient quantity to the healthy functioning structure, the balance of the function would be completely restored ; hence it is that such cases are always characterized by those violent respiratory efforts which have for their object the freer introduction of air, and that urgent sense of want of breath which is the constituted stimulus to these efforts. We recognize therefore, in the very urgency of asthmatic dyspnoea, evidence that the mischief is in the air-passages, and that it of such a nature as to shut off the air-supply. ITS PATHOLOGY AND TREATMENT. 19 But the sounds of asthma give us perhaps still more certain and circum- stantial evidence as to the condition of the bronchial tubes. We know in health that respiration is noiseless, but that when the breathing becomes asthmatic it is accompanied with a shrill sibilant whistle. We know, too, that hollow tubes give no musical sound when air rushes through them, if they are of even calibre, but that if they are narrowed at certain points, if their calibre is varied, the air in them is thrown into vibrations, and they become musical instruments. The wheezing of asthma, then, is as positive evidence of bronchial contraction as if we could see the points of stricture —it is physical demonstration. Now, in what ways may the bronchial tubes be narrowed ? In four, I think, as shown in the accompanying diagram.—By a plug of tenacious mucus partly closing the passage, Fig. 1, a ; by congestive or inflammatory thickening of the mucous membrane, Fig. 2, b ; by plastic exudation thrown out in the submucous areolar tissue in severe bronchitis, and undergoing subsequent slow contraction (in the same way as we see in oesophageal and u>- Diagram showing the four ways in which the bronchial tubes may be narrowed. 1. Bronchial catarrh. 2. Recent bronchitis. 3. Old bronchitis. 4. Asthma. urethral stricture), Fig. 3, c; and by contraction of the circularly disposed organic muscle which exists in the bronchial wall, Fig. 4, d. The last is spasmodic stricture, the other three are not; the first is no stricture of the tube at all; and the second and third are inflammatory stricture; the second recent, vascular, and mucus ; the third old, fibrous, and submucus. In all these ways the column of air in a bronchial tube may be constricted, and the tube converted into a musical instrument—the seat of a sound that will be sonorous or sibilant rhonchus, of high or low pitch, according as the tube is large or small. Now, which is the cause of the sound in the case before us—the sibilus of asthma ? The sibilus depending on a plug of tenacious mucus sticking to the side of the tube is generally (always ultimately) relieved by coughing ; the sibilus of asthma is never affected by coughing. Inflammatory tumidity of the mucous membrane can never be dissociated from the symptoms of existing bronchitis, and the sibilus arising from it is not of transient appearance and disappearance ; the sibilus of asthma, however, may come one minute, and the next be gone, 20 ON ASTHMA : and is ever changing ; morever, the signs of bronchitis are absent. The sibilus arising from the contraction of plastic exudation thrown around the tube is unvarying and irremediable—a permanent condition, and must have been preceded by some recognized attack of severe bronchitis ; the wheeze of asthma, on the other hand, ceases with the paroxysm, and there need not have been bronchitis in any part of the previous history of the case. We have thus got rid of three of the possible causes of sibilus— we have seen that in the case before us (asthmatic wheezing) it cannot be produced by mucus plugging, by vascular tumidity of the mucous mem- brane, or by the slow contraction of old plastic exudation thrown around the tube. Muscular spasm alone remains. And should we have in this a condition consistent with all the phenomena, and sufficient for their pro- duction ? Perfectly." The supposition of spasmodic stricture of the air- tubes would explain the sudden access and departure of the dyspnoea, for it is a state that may be instantaneously induced, and may instantaneously vanish; it is consistent with perfect health in all other respects, with the absence of all organic disease or vascular disturbance in the lungs (except that which results from it), with the kind and characters of the sounds generated, with the particular type of the dyspnoea, with the effects of remedies, and with all those circumstances that point to the nervous nature of the disease, such as its causes, the effect of motion, its periodicity, etc.; for only by the production of muscular contraction of their walls can nervous stimuli affect the condition of the bronchial tubes ; everything, therefore, that points to the nervous nature of the disease, points to spasmodic bronchial stricture as its proximate pathological condition. Thus we see, by evidence as certain as sight, that in asthma bronchial spasm must and does exist, and that no other conceivable supposition will explain the phenomena. And we see this independently of that anatomi- cal and physiological support that dissection and experiment supply, and that has hitherto been the chief evidence adduced. But we find in the muscular furniture of the bronchial walls and the nervous furniture of the whole bronchial system, a valuable confirmation of the correctness of these views, both negatively and positively, for while the absence of these structures would be a sad stumbling-block in the way of our inferences from other evidence, their presence supplies exactly the required machinery. Nay, more, it is the most positive proof that could possibly be that muscular contraction of the bronchial tubes does take place. For what is the purpose of circularly disposed muscle, if not to vary the calibre of the tube it invests ? The muscular coat of the bron- chise consists of circularly disposed bands of fibre-cells, forming a continu- ous layer immediately beneath the mucous surface ; these fibre-cells may' be seen in tubes of great minuteness—as small as one-tenth or one-twelfth of a line in diameter. The nervous system of the lungs is derived from the vagus, the cervical portion of the sympathetic and the anterior and posterior pulmonary plexus, and is from these origins furnished with wide- spread and varied connections. It is these widespread nervous connections that can alone explain some of the phenomena of asthma to which I shall have presently to refer. The' nervous system of the lungs, thus derived, consists of ramifying plexuses, supported by the bronchial tubes as upon a scaffolding, and conducted by them to every part of the lungs. These plexuses form a sort of network, investing the bronchial tubes even to their finest ramifications, and are furnished with microscopical ganglia. But besides this anatomical evidence, we have the positive proof of di- rect experiment; for Volkmann, C. J. B. WiUiams, and others to whose ITS PATHOLOGY AND TREATMENT. 21 accounts I must refer the reader, have clearly shown that the bronchial tubes undergo contraction, in some cases even to complete occlusion, from the application of various stimuli both to the tubes themselves and to the trunks of the pneumogastric nerves. This completes the chain of evidence that the essential condition in asthma is bronchial spasm. Third.—That the phenomena of asthma are those of excito-motory or re- flex action. Whenever the peripheral application of a stimulus results in muscular motion we say that the phenomena are reflex. And so they are, univer- sally. As far as our present knowledge goes, we believe that a stimulus applied to a sentient surface or organ must first be transmitted to a ner- vous centre by incident and thence reflected by motor filaments, before it can affect the muscular tissue and stimulate it to contraction. The ner- vous centre may be a ganglion of microscopical minuteness, and the fila- ments emanating from it to their peripheral distribution may be of ex- treme shortness; but still, however near the seat of movement may be to the seat of stimulation (and they may be completely coincident), such a centripetal and centrifugal course, and such an intervention of a centre, are essential. We see a very good example of this kind of reflex nervous action in the peristaltic movement of the intestines. In this case the stimulus travels along a perceptive filament to one of the ganglia of the ab- dominal portion of the sympathetic; there it comes into relation with a motor filament, and is by it transmitted to the muscular wall of the intes- tiner i Of just such a nature is the contraction of the bronchial tubes in obedience to sources of irritation applied to their internal surface : the filaments distributed to the mucous surface receive the impression, along them it travels to some of the scattered ganglia of the pulmonary plexuses, and thence returns by motor filaments to the bronchial muscle to which these are distributed. This is the normal function of the bronchial ner- vous system ; it is for the production of bronchial contraction, in obedience to stimulus thus applied, that it is especially organized.^ It is by this re- flected path that surface-stimulation arrives at and contracts the muscular wall. It is in this way that the bronchi know when and where to contract; that a plug of mucus produces a circumscribed strait through which cough drives it with greater force ; that exudation occupying the capillary bron- chial tubes is expelled by their peristaltic contraction ; that offending ma- terial that has found ingress through the glottis is shut off by bronchial stricture from reaching the ultimate lung-structure—supposing, that is, such actions really to take place. M In asthma from the effluvium of hay, and of certain animals, as cats and rabbits; asthma from inhaling the emanations from ipecacuan powder ; asthma from breathing ammoniacal or carburetted fumes; asthma produced by certain airs ; asthma complicat- ing bronchitis—in all these the bronchial spasm is of this natural, physio- logical character; the seat of the application of the stimulus and its re- flected path being the same as that by which ordinary stimuli arrive at, and produce contraction of, the bronchial muscle. \ But one of the peculiarities of asthma is that it may be induced by stimuli applied to remote parts : in these cases the nervous circuit is much longer, and the phenomena of reflection clearer and more conspicuous. Take, for example, that most common of all the varieties of asthma, what we may call peptic asthma, in which the induction or prevention of attacks is entirely controlled by the state of the digestive organs ; in which an error ' This point will be further discussed in the concluding paragraphs of this chapter. .2 -i ON ASTHMA : in diet—the eating some particular thing, eating too largely or late in the day—is sure to bring on an attack ; while a certain dietetic abstention is as certain to be attended with immunity from the disease. Here the re- flex character of the phenomena is clear, and the nervous circuit by which the reflection is completed conspicuous and evident.' I think there are three degrees of remoteness of the application of stimulus producing asthma, and thus three groups into which we may divide these clearly re- flex cases. First.—Those that I have just mentioned, in which the source of irri- tation is alimentary and generally gastric. Here the nerve irritated is the gastric portion of the pneumogastric, by which the stimulus is con- ducted to the medulla oblongata ; this is probably the seat of the central reflection, and transmits the stimulus immediately to the lungs by the pul- monary filaments of the same nerve, the bronchial muscles contracting in obedience to this reflected stimulation, just as they would have done if it had been primarily pulmonary. Here we have only one nerve concerned —the pneumogastric—but two portions of it, one of which plays an affer- ent and the other an efferent part, while the portion of the centre involved is confined to the origin of the nerve, to the seat of implantation of these respective gastric and pulmonary filaments. Second.—Those cases in which the irritation is more remote and is confined to the organic system of nerves; e.g., asthma produced by a loaded rectum or an irritated uterus. • Third.—Where the cerebro-spinal system is the recipient of the irrita- tion which is the provocative of the attack; for example, a remarkable case related to me by Dr. Chowne, in which the application of cold to the instep immediately produced the asthmatic condition. \, Of the3e two last groups of cases I know of very few examples, and I may dismiss them with a few words. A case came under my observation some years ago in which the patient could regulate his asthma entirely by the condition of his bowels. They were, as a rule, relieved every evening : if the customary relief took place, and he retired to bed with an empty rectum, he awoke the next morning well; but if he neglected to relieve his bowels, or his efforts to do so were abortive, he was quite sure to be awoke toward morning by his asthma. Strange as this may appear it is strictly true. Dr. Copland remarks that the attack is often preceded by costiveness and inefficient calls to stool—an observation quite in accord- ance with the case I have just related ; and I should be disposed to think, myself, that these were not only precursory and premonitory symptoms, but that they had something to do with the causation of the asthma that followed them—that the attack had & propter as well as a. post relation to them._ Of a strictly analogous nature are those cases of hysterical asthma in which the attacks are preceded by recognized symptoms of uterine irri- tation. The remarkable case communicated to'me by Dr. Chowne to which I have already referred, was as follows : J. G-., a man of about fifty years of age, made application to an insurance office for the assurance of his life. In reply to the questions of the physician of the office, he stated that he was liable to spasmodic asthma. He stated that he was subject to these attacks if by any accident cold water fell upon his instep or his in- step in any other way became cold. The impression on the mind of my informant, who was the medical man who examined him, was that this was the commonest, but he is not sure it was the only, cause of the attacka The asthma came on suddenly and immediately, and the attacks were very severe. The circumstances were considered so curious that great pains ITS PATHOLOGY AND TREATMENT. 23 were taken thoroughly to sift the case, and the result was that the facts were clearly established, and the man's life refused in consequence. But while cases illustrating in this remarkable way the excito-motory nature of asthma, and the distance from which stimuli may reach and in- fluence the innervation of the lungs, are rare, cases of peptic asthma, in wliich the attacks are caused by pneumogastric irritation, are so common, that I think few cases could be found of true spasmodic asthma in which the disease is uninfluenced by the state of the digestive organs, while in a very large number it is entirely under their control. This fact is so patent and so generally recognized that it has by many writers been made the basis, of their classification of asthma ; thus Dr. Bree and Dr. Young erect into a distinct species those cases that are dependent on gastric irritation. Therapeutically, the full appreciation of this fact is most important; more is to be done for our patients on the side of the stomach than in any other direction. An observant and thoughtful physician once said to me that he considered dietetic treatment the only treatment of asthma. , But there is yet again another class of cases that have suggested to my \ mind the belief that asthma is sometimes central, not reflex, in its origin ; that it may originate in irritation of the brain itself, or the spinal cord. The two following cases appear to me to be examples of this kind of " cen- tral" asthma. The first was communicated to me by my brother, Mr. James Salter, and occurred under his own observation. The patient was a boy of about ten years old, and the disease acute hydrocephalus, which ran a fatal course in about a fortnight. Five days before his death he was suddenly seized with an attack of dyspnoea of the asthmate kind; it was very severe, lasted about half an hour, and then entirely vanished. The following day he was seized with a precisely similar attack ; but this was the last; the symptoms never reappeared, and the patient sank in the or- dinary way, from the brain disease, about four days afterward. He had never before suffered from asthma ; there were no chest symptoms either before or after the attacks—no cough, no expectoration. My brother is very precise as to the nature of the dyspnoea ; he says there was nothing cardiac about it—no panting, no orthopnoea—but that it had the laboring " difficult" character of asthma. I conceive that in this case the bronchial spasm was a phenomenon of deranged innervation from central irritation, analogous to the jactitations, rigidity, and convulsions characteristic of hydrocephalus. The other case was that of a man of about fifty years of age, subject to epilepsy. His fits had certain well-known premonitory symptoms and oc- curred with tolerable regularity, I think about once a fortnight. On one occasion his medical attendant was sent for in haste and found him suffer- ing from violent asthma ; the account given by his friends was, that at the usual time at which he had expected the fit he had experienced the accus- tomed premonitory symptoms, but instead of their being followed, as U3ual, by the convulsions, this violent dyspnoea had come on. Within a few hours the dyspnoea went off and left him as well as usual. At the ex- piration of the accustomed interval after this attack the ordinary premoni- tory symptoms and the usual epileptic fit occurred. On several occasions (I do not know how many) this was repeated, the epileptic seizure being, as it were, supplanted by the asthmatic. Of these four points my infor- mant, who was the medical attendant, seemed certain: that there was nothing amiss with the lungs either before or after the attacks, that the character of the dyspnoea was asthmatic, that each attack of asthma oc- curred at the usual epileptic period, and that they were preceded by the 24 on asthma: premonitory symptoms that ordinarily ushered in the epilepsy. I thrnk that such a case admits of only one interpretation—that the particular state of the nervous centres that ordinarily threw the patient at certain periods into the epileptic condition, on certain other occasions, from some unknown cause, gave rise to bronchial spasm ; that the essential diseased condition was one and the same, but that its manifestations were altered, temporaiy exaltation and perversion of the innervation of the lungs sup- planting unconsciousness and clonic convulsion. Bearing in mind the many points in their clinical history that asthma and epilepsy have in com- mon, this case is one of peculiar interest. To this same category of central asthma we must, in strictness, assign those cases in which the paroxysm is brought on by violent emotion, as in that remarkable instance I have related of the gentleman who had, on two distinct occasions, violent spasmodic asthma suddenly induced by alarm from the fear that he had poisoned his wife. In such a case the seat to which the stimulus is primarily applied is the brain itself. Lastly, there is a class of cases in which the exciting cause of the par- oxysms appears to be essentially humoral. I have stated that the most frequent of the exciting causes of asthmatic attacks are alimentary, and that an error in diet, or the mere introduction of food into the stomach, produces bronchial spasm by reflex stimulation, through the intervention of the pneumogastric nerve. But is this the only way in which the lungs can be affected by what is put into the stomach? No. Although the pneumogastric nerve is the only single structure that has a distribution common to both organs, yet the venous system affords a very close and intimate bond of connection between the stomach and the lungs ; for any rapidly absorbable material introduced into the stomach is at once taken up by the venous radicles of the gastric mucous membrane, and within a few seconds, having passed through the liver and the right side of the heart, finds itself in the pulmonary circulation. In this way the blood in the lungs is liable to constant change in its composition from admixture with it of the different materials thus taken up by the gastric veins ; and, from the absence of secernent or elective power on the part of these veins, is ever at the mercy of the food. The chief parts of the normal results of healthy digestion, or the morbid results of depraved digestion, and that numerous class of bodies which are at once taken up without any change, are thus thrown directly upon the lungs. In the intestines we have an additional and still more direct channel for the introduction of the con- tents of the alimentary canal into the pulmonary circulation, namely, the lacteal absorbents. It is, I believe, in this way, by the actual presence in the vessels of the lungs of the materials taken up from the stomach and intestines, that the introduction of food into the alimentary canal fre- quently gives rise to bronchial spasm. A contaminate blood is the irri- tant, and excites the bronchial tubes to contract through the intervention of the pulmonary nervous system, just as the effluvium of hay or an irri- tating gas would. In the one case the irritant affects the surface to which the nerves are distributed, in the other the capillaries among which they lie. JWhen I say a " contaminate" blood, I do not mean that the material present in it is necessarily peccant. I believe it may be perfectly normal, and yet produce asthma. /\I believe that digestion may be everything that it should be, and its results in no way different from that of a perfectly healthy person, and yet they shall, in an asthmatic, produce asthma the moment they arrive at the lungs. I believe this because some of the ma- terials that give rise to asthma are such as undergo no change, but are at IT8 PATHOLOGY AND TREATMENT. 25 once absorbed, and must therefore necessarily be identical in the lungs of the sound man and in the lungs of the asthmatic, and also because many persons who are rendered asthmatic by taking food exhibit no symptoms of deranged stomach-action whatever _>With one such case in particular I am very familiar ; it is that of a lady who every day within a few minutes after commencing her dinner experiences that dry constricted straitness of breathing characteristic of asthma ; even if she has her asthma at no other time, she will have it then ; after lasting a quarter of an hour, or half an hoar, it passes completely off. Now this lady's digestion is remarkably good, unusually powerful and rapid ; she is free from the ordinary restric- tions of diet that most people are obliged to acquiesce in—radishes, cu- cumbers, and other unwholesomes, agree with her perfectly well: and the production of the asthma does not depend upon the quality of the food ; such things as I have mentioned do not seem to induce it, while she will often become asthmatic during the plainest meal. - I believe in this, as in hay, ipecacuan, and other asthma, that the irritant differs not in the asthmatic and the healthy person, but that the essential difference is in the irritability of the pulmonary nervous system ; that it resents that which it should not resent; that its morbid sensitiveness exalts that into a stimulant which should not be a stimulant, and that thus the pulmonary nervous system registers, as it were, on the bronchial tubes those changes in the constitution of the pulmonary blood of which it should be uncon- scious. There are, however, certain articles of diet which, either from their being peculiarly offensive when materially present in the lungs, or apt to give rise to dyspepsia and its vitiated results, or specially irritating to the gastric portion of the vagus, are very apt to induce asthma. Such asthmatic articles of food are, cheese, nuts, almonds, and raisins, and sweet things in general, salted meats, condiments, potted and preserved and highly seasoned things, fermented drinks, especially malt liquors and sweet wines. I think malt liquor, especially the stronger sort, with a good deal of carbonic acid gas in it, is perhaps the most asthmatic thing of any ; next to that I should place raisins and nuts. I know the case of an asthmatic gentleman who cannot eat a dozen raisins without feeling his breath tight and difficult. But there is great caprice about asthma in this respect, strongly marked idiosyncrasies in individual cases. Thus, in one case, a single glass of hock would invariably bring on an attack, though any other wine might be drunk with impunity ; in another, Bhine and Bordeaux wines—hock and claret—were the only ones that could be drunk ; a dinner at which they alone were partaken of was sure never to be followed by asthma; but' if port or sherry were drunk the asthma would infallibly come on within an hour or two. In another case, the whole mischief of a dinner, its sting, lay in its tail, in the usual post-pran- dial coffee ; if that vicious drink was declined no harm came of the din- ner, but if it was partaken of, on came the asthma. But why, it may be asked, do I choose to adopt the opinion that these different alimentary substances produce asthma by their material presence in the blood of the lungs, consequent on their gastric absorption ? Why is not the supposition that they act as irritants to the gastric portion of the vagus sufficient for the explanation of all cases ? I do not say posi- tively that it is not sufficient; I do not say it is not the sole way in which all these articles of diet excite asthma.--' But there is in particular one cir- cumstance that makes me think that some of these materials at least, and in some cases, act by their presence in the lungs themselves, and it is this 26 ON ASTHMA : —that they induce the asthma in just such time as they would take to reach the lungs subsequent to their absorption ; that the interval between the taking the material and the supervention of the asthma will be long or short according as the absorption of that particular material is immediate or deferred. ^Thus, in a case which once came under my notice> m ™cli the taking of wine or any alcoholic drink was always followed by asthma, the asthma appeared immediately, within a minute or two; while in an- other case, in which the food producing the asthma was such as would furnish material for lacteal absorption, the asthma did not come on till about two hours after taking the food ; that is, when the chyle would be beginning to reach the blood which was being poured into the lungs. But we must not forget that asthmatics are very commonly dyspeptics, and often exhibit symptoms of perverted and capricious stomach action that suggest to one's mind the belief that the innervation of the whole of the vagus is vitiated, its gastric as well as pulmonary portion, and that the dyspeptic and asthmatic symptoms are but parts of a whole.' What I would wish, then, to express on this subject is—that I believe it possible that asthma is sometimes produced by particular materials ad- mixed with the blood in the lungs, and that therefore it is so far humoral ; but that these particular materials—whether absorbed unchanged, as alcohol, ethers, and saline solutions, or the results of healthy digestion, or of perverted digestion—have nothing particular in them, but are the same as they would be in any non-asthmatic person, and that the essence of the disease in these cases, as well as in all others, consists in a morbid sensi- tiveness and irritability of the pulmonary nervous system. Great and valuable light is often thrown on pathological questions by considering the laws of the physiology of the part concerned, for pathology is often but deranged physiology, and pathological aberrations in strict subservience to physiological laws. Let us, then, see if we can detect in the probable purpose of the muscular endowment of the air-tubes an ex- planation of any of the phenomena of asthma. What is the purpose of the muscular contractility of the air-passages ? This is a question that has been variously answered, and whose certain solution is beset with considerable difficulties. In one light we may look upon the bronchial system as the ramifying efferent duct of the great con- glomerate gland the lungs, of whose excretion, carbonic acid, it affords the means of outdraught. Now, the ducts of all large glands—liver, pancreas, salivary glands, kidneys, ovaries—are furnished with organic muscle, so that the existence of muscular elements in the walls of the bronchial tubes is in strict conformity with anatomical analogy. But when we pass on from anatomy to function all analogy ceases. The purpose of the muscu- lar endowment of the ducts of glands in general is the expulsion of the secretion; little waves of vermicular contraction pass along them, always in a direction from the gland, and thus their contents are driven along toward the orifice. Such cannot be the purpose of the muscularity of bronchial tubes, for they are permanently and necessarily patulous; indeed, throughout their greater length a special arrangement is adopted by which their closure shall be effectually prevented by means of the rings and flakes of cartilage scattered throughout their walls. In the larger tubes these are such and so placed that only a slight amount of contraction is possible ; they are continued down, in increasing tenuity and scantiness, 1 For a fuller discussion of this point the reader is referred to Chapter XII. where some of these cases of asthmatic dyspepsia are narrated. ITS PATHOLOGY AND TREATMENT. 27 to tubes of a smallness of half a line in diameter, and wherever they exist perfect closure is impossible; so that in none except tubes of extreme minuteness can absolute occlusion take place. But beyond the point of the cessation of cartilage flakes muscle still exists; it has been demon- strated in tubes T£7th of an inch in diameter, and probably exists even in the ultimate lobular bronchia? : here, of course, perfect closure can be effected. What are the acts, then, of which the bronchial tubes, thus constituted, are the seat ? Bespiration and cough. For we must consider cough a normal act. It is the constituted mechanism of expulsion of any particle j of foreign matter which may at any time be introduced with the respired air, and against whose ingress the stricture function of the glottis so im- perfectly provides. Indeed, the respiratory organs have no power of selection, no means of filtering the material on which they are every moment dependent for the exercise of their function ; they are ever at the mercy of the air, and of any materials that may contaminate it. '^Tlie power, therefore, of expelling any foreign or offending particle that may have found entrance becomes a necessary appendage to respiration. Cough is, no doubt, often a phenomenon of disease, but it becomes patho- logical from the material on which it is exercised and not from the essen- tial nature of the act.J~If exercised on blood, pus, or excessive mucus, it is a symptom of disease ; if on some foreign particle that has found accidental ingress, it is strictly normal. It is no more pathological than sneezing is pathological, which a particle of dust, or a sunbeam, may cause at any time. What purpose, then, if any, has the muscular endowment of the air-passages in relation to these two acts—respiration and cough ? It has been maintained by many that the bronchial tubes contract at each expiration, and so assist in the expulsion of the air. But the character of the fluid expelled—gaseous, and the method of its expulsion —quick, transient, and iterated, are either such as the ordinary slow ver- micular contraction of organic muscle would be appropriate for; it is impossible that bronchial tubes can expel the expired air in the same way as the ducts of glands do their secretion ; it is impossible that a wave of contraction can pass from extremities to trunk of the bronchial tree at each expiration ; it would be a rapidity of transit entirely at variance with all that we know of the law of organic muscle contraction. Moreover, we know that uninterrupted patulence from glottis to air-cell, both in inspira- tion and expiration, is an essential condition of normal breathing. If there is any bronchial contraction coincident with expiration it must be a slight narrowing of all the tubes, in proportion to the contraction of the entire lung, which would act, not as a special expiratory force, but would merely diminish the amount of residual air locked up in the air-passages at the end of expiration. This slight contraction of the whole bronchial system at each expira- tion I am, for the following reasons, inclined to believe. I have long observed that rhonchous and sibilant rales are often only audible during expiration ; that in inspiration they cease ; that they are frequently con- fined to the end of an expiration, not becoming audible till the expiration is half performed ; that the longer and deeper the expiration the louder they are ; and that the inaudible respiration of persons in apparent good health, particularly the old, may be rendered wheezing by making them effect a prolonged expiration. I have remarked this not only with the dry sounds of asthma, but with the moist rales of bronchitis ; the crepitous wheeze of senile bronchitis is often confined to the termination of the ex- 28 ON ASTHMA \ pirations. If you tell a person with unsound lungs to wheeze he immediately effects a prolonged expiration, as if he knew that that was the waj to produce a wheeze. Now, the source of sound—the plug of mucus, or the inflamed tumid membrane—exists as much during inspiration as expiration : why then should the sound be present in the one and absent in the other ? On what does it depend ? Manifestly on the alternate con- traction and dilatation of the air-passages.r The plug of mucus, or the tumid membrane, which does not narrow the tube sufficiently to give rise to a musical sound in inspiration, in expiration does. I do not know how we can explain these phenomena except by supposing that all the bronchial tubes undergo contraction during expiration, and thus magnify the effects of any sources of inequality in their calibre ; for a plug of mucus, for example, that would form hardly any impediment to the passage of air in a wide and patulous tube, would form a considerable barrier, and throw the air into strong vibrations, if that tube were in a state of contraction. V" Moreover, I have noticed (and this is a very curious fact) that when the breathing is inclined to be asthmatical, the dyspnoea may be aggravated, and the asthmatic feeling very much increased, by a prolonged expiration,' while, on the other hand, the spasm may be broken through, and the respiration for the time rendered perfectly free and easy, by taking a long, deep, ,full inspiration. In severe asthmatic breathing this cannot be doneT'; but in the slight' bronchial spasm that characterizes hay asthma I have frequently witnessed it. It seems as if the deep inspiration overcame and broke through the contracted state of the air-tubes, which was not immediately re-established. Now all this looks as if expiration favored, and inspiration opposed, contraction of the air-passages; in fact, I think it amounts to positive proof of it But this does not at all imply that the bronchial tubes undergo distinct muscular contractions at each expiration. I think it possible to explain the phenomena otherwise. I think it possible that the diminution of their calibre at expiration may be due to the constant and unvarying tendency of their muscular and elastic walls to contract, y This tendency is antagonized and overcome during inspiration, by which the tubes, like the other contents of the chest, are forcibly distended ; in expiration this tendency is no longer opposed, and, like the other con- tents of the chest, the tubes collapse. Still the assumed active contrac- tion of the bronchi is quite consistent with the phenomena, especially those which I mentioned with regard to asthma—that a long expiration, namely, deepens the spasm, while a full inspiration may temporarily annihi- late it. This looks as if bronchial contraction and inspiration were incom- patible, and could not coexist. Still, it would be possible to explain both these circumstances by supposing that prolonged expiration merely suffered the tube more completely to yield to the pre-existing asthmatic spasm, while the distention of expiration was too strong for it and over- came it. 1 I am aware that this is in direct contravention of the statement of Laennec, Williams, and other authorities on thoracic diseases, who affirm that after a prolonged and deep expiration the chest may be freely distended ; the respiratory murmur being audible and loud, and the spasm apparently temporarily suspended. I should be rather inclined to guess that in this case the re-establishment of the respiratory murmur and the suspension of the spasm were the result not of the ftzpiration but of the full inspiration that has succeeded it. At any rate. I can only say that'I have never observed what Laennec and Williams affirm, and have frequently seen what I have above described; and respect for authority, however high, should never be pushed to the concession of anything positively observed. ITS PATHOLOGY AND TREATMENT. 29 In relation to cough, the opinion has been advanced that the muscularity of the bronchial tubes may, by diminishing their calibre, increase the rapidity of th6 rush of air driven through them by the act of coughing, and thus increase its expulsive power. If this contraction were general, and extended to the smaller tubes, the reverse would be the case, for a smaller stream of air would be brought to bear upon the obstructing material. If, however, it is a circumscribed contraction, confined to the situation of the matter to be expelled, then it would be a veritable adjuvant, and the air would rush through the point of narrowing with increased rapidity, and therefore increased expulsive power, just as narrowing an outlet of water clears and deepens the channel. But the contraction be- ing at the seat of the matter to be expelled, and there alone, is an essential condition to this increase of expulsive power. A little glottis is, as it were, formed there, and the material inevitably driven through it. But there is a third purjjose, I think, arising from this very danger of the access of deleterious matter to the lungs, more important than either of the other two to which I have referred, and which I believed to be the purpose, jjar excellence, of the muscularity of the air-tubes. It is the guarding the delicate ultimate lung-structure, the shutting off from the air-cells, and preventing reaching them, any deleterious material that may have gained entrance through the glottis. JlAfter having passed the glottis there is no other means by which the further progress of any foreign matter may be arrested ; and its arrest ere it reaches the pulmonary structure seems as essential to the well-being of the lung a's its subse- quent expulsion by cough. We know, in fact, that very little of the foreign particles contaminating the air reaches the air-cells; that they are almost entirely arrested and expectorated ; and we know, too, that the respiration of air charged with any irritating or noxious material, such as the smoke of burning pitch, pungent vapors, dust, etc., will immediately produce in many people the symptoms of bronchial stricture. Another office that has been claimed for the muscularity of the bronchial tubes is the regulation of the supply of air to those portions of the lung in which they terminate, in the same way as the muscularity of the arteries regulates the blood-supply to the capillaries. J. We can easily understand how, when one lung or one portion of a lung is injured, a re- laxation of the bronchial tubes of the other portion would enable them to deliver to it a freer supply of air, and thus capacitate it better for doing double duty. On the other hand, we can imagine how, in certain violent inspiratory efforts, a narrowing of the bronchial tubes would limit the supply of air and exercise a conservative and protective influence by prevent- ing too great and sudden a distention. But if we would form a correct idea of the purposes which are stored up in an organ, our attention must not be restricted to its working in health, but must embrace also those exceptional processes that arise in the course of disease—those latent, and, during health, inoperative powers kept in store, as it were, against the emergencies they are to meet—by the possession of which, in its different organs, the body becomes not only a self-maintaining and self-regulating, but a self-correcting machine. Have the bronchial tubes any such exceptional office, adapting them to a patholo- gical exigency ? Such a one has been assigned them. It has been main- tained that when the smaller bronchial tubes become filled with secretion, as they so commonly do in disease—with mucus, for instance, as in capillary bronchitis, or with mucoplastic matter, as in pneumonia—they empty themselves of it and pass it on into the larger tubes by a peristaltic con- 30 ON ASTHMA : traction. This would be the acquisition in disease of the same kind of action as the ducts of most glands have in health. There are two strong negative reasons in favor of this view. One is that there is in these minute bronchial tubes an absence of that anatomical peculiarity that would prevent anything like a peristaltic contraction of the larger ones— namely, the flakes of cartilage. The other is that these ultimate tubes are wanting in the ordinary mechanism of discharge by which the bronchial system keeps itself empty—the vis a tergo, namely, of cough; for, having behind them only so small a volume of air—that contained in the lobule or group of lobules in which they terminate—sufficient explo- sive force cannot be brought to bear upon the mucus obstructing them— there is no air behind it to drive it forth. The larger the tubes, the more effectual cough becomes, because the greater the portion of lung with which they correspond, and the larger the volume of air on which the parties of the chest exercise their pressure in the explosive expiration of cough. The ultimate bronchin?, then, being deficient in this power of clearing themselves, we should naturally expect that some succedaneum would be provided, and this we recognize in the peristaltic contraction of which they are probably the seat. Were it not for this, one can hardly conceive by what mechanism they would empty themselves of the materials by which, as shown by the sounds of respiration during life and jjost- mortem examination, they are so apt to become infarcted.1 .✓- Now can we see in these real or probable purposes of fne muscular contractility of the bronchial tubes any explanation of the phenomena of asthma, and any clue to the ultimate pathology of the disease ? I think we can, most clearly. n chest of young asthmatics. Asthma never kiUs ; at least I have never seen a case in which a paroxysm proved fatal. If death did take place from asthma it would be by slow asphyxia—by the circulation of imperfectly decarbonized blood; and before this occurred I think the spasm would yield. When a case of asth- ma terminates fatally it does so by the production of certain organic changes in the heart and lungs ; and it is on this tendency to the genera- tion of organic disease that the gravity of asthma depends. The consequences of asthma admirably illustrate two laws of our organization: one, that the workings and processes of hfe are so intimately bound together, so exactly fit and interlock, that one cannot go wrong without dragging the rest with it; the other, that healthy function is as necessary to healthy structure as healthy structure is to health}' function. Without asserting that the perverted function of a tissue or organ is in all cases dependent upon some real though perhaps inappreciable perversion of its structure or constitution (which, though perhaps probable, is at present beyond our demonstration), we may safely affirm the converse— that no tissue or organ can long be the seat of perverted action without perversion in its structure or constitution inevitably following. Organs are made for action, not existence ; they are made to work, not to be; and only when they work well can they be well. It is the universal law of or- ganization that the function of parts shall be, if not absolutely coincident, at any rate indissolubly connected, with their nutrition. The very nutri- tion of organs is planned on the supposition of their being working machines, and in exact accordance with the work they have to do ; so that their working can neither be suspended nor damaged without interfering with their nutrition, and therefore with their structure. Organs either misused or disused invariably organicaUy degenerate. If we examine the chest of an asthmatic who has but recently been af- fected with his disease, or whose attacks have been infrequent, we shaU very likely find evidence of perfect anatomical soundness of all its organs: but if we examine him again in ten years we shaU to a certainty, if the pa- tient has in the interval suffered constantly from attacks of his malady, ITS PATHOLOGY AND TREATMENT. 83 find evidence of organic disease of the lungs, and very likely of the heart. Now, why is this ? Why should organic disease be the inevitable sequel of that which is at first a mere functional and occasional derangement ? From the very law I have just above enunciated—that functional disorder cannot long exist without dragging in its train organic change. The consequences of asthma appear to me to be fourfold : 1. The di- rect results on the bronchial tubes themselves of the inordinate action of their waUs. 2. AU those results of obstructed circulation, first pulmo- nary, then systemic, which the inadequate supply of air to the lungs in- duces. 3. That special result of the unequal and partial distribution of air to the lungs—emphysema. 4. The general effect of the disease on the physiognomy and build of the patient—the production of what may be caned the asthmatic physique. J, 1. Direct Results of the Asthmatic Spasm on the Bronchial Tubes them- selves.—Organic muscle obeys the same laws as voluntary ; its nutrition, and therefore its development, is proportioned to its activity; and this evidently from the same final cause—that it may be equal in its work. No sooner is its activity exalted, or more work thrown upon it, than it imme- diately hypertrophies : witness the urinary bladder in stricture, and the gall-bladder in biliary calculus. AThe bronchial tubes in asthma afford but another example of the same thing, and their excessive action issues, from the operation of the same law, in a similar hypertrophous development. Accordingly, we constantly find, among the morbid appearances mentioned in the post-mortem examinations of asthmatics, an undue conspicuousness and thickening of the circular fibres of the bronchia?. One certain result of this hypertrophy of the bronchial muscles is a permanent thickening of their walls and consequent narrowing of their calibre ; and one possible result is a greater disposition on the part of the hypertrophied muscle to take on a state of contraction. To the former, perhaps, is in part due that slight constant dyspnoea which is so disposed to develop itself in asthma ; to the latter, the increasing tendency to and frequency of spasm which characterizes some cases. Contraction of the bronchial tubes—a permanent diminution of their calibre—is another direct result of asthma. A certain amount of narrow- ing is inevitably involved, as I have just stated, in the increased thickness of their walls, due in part to the hypertrophy of their muscular element, in part to the congestive tumidity of the mucous membrane, which is the almost invariable accompaniment of long-continued asthma. Perhaps, too, as suggested by Dr. Williams, the very fact of an increase of the contrac- tile element of the walls of the bronchias involves a degree of permanent passive contraction in excess of what is natural, just as the irritable blad- der is a contracted bladder as well as a thickened one. A certain amount, then, of thickening and a certain amount of contraction of the bronchial tubes, is fairly to be assigned to asthma, and has in it its sole and suffi- cient cause. But we sometimes find in cases of asthma a degree of contraction far beyond what is thus explicable, amounting to complete occlusion. Now remembering how frequently asthma is complicated with bronchitis, how exactly such a condition of extreme contraction or occlusion is that which old severe bronchitis tends to produce, and how inadequate simple spasm seems to produce it, I am inclined to think that the asthma has nothing to do with it, that it is to be assigned whoUy to the bronchitis that has com- plicated the case, and that cases of asthma in which it is found are always mixed cases. This kind of bronchial contraction, converting the tube into 84 ON ASTHMA : a fibrous impervious cord or band, thickened and knotty, I believe to he always inflammatory in its origin. . . Dilatation of the bronchial tubes is another morbid condition that has been found in asthma. I think the most dilated bronchial tubes I have ever known were in a case of asthma. But whenever I have seen it there has been bronchitis as weU as asthma, and, for the reason I have just assigned in the case of contraction, I should attribute this also to the bronchitis and not to the asthma. I do not see how bronchial spasm could possibly generate it, whereas I do see in the destruction of the vital and physical properties of the bronchial walls by severe inflammation the most rational explanation of its production. And I may here remark in passing, that there are two circumstances that greatly impair the value and reliabUity of the specimens of the mor- bid anatomy of asthma found in our museums: one is, the looseness with which the word asthma is, and still more has been, used ; the other, the extreme frequency with which, even in cases of true asthma, bronchi- tis has at some time or other existed. 2. The Results of Obstructed Circulation induced by Asthma.—Asthma is a state of partial apncea, and it therefore gives rise to an identical mor- bid anatomy, differing only from that of absolute apncea in its incomplete- ness, and in those ulterior changes for which in absolute apncea, suddenly induced, there is no time. When a man is drowned we know that an im- passable obstruction is at once established to the passage of the blood through the lungs ; within a minute or two the stoppage is complete. The pulmonary arteries, stiU filled from behind, become engorged with the blood that they cannot pass on ; the right chambers of the heart become distended with the blood which they are unable to empty into the en- gorged arteries; and thus, the obstructing force propagated backward, the cavse and their tributaries become distended with accumulated blood in increasing quantities as long as hfe is prolonged. Meantime, the left side of the heart receives hardly any supply, and its action fails for want of its normal stimulus, whUe the right side becomes less and less able to contract on its bulky contents. Soon, from these opposite causes on the right and left sides, the heart ceases to beat, and hfe is extinct. We open the body, and find—arteries, left side of the heart, and pulmonary veins empty; pulmonary artery, right side of the heart, and aU the great systemic veins gorged with black blood. Now there can be no doubt that exactly the same thing takes place at every attack of asthma, but only to a degree that is compatible with life. If we could see into an asthmatic during a fit we should see a certain dose of the same deranged distribution of blood, and from the same cause—ar- rest of the pulmonary circulation from the shutting off of air. We should see pulmonary arterial congestion, distended right heart, large veins full, and a scanty supply of imperfectly arterialized blood finding its way to the left ventricle. AU external manifestations are consistent with this: the small and feeble pulse, the irregular and faltering systole, the turgid veins of the head and neck, the occasional haemoptysis, the dusky skin. If aU the bronchial tubes could be simultaneously so contracted as to be completely occluded the same result would take place as if a ligature were placed round the windpipe, the deprivation of air would be complete, and death would supervene. But such is not the case, all the bronchire are not simultaneously contracted, and their contraction does not amount to complete occlusion. The arterialization of the blood is lowered, not ar- rested, and hfe is maintained. By and by the spasm yields, air is freely ITS PATHOLOGY AND TREATMENT. 85 admitted, the bar to the free transit of blood ceases, the pulmonary vessels unburden themselves, and all is well again. But can such a state of things exist long, or exist often, without pro- ducing other organic changes ? Certainly not. No tissue or organ can be long or often the seat of vascular disturbance without becoming more or less disorganized. I shaU consider the changes that result from this stoppage at the pulmonary circulation, that every attack of asthma gives rise to, in the order in which they occur—in the lungs, in the heart, and in the systemic venous system ; that is, in those three segments of the circu- lation along which, in a retrograde direction, the obstructing force is propagated. In the lungs the first result is what is caUed venous congestion—a term in part correct and in part erroneous ; for, while the congestion is congestion with venous blood, the congested vessels are really branches of the pulmonary arteries. I am not aware that the exact seat of this con- gestion is determined, whether it is limited to the branches of the pulmo- nary arteries, or involves the capillaries as well. That wiU depend on the precise point of the seat of obstruction. If the capillaries are congested the seat of obstruction must be in front of them ; if the capillaries them- selves are the seat of the obstruction they cannot be congested—the con- gestion must be hmited behind them. Now, I am inclined to think that the exact seat of the obstruction is in the minute venules,1 just where the blood is passing from the capillaries into the pulmonary veins; and my reasons are these : the cause of the stoppage is the blood not being what it should, not being properly decarbonized. Now, the capillaries are the seat of its decarbonization ; it is not, therefore, until it leaves them and arrives at the ultimate pulmonary venous radicles that it becomes what it should not be—venous blood where it ought to be arterial. That point, then, where its defective arterialization must be first recognized, must be the point of its arrest. This would imply capillary engorgement. Whether 1 I have already referred to Dr. George Johnson's observations on the thickening that takes place in the muscular element of the walls of the minuter arteries of the kidney, skin, etc., in cases of chronic renal disease, and to the bearing that those ob- servations have on the question both of the seat and mechanism of the pulmonary stasis of apnoea. If the interpretation that Dr. Johnson's observations irresistibly suggest is the correct one, then the question as to the point at which the bar to the circulation through the lungs is placed is set at rest—it must be in the terminal twigs of the pulmonary artery, and not in the capillaries. If, when from functional inca- pacity of an organ, the changes that ought; to take place in its capillaries do not take place, and the blood is therefore not in a fit 6tate to pass through and from them, the minute arteries are thrown into a state of persistent contraction, then we must im- agine that such would be their condition in the lungs in apnoea. That it really is so, and that it is in the terminal arteries and not in the capillaries that the obstruction to the pulmonary circulation takes place, is shown by the emptiness of the capillaries after death from acute apnoea. In dogs killed by plugging the windpipe, and in cul- prits who have been hung, the lungs are found remarkably anasmic, and, when the chest is opened, collapse to an unusual degree (the amount of collapse always being a measure of the anaemia, and the incapacity of collapse of the engorgement, of a lung). Although no longer tenable, I think my hypothesis, that the point of stoppage in apnoei was at the minute venous radicles, had prima facie probability in its favor, and the only way in which we can conceive, in relation to efficient cause, the production of contracted arteries by imperfect capillary function, is by supposing that the abnor- mal condition of the blood in the capillaries acts as a stimulus to the vaso-motor nerves, and that this stimulus, propagated backward, reaches and is spent upon the muscular walls of the minute arteries; while the only way in which we can explain the phenomenon in relation to final cause, is by supposing that the object of the con- traction of the arteries is to limit the supply of blood travelling to a capillary system whose functioning power is actually or relatively impaired. 86 ON ASTHMA : the absolute capiUaries are involved in the engorgement I cannot say, or whether it stops at the ultimate twigs of the pulmonary artery. It should be made the subject of careful microscopical observation, which I have not yet made it. Indeed, I am not aware that the state of the vessels in chronic pulmo- nary congestion has ever been made the subject of microscopical investi- gation. One result of this impeded circulation through the lungs which I be- lieve will one day be demonstrated, is thickening of the walls of the ulti- mate arterial twigs analogous to that which Dr. Johnson has shown to take place in impeded circulation through the kidney, and produced in an identical way. This, too, I regret to say, I have never, since the idea oc- curred to me, had an opportunity of verifying.2 Another result is, that the engorged vessels gradually lose their tone and yield to the distending force of the blood, so that the congestion becomes more and more consid- erable, and of more and more easy induction. Another result is, that the serous portion of the accumulated blood transudes the waUs of the ves- sels, and, escaping into the areolar tissue and air-ceUs, gives rise to oedema. From this accumulation of blood, and displacement of the air in the air-ceUs by serum, parts of the lung may undergo what has been called splenization, becoming quite solid, airless, sinking in water, non- crepitous, and black. And this is the state in which the more dependent parts of the lungs of those who have died of chronic asthma are often found—a state not to be distinguished from that of the lungs in fatal chronic bronchitis, and which is, in fact, the morbid anatomy of slow apnoea, however produced. Hypertrophy and dilatation of the right side of the heart has long been a weU-known and recognized comphcation of asthma. In examining the chest of an asthmatic patient we often find the heart's pulsation plainly felt, and even seen, in the scrobiculus cordis, whUe in its normal situation it can hardly be perceived. For this there are several reasons. One is, that during an attack of asthma the diaphragm is strongly and perma- nently contracted, refusing to ascend far even in expiration, so that the heart is drawn down lower than usual; another, that an emphysematous left lung may thrust it downward and to the right, and also, by overlap- ping it, produce that undue resonance in the region of the heart's dulness and that indistinctness of the apex-beat beneath the nipple which are recognized signs of emphysema in this situation. But a third reason un- doubtedly is dilatation of the right ventricle. Although this last is the only cause I have seen assigned for this clisplace- 1 There can be no doubt that ultimately the entire pulmonary circulation becomes engorged in chronic apnoea —arteries, capillaries, and veins. But this is not at all in- consistent with the fact that the first result of acute apncea is contraction of the ter- minal arteries, and the production of an anaemiated and not a congested condition of the lungs; it is only to suppose that the same thing occurs in congestion as in inflam- mation—that the same arterial contraction precedes the capillary engorgement of the one as precedes the capillary engorgement of the other. Indeed, we may with per- fect reason go a step farther, and believe that the capillary engorgement of the lung in chronic apnoea is the ultimate result of arterial exhaustion and relaxation super- vening on the s ate of contraction, as the capillary engorgement of inflammation is of the arterial relaxation and dilatation which supervenes on that spasm of the smaller arteries which appears to be the essential first step of the inflammatory process 2 Since the above was printed, eight years ago, I have not had a single opportunity of examining the lungs after death in a case of pure, uncomplicated asthma From cases complicated with bronchitis, or emphysema, no inference can be drawn! ITS PATHOLOGY AND TREATMENT. 87 ment of the heart's beat I insist on the other two as adjuvant, because they are evidently sufficient of themselves to drive the heart down into the scrobiculus and transfer its pulsation thither without any dilatation of the ventricle. In cases of recent asthma, where there has been no time for dilatation or hypertrophy of the right ventricle to take place, and where, in the intervals of the attacks, the situation of the heart's beat has been perfectly normal, I have felt and even seen this pulsation in the scrobiculus very strongly marked at each fit, coming with the fit and going with the fit. Now, hypertrophy and dUatation of the right ventricle are not condi- tions that can come and go. It is evident, then, that a transference of the heart's pulsations to the scrobiculus may be produced by simple displace- ment of the organ, without any extension of its right chambers ; and, therefore, when occurring during a paroxysm of asthma, this sign is not to be relied upon as evidence that the heart has organicaUy suffered.1 But why should heart disease be the legitimate sequel of asthma? Why should the stricture of the bronchial tubes tend to produce hyper- trophy and dilatation of the right ventricle ? The connection of these re- mote and apparently dissociated conditions is at once supphed by the law of apnoea which I have just now referred to—that the shutting off of air from the lungs immediately brings the pulmonary circulation to a stand-stiU, and places in front of the right chambers of the heart an obstacle which they cannot overcome. This obstacle at the pulmonary circulation provokes unwonted efforts on the part of the right ventricle, which, of course, becomes more or less hypertrophied. After a time the ventricle yields to the dis- tending force of the accumulated blood, next, the auricle, and, finaUy, the great veins and the whole of the venous system ; so that ultimately asthma may end in general venous congestion and dropsy, just in the same way as primary cardiac disease. But asthma may go on for a long time without any such results. It is surprising how severe the paroxysms may be, and for how many years the disease may continue (provided the fits are not prolonged and frequent), without the heart being in the least affected. It is only in cases of very long standing, and when the fits are tedious and leave a cer- tain amount of permanent dyspnoea in the intervals (especially if there is some bronchitic complication), that these changes in the heart take place. As far as my experience goes, I should say that they never occurred as long as the recovery in the intervals was absolute. I cannot, therefore, agree with Dr. Todd (Medical Gazette, vol. xlvi., p. 1001), in the importance he assigns to evidence of dilatation of the right ventricle as a diagnostic sign of asthma. "I look upon this sign," he says, "as one of the most character- istic symptoms of asthma ; and I consider its presence in any case where I suspect asthma as a clear confirmation of the correctness of those suspi- cions. In accordance with this view, one of my first steps in examining a patient whom I suspect to be asthmatic is to apply my finger to the scrobi- culus cordis. If I find no beating of the heart there, my conclusion is a contingent negative. But if I find it beating there, and not in its natural position under the nipple, my conclusion is a certain affirmative." Doubtless, in a case of suspected asthma, evidence of dilatation of the ] Of the truth of this any one may satisfy himself by placing his finger on his scrobiculus cordis and taking a deep inspiration, when he will immediately feel the cardiac pulsations, which will continue as long as he keeps his chest at full distention ; —he expires, and it is gone. Here we have the same conditions with regard to the situation of the heart that we have in asthma, only in a less degree—lung distention nnd flattening of the diaphragm ; in fact, in asthma the parietes of the chest, dia- phragmatic and costal, are in a state of permanent extreme inspiration. 88 ON ASTHMA : right side of the heart would strengthen the diagnosis ; but the absence of it would go no way at all to negate the supposition that asthma existed. It would simply show that one of the results of asthma had not yet arisen, and it would establish a presumption that the disease had not been of long standing, that it was unassociated Avith chronic bronchitis, and that it had as yet inflicted no organic changes in the lungs. A patient's heart-beat may be in every way normal, and yet half an hour ago he may have been in the agonies of an asthmatic paroxysm. The positive evidence of heart- change in asthma is of some value ; its negative evidence is worthless. 3. Emphysema is certainly the commonest of aU the morbid changes that asthma tends to produce. I should say it was extremely rare to find the lungs of those who have long suffered from asthma entirely free from emphysematous inflation.- The best examples of emphysema that I have ever seen have been in the post-mortem examinations of chronic asthma. Adopting that view of emphysema so ably advocated by Dr. Gairdner— that it is essentially a compensatory dilatation, and implies the neighbor- hood of non-expansible lung-^I believe the mechanism of the production of emphysema by asthma to be as foUows : The bronchial spasm shuts off the air; the shutting off the air produces vascular stasis ; the congested vessels relieve themselves by the characteristic mucous exudation ; the con- tinued occlusion of the bronchial tubes, if the spasm does not yield, shuts up this mucus, and prevents its escape, and, at the same time, by barring the access of air, prevents efficient cough ; so long as the spasm lasts, therefore, its escape is doubly prevented—by direct obstruction and by the want of the natural machinery for its expulsion. The tubes affected by the asthmatic contraction thus become obstructed in a twofold way—at first narrowed by spasm, and then completely occluded by mucous infarc- tion. As long as the spasm lasts the escape of the mucus is impossible. In the meantime, whatever may have been the length of the attack (and we know that it often lasts for days), the inspiratory muscles are making the most violent efforts to fiU the chest, and are, in fact, keeping it in a state of extreme distention. _>_ The length of time required for the removal of air from a lobule, from which communication with the external atmosphere is completely shut off by occlusion of its corresponding bronchial tube, I do not know ; so I do not know if, in a single attack of asthma, any actual lobular collapse could take place, although, in a prolonged attack of some days, I feel no doubt that it would. At any rate, the lobules whose bronchia? are occluded can- not yield to the distending force of the inspiratory muscles; the whole distention of inspiration is, therefore, spent on those portions of the lungs whose communication with the external air is free ; the open lobules have to expand for themselves and their occluded neighbors ; and undergo an excessive inflation in proportion to the amount of lung that is non-expansi- ble—in other words, they become emphysematous. If we consider how complete the occlusion must be by this double process of spasm and in- farction, how protracted asthma often is, and how violent are the inspira- tory efforts that characterize it, I do not think we shall wonder at any amount of emphysema that is thereby produced, nor at its being one of the commonest organic changes to which asthma gives rise. It will be seen, if the account I have just given is correct, that asth'ma produces emphysema just in the same way that bronchitis does. The two processes are essentially identical. In the one case the bronchial tubes are narrowed by inflammatory thickening of their walls and occluded by in- flammatory exudation (muco-pus); in the other, they are narrowed by ITS PATHOLOGY AND TREATMENT. 89 spasmodic contraction and occluded by the exudation of congestion (viscid mucus). The only difference is, that the narrowing and occlusion of bron- chitis are generaUy of longer duration than those of asthma. I think Dr. Walshe is quite right in his opinion that " the connection of emphysema with spasmodic seizures is certainly sometimes, possibly always, dependent on an intervening irritative or passive congestion of the tubes." That it is so sometimes I think is certain, because I think that congestion of the tubes is the immediate result of prolonged spasm. But is it always ? If not, then emphysema may result from the spastic occlusion of the tubes without any mucous infarction. Is this possible ? Is asthmatic spasm ever so complete and continuous as to produce, without mucous exudation, the results of plugging—lobular isolation and coUapse ? This is a question that I think would be very difficult, at present, perhaps, impossible, to answer. One thing I feel strongly persuaded of, that it is not necessary that there should be any true bronchitis, anything actually inflammatory, in order that asthma should result in emphysema. I have seen emphysema developed in a case of asthma in which bronchitis never existed. It is hardly worth while for me to describe the symptoms that mark the closing scene of those miserable cases of asthma that terminate in the production of these organic changes in the heart and lungs that I have just been describing. When once the right cavities of the heart have become dilated, and the obstructing force retrogrades upon the systemic veins, the symptoms are not to be distinguished from those which charac- terize a similar condition induced by chronic bronchitis. The cases differ alone in their previous history. There is the same rattling wheeze, the same choking cough, the same orthopnoea, the same abundant frothy expectoration (but in the case of bronchitis more purulent), the same venous regurgita- tion, the same choked-up breathlessness, getting ever worse and worse as the oedema and congestive solidification rise higher and higher in the lungs, the same general cedema, beginning at the feet and graduaUy creep- ing up the trunk, the same cyanosis. The sufferings of this gradual chok- ing out of life are most painful to witness, tiU the increasing heaviness from the circulation of venous blood in the brain deepens into the insensi- bility which ushers in dissolution. 4. Acquisition of the Asthmatic Physique.—Asthma is a disease that stamps on the body its own indelible marks. So characteristic and un- mistakable is the physique of asthma, so plainly, so legibly, does the asthmatic bear about with him the impress of his disease, that any one who has once observed it wUl never fail to recognize it, and would be safe in basing a diagnosis on its unaided testimony. In confirmation of this I may mention a circumstance or two that have occurred to myself. I frequently meet in the streets of this city a distinguished savant, who.is a great sufferer from asthma, and if I were to meet him at Pekin I should know him to be an asthmatic. The first time I saw him I was walking behind him, but immediately recognized the characteristic con- figuration. So certain did I feel of it, and so curious was I to see if I could derive from his face any confirmation of my impression, that I over- took him, and, as I passed, saw at once who he was, from his resemblance to a photograph I had seen of him ; and then I remembered what I had heard about his malady. This previous knowledge, however, could have had nothing to do with my impression, as at first I had no idea who he was—in fact, had never seen him before. On another occasion, I was going down to Brixton in an omnibus, and 90 ON ASTHMA : sitting near me was a gentleman whose figure and appearance very much t struck me. He looked well in the face, was breathing without the slightest difficulty, and was engaged in animated conversation with his next neighbor. But I felt sure he was an asthmatic ; he was exceedingly thin, his shoulders very high, and his back so rounded, that though quite a tall man, he sat lower, a good deal, than I did. He left the omnibus before me, and in walking his stooping gait and rounded back were sthl more conspicuous. When I left the omnibus, I asked the conductor " if he knew that tall, thin, stooping gentleman that got out at such and such a place." "Oh, yes," he said; "it is Mr.----, of ----." "Do you know," I asked, " if he is subject to a complaint in his chest, that gives him fits of difficult breathing ? " " Oh, yes," he replied, " and has been for a long time—for years ; sometimes he can hardly walk to the omnibus." Here, then, are two cases in which I recognized the presence of asthma merely by the changes in the physiognomy and configuration which it produces. I have done the same thing in several other instances. T often say to myself, as I pass an individual in the street with the characteristic configuration, " You are an asthmatic." What, then, is this unmistakable impress of asthma ? How is it to be described ? In what peculiarities does it consist ? Partly those of the figure, partly those of the face. In configuration the asthmatic is round- backed, high-shouldered, and stooping; but whUe the body is bent forward, the head is thrown back, and buried, as it were, between the elevated shoulders. There is no movement or pliancy in the body, but the chest is fixed and rigid, like a box, and from it the arms depend, hanging motionless, or swinging like two pump-handles, rather thrown back, and bent at the elbows. In walking the legs seem the only part of the body that moves. From the roundness of the back, the asthmatic, for his height, always sits low. Those who have suffered from asthma long are almost invariably thin, often to a degree, amounting to emacia- tion ; their limbs are attenuated and bony, every rib can be counted, and their clothes hang loosely on them. From the entire absence of subcuta- neous fat the superficial veins are very conspicuous ; though it is possible that venous obstruction, from impeded circulation through the lungs, may have something to do with their prominence—that it may be, in fact, slight general varix. The prominence and tortuousness of the veins is sometimes remarkable, especially in old asthmatics. The hands of an asthmatic are very characteristic; they are cold, blue, thin, and veiny. This blueness and coldness of the extremities is partly due, no doubt, to the feebleness of the circulation in them, but in part, especiaUy if there is some permanent dyspnoea, or the patient is at the time suffering from an attack, to imperfect decarbonization of the blood. But the blueness of surface is not confined to the extremities ; the complexion of the asthmatic is often distinctly cyanotic—a slight but -per- ceptible duskiness. Where, however, there is no dyspnoea between the attacks, and the intervals are long, especiaUy in young subjects, I do not think the complexion is perceptibly affected. The face has generally rather an anxious expression, and often bears an aspect of age greater than the real age of the patient; even if not dusky it is always pale, and, like the rest of the body, is thin—the cheeks are hollow and the lines of the face are deeply marked. The mouth is generaUy open and the jaw rather hanging. There is a pecuharity about the eyes to which I would call particular attention, to which I often have directed attention among the patients at the hospital, and on the strength ITS PATHOLOGY AND TREATMENT. 91 of which alone I have frequently diagnosed asthma ; they are turgid, watery, and prominent. I believe this to depend, like the enlargement of the superficial veins, upon venous obstruction ; the turgidity is that of the veins of the conjunctiva; the wateriness is due to an unusual amount of mucus and tears which the engorged mucous membrane and lachrymal gland pour out; while the prominence is due to the turgidity of the veins of the orbit. Wherever I find this appearance of the eyes in connection with chronic asthma, I look out for dilated right heart. The asthmatic's voice is often very peculiar ; it is feeble and slightly hoarse and rough ; he speaks as a healthy person would speak if he were to expire as long as he could and then begin to speak—as if he were mak- ing use of the last breath in his lungs ; and it is, indeed, to the small res- piratory resource that he has for speech that this feebleness and roughness of the asthmatic's voice is due. His sentences are short and frequently interrupted by a single dry cough. Many of the external characteristics of asthma that I have enumerated, such as the gait, the dusky complexion, the eyes, the voice, wiU be seen at once to be those rather of chronic dyspnoea than of asthma, and I would so far qualify their value as diagnostic signs. Indeed, their value is rather generic than specific. In the purest cases of spasmodic asthma, in which there is no trace of dyspnoea in the intervals, they are the least marked, and are the most conspicuous in those which are complicated with some chronic bronchitis or bronchial congestion, so that I look upon their ab- sence as a good sign, as a sign that the lungs are sound and unscathed ; and it is because asthma seldom exists long without producing such chan- ges as permanently embarrass the breathing, that these changes in the phys- iognomy and configuration come to be signs of asthma ; they are just as much a part of its clinical history as those internal changes in the lungs and heart, of which they are the sure sign and accompaniment. I have, however, seen the asthmatic physique very strongly marked in some cases where the lungs were organically sound; but these were always cases where the paroxysms were very long, lasting for days or weeks, so that the efficient cause was in continued operation for a long time ; or else they were cases in which the asthma had been very severe in childhood, when the figure was forming, so that it got set in the asthmatic shape, and, al- though the disease afterward quite disappeared, the figure never recov- ered itself. Such cases carry a certain highness of shoulders and round- ness of back with them to the end of their days, however completely the asthma may be in mature life recovered from. Sometimes, however, on the disappearance of the disease, a wonderful improvement may take place in the figure, especiaUy if the patient is young. This was strikingly shown in the case of a young lady who came under my care three years ago. She was then seventeen years of age, and I described her in my notes as " a healthy-looking, fine girl, with no asthmatic stoop." Two years pre- viously my friend Mr. Bailey, of Liverpool, had sent me an account of her case, in which he described her as "high-shouldered, back very round, and very thin." But in the meantime her asthma had almost disappeared. The degree of deformity of the back is, in some cases, truly remarkable ; and (although I have not examined any of the spines of these cases after death) such as I cannot but think must involve some anatomical change in the bones or intervertebral disks. The curvature is always direct antero- posterior, never lateral, and involves the middle or lower dorsal vertebrae. In one case I have seen the angle made by the curvature almost as consid- erable as an angle of a hundred degrees. Now, it is certain that such a 92 ON ASTHMA : change in direction as this, almost a right angle, effected within the length of a few vertebrae, could only be produced by a great shortening of the anterior aspect of the column, involving a vertical shortening of the ante- rior part of its separate elements—vertebrae, or intervertebral disks, or both—converting the bodies of the vertebra?, or the disks of fibro-cartUage between them, into wedges, as shown in the accompanying diagram. The agency by which a disease affecting the air-passages produces this curvature of the spinal column was, at first, not very clear to me, and it was long before I arrived at what I believe to be its true explanation. It cer- tainly was not a change of form having for its object the enlargement of the thoracic cavity, like the barrel-chest of emphysema ; it was manifest that such a deformity must materiaUy prejudice the size, the shape, and the movements of the thorax. It was equaUy certain that there was no spinal disease ; that the curvature was the result of repeated attacks of asthma; that it was the permanent retention and constant aggravation of Pig. 3.—Diagram showing the change of form in the bodies of the vertebra, or intervertebral disks, in- volved in the anterior curvature of asthma: a, natural shape; b, if the disks, c. if the bodies of the vertebras become wedge-shaped. the asthmatic stoop which always exists during the paroxysms. But, be- yond this, its nature and causation did not appear intelligible. At length I was guided to what appears to me to be its true rationale by the foUow- ing considerations: First.—Pressure produces absorption of the part pressed on ; e.g., the absorption of the sternum and ribs in aneurism. Second.—In stooping—i.e., in forward curvature—there is vertical pres- sure along the anterior face of the spinal column ; i.e., its elements exercise vertical pressure upon one another in their anterior portions. Third.—The unsupported spine tends to faU forward—i.e., to anterior curvature ; the whole array of the muscles of the back are erectors of it. Fourth.—When the muscles of extraordinary respiration are engaged in extraordinary respiratory efforts they cease to play their ordinary role ; e.g., the homo-hyoid muscle is ordinarily a depressor of the hyoid bone, but in asthma it is an elevator of the scapula, and powerless to depress the hyoid bone ; the sterno-mastoid is ordinarily a rotator and anterior flexor of the head ; in asthma, it is an elevator of the sternum and clavicle, and power- less to move the head. I infer, therefore, that the muscles of the back, being engrossed during the asthmatic paroxysm with their violent respiratory labor, cease to act as erectors of the spine. The back is, therefore, unsupported, and obeys its natural tendency to faU forward. This, I am sure, is the true explanation of the asthmatic stoop ; and we see, consistently with this view, that any ITS PATHOLOGY AND TREATMENT. 93 effort to straighten the back is immediately attended with additional dis- tress (because the muscles are temporarUy withdrawn from their respira- tory action), and that the stooping is always in proportion to the dyspnoea —that is, in proportion to the degree in which the muscles of the back are engrossed by the breathing. The back being, therefore, left thus to itself, and faUing thus forward, the anterior parts of the bodies of the vertebrae and intervertebral disks are pressed together ; and if the asthmatic state is continued long and occurs frequently, this pressure is so protracted that it produces absorption of this part of the bodies of the vertebrae, or the inter- vertebral fibro-cartilages, or both ; they become wedge-shaped, and the temporary stoop becomes a permanent curvature. Now, I admit that I have never examined the spine, post-mortem, in cases of this asthmatic deformity ; and I merely offer this hypothesis as a reasonable explanation. In cases in which I#have seen it there has not ex- isted the slightest ground for believing that there was any spinal disease. In the most marked case that I ever saw (of which I have been disappointed of giving a figure, from the loss of a photograph I had had taken and the subsequent death of the patient), the back was straight before the asthma came on, and the patient taU ; but as the asthma became worse and the attacks longer and more frequent, the stoop, which he always had dur- ing the attacks, went off less and less in the intervals, and gradually became more and more considerable, till it settled into a permanent deformity, which, though his legs were long, made him quite a short man. No pain is experienced in the back in these cases (except an aching of the dorsal muscles during the asthma, from their violent respiratory exertion). Moreover, the curvature is never confined to a single vertebra, or to two or three, and is never angular; it is rounded and gradual, and involves a considerable portion of the back. In such an absence of all evidence of spinal disease, and with an amount of curvature, in some cases making some change of form in the elements of the spine a physical necessity, I do not see what explanation can be offered other than that I have given. If correct, it is certainly interesting ;• it has the interest of all facts which elucidate a modus operandi, and furnish the connecting links between as- sociated but apparently diverse phenomena. When my mind was engaged in thinking on this subject a case of an- other nature occurred to me which confirmed my ideas, and seemed to show that mere loss of power on the part of the muscles of the back was adequate to the production of anterior spinal curvature. A man in the prime of life, with an erect figure, who had never had anything the matter with his spine in any way, was seized with severe rheumatism in the mus- cles of the back, and the pain was so aggravated and rendered so intense by attempting to stand upright, that the muscles refused to perform their office ; the unsupported spine bent forward as far as its elasticity would permit, and the back became round and the gait stooping, like that of an old man. This went on for some months, without any decided curvature appearing ; at length, distinct and gradually increasing curvature mani- fested itself, involving the seventh and eighth dorsal vertebra?, and to such an extent as to show that their bodies must have undergone some change of shape. The patient recovered from his rheumatism, regained the power of supporting his back, and the curvature was arrested ; but it has never disappeared. If, then, loss of power of the spinal muscles, paralyzed by rheumatic pain, is adequate to the production of organic curvature in the way that I have supposed, why should not their paralysis, as erectors of the spine, 94 on asthma: from their being engrossed in their respiratory action, be attended with the same result ? . In young asthmatics, who have suffered from their disease in infancy, I have observed a configuration of chest which I have seen, to a certain ex- tent, in cachectic rickety chhdren who have not suffered from asthma, but which I am not sure I have ever seen in chhdren who have not suffered from any chest affection. I am not sure, therefore, what share in the pro- duction of the deformity ought to be assigned to the asthma, or what to the deficient strength of the bony parietes of the chest; or whether im- perfect ossification and chest-mischief are both necessary for its produc- tion. What inclines me to think that the latter cause is the chief one (or, at least, an essential one) is, that the deformity is just such as would bo produced where there was an impediment to inspiration, and where violent but ineffectual inspiratoiy efforts were made by weak parietes—just such, in fact, as one sees in the inspiration of atelectasis or laryngitis. In these cases, the upper part of the chest—above the fifth or sixth rib —is naturally shaped; but below that level, on each side of the sternum and along the margin of the false ribs, corre- sponding to the cartilages of the seventh, eighth, ninth, and tenth, the surface, instead of being convex and fuU, is excavated in two hollows. These hoUows are bounded internaUy by the lower part of the sternum, which stands forward between them in a ridge ; and externaUy by the extremities of the ossified portions of the ribs, which form a ridge on the outside. The situa- tion of this flattening in of the thoracic parietes —its coincidence with the cartilages of the ribs —suggests the way in which it is produced, and explains how asthma might cause it. I take the method of its production to be this: When there is any impediment to the ingress of air into the lungs—from narrowed bronchial tubes, as in asthma, or any other way—the air cannot rush in so fast as the thoracic parietes are expanded, a partial vacuum is therefore formed in the chest, and the pressure of the air within it no longer balances that of the ah* with- out. This unbalanced external atmospheric pressure presses on the whole of the thoracic parietes equally, and drives in the most yielding ; in other words, the bony ribs, raised against it by the respiratory muscles, are able to resist it, but the soft cartilaginous portions are not. It must be re- membered, too, that the diaphragm is attached along the margins of all the ribs below the fifth ; its strong contractions during the asthmatic par- oxysm would tend therefore to draw them in, and, being less opposed by their yielding cartilaginous portions, would concur in the production of this change of shape. This condition would, of course, at first only last as long as the paroxysm; but if the attacks were frequent and severe at a time when the cartilaginous portion of the ribs was considerable and the figure forming, one can easily understand how the deformity would be- come permanent, and how asthma would in this way produce such a change in the form of the chest as I have been describing. But the actual event to which I think this form of chest directly points —the particular morbid change that it immediately implies—is pulmonary coUapse. One cannot but be struck, on looking at such chests, with their Fig. 4.—From a photograph of an asthmatic, whose disease dated from whooping-cough at three months old. ITS PATHOLOGY AND TREATMENT. 95 exact resemblance (except in the absence of what one may caU the dia- phragmatic stricture—the drawing in of the attachment of the diaphragm at each inspiration, as if a ligature were put round the body) to the shape of the chest in the inspiration of infants suffering from bronchial plugging, or its established result—atelectasis, or from croup, or laryngitis, or any affection that, preventing the ingress of air and the expansion of the lung, refuses to allow the parietes to follow the movements of the inspiratory muscles.1 Pulmonary coUapse would certainly be a more potent cause of this deformity than unaided asthma, because it is a more permanent con- dition and involves a more complete inexpansibility of lung, and therefore would more effectuahy resist the inspiration-movement of the softer parts of the parietes. In as far, then, as this heteromorphism points to atelectasis its occur- rence in cases of asthma tends to confirm what I have already said of the tendency and sufficiency of that disease to produce this condition of lung. But remembering that it is only in cases that have become asthmatic young that this state of chest is weU marked, and remembering how com- monly asthma dates in the young from catarrhal bronchitis, from the bronchitis of measles, or from what has been caUed "whooping-cough with bronchitis" (which is nothing more than whooping-cough in which the bronchitic portion of the malady has extended far and severely into the bronchial tree)—remembering this, I say, one cannot but see it possi- ble that, at least in many cases, the pulmonary coUapse may have been produced in the ordinary way, by mucous plugging of the bronchial tubes from the primary bronchitis, and not from the consequential asthma in the way I have suggested. I have seen this deformity strongly marked in cases where ordinary bronchitis had never occurred, and where the patient was entirely free from bronchitic complication or tendency«*r but the asthma dated from whooping-cough in infancy—and, in my opinion, no form of bronchitis has so great a tendency to generate coUapse as that of whooping-cough. Dr. Gairdner, of Edinburgh, in his excellent papers on the " Patholo- gical Anatomy of Bronchitis," aUudes to this deformity of chest as an oc- casional permanent result of pulmonary coUapse. " In rickety individuals," he says, "it is not only more marked, but apt to become permanent, espe- ciaUy when such subjects are affected with any considerable or persistent bronchitic affection. In such cases, the reversed movement of the ribs is stereotyped, as it were, in the form of chest caUed pigeon-breast, in which the sternum is protruded, particularly below, and the whole lateral region, including also the lower costal cartilages in front, flattened, or even at some points rendered irregularly concave." One result of this coUapse of the cartilages of the ribs is that they do not stand out from the sternum as they should ; but decline from it at too acute an angle, narrowing and elongating the scrobiculus cordis. Figure 4, a very good example of this configuration, is taken from a photograph of an asthmatic who suffered from his disease from the age of three months. The condition has existed from his earliest recollection, and during his childhood was much more considerable, for since he has grown up his disease has nearly left him, and the shape of his chest has much improved. y I am of opinion that the occurrence of asthma once renders the subject \ of it more liable ever afterward to a recurrence of it. )Jt is very rare to I have seen it strongly marked in the inspiration of laryngitis even in adults. 96 ON ASTHMA : hear of a person having a single attack ; so rare that I am not sure that I have ever heard of a case. It might be said that a person who has had asthma once must have a predisposition to the disease, and therefore in him it will be likely to occur again, and since some attack must be the first, the first wiU be followed by the succeeding ones. But I do not think this is sufficient to explain the very common fact that a person may pass half his life before he has his first fit, but after it has once occurred, will never pass a month without it; neither the fact that after asthma has once occurred causes wiU excite it that would not before ; nor do I see why the same fact should not point to the same conclusion in asthma as it does in epilepsy and rheumatism. So it is I feel assured, but why it is I cannot pretend to say. \Is it that a certain nervous action having been once set going is, ipso facto, re-excited on the slightest provocation ?^Is it a case of mere vicious habit ? Is it that the bronchial muscle becomes so hypertro- phied by the asthmatic spasm that it becomes increasingly prone to take on a state of contraction ? ITS PATHOLOGY AND TREATMENT. 97 CHAPTER VIII. TREATMENT OF THE ASTHMATIC PAROXYSM.—TREATMENT BY DEPRESSANTS. Preliminary measures.—Ipecacuanha. Tobacco. Tartar-emetic.—Their modus oper- andi.—Their relative value and methods of administration.—Cases.—Value of to- bacco in hay-asthma.—Cases.—Caution with regard to tobacco.—Importance of' early administration of these remedies. —Practical observations. The treatment of asthma, hke that of aU paroxysmal diseases, naturally divides itself into the treatment of the paroxysm and the treatment in the intervals of the paroxysms, and although the last is the real treatment of the disease, whUe the treatment of the paroxysm is merely the treatment of a symptom, yet the paroxysm being in asthma, potentially, though not essentiaUy, the disease (for it is its sole manifestation, the only source of suffering, and the cause of those organic changes in the heart and lungs by which alone asthma threatens life), its treatment holds the first place in the therapeutics of the affection. If the paroxysms are mitigated the dis- ease is rendered proportionally trifling—if they are prevented the disease is extinguished. The persistence of the asthmatic tendency is of not the slightest consequence as long as the fits are warded off, or indefinitely postponed ; and thus the mere negative treatment of abstention from the exciting cause of the paroxysm may amount to a virtual and final cure. The first thing to be done on being caUed to a patient in a paroxysm of asthma, is to ascertain if there is any exciting cause actually present and in operation, and if so, to remove it. An undigested meal or a full rectum may, as peripheral irritants, produce bronchial spasm ; the one, I think, through the pneumogastric nerve, the other through the sympathetic, and thus an emetic which relieves the one, and an enema (or any other means) which evacuates the other, may put a stop to the attack. I have previously mentioned a case in which the occurrence of an attack was entirely deter- mined by the loaded or empty condition of the rectum : if the patient re- tired to bed without the bowels being relieved he was sure to be awoke in the night with asthma ; if they were moved before going to bed he awoke, at the usual time in the morning, weU. The relief obtained by an emetic is weU known. At once ascertain, then, the condition of the patient in these respects, inquire what he last ate and when he ate it, and if his bowels are loaded ; and if there is any source of offence in either situation—stomach or lower bowel—secure its immediate evacuation. Ascertain, too, the state of the air he is breathing, if there is in it any known or unknown irritant, any of those subtle emanations of which asthmatics are so sensible, if there is a hay-field near, or ipecacuanha powder in the room, or dust, or smoke, and if so, let the removal from these influences be the first step taken. In- quire, too, if the patient has ever been seized with an attack in the same 7 98 on asthma: place before, if he has had any reason to imagine that that particular air did not agree with him, or if in any local peculiarities it resembles places that he has previously found offend his asthma. If so, get him away at once, never mind how difficult it is to move him, transport him to some place, or some kind of situation known to agree with him. Very likely be- fore he has gone a mUe or two he wiU be quite well; whereas all treatment will be powerless as long as he is under the influence of the injurious air. Let it be your first care, too, to place your patient in a favorable posi- tion ; get him out of bed and bolster him up in an arm-chair, and place before him a table of convenient height, with a pillow on it, on which he may rest his elbows and throw himself forward.- It is quite surprising, almost incredible, how much comfort this will give, and not only so, but how it will actually relieve the breathing and dispose the spasm to yield. Sometimes the patient's breath is so bad that he cannot sit; the same ar- rangements must then be made for him in a standing posture. But if, as wiU probably be the case, the spasm persists in spite of these preliminary measures, and if no exciting cause can be discovered by whose removal the paroxysm may be at once arrested, our next step is to cast about for some remedy by which we may hope to cut it short. In our choice of this we shall be very much influenced by our patient's former ex- perience. Few asthmatics suffer long from their disease without having discovered what particular remedy is most efficacious in their case, and in this respect different cases of asthma vary so much, and display such a caprice, that I really know of no other guide except the patient's experi- ence. Of all the different kinds of evidence on which we buUd our theories of the pathology of diseases there is none more convincing, or that teUs a plainer tale, than that which is derived from therapeutics. The success of a remedy given on certain .principles proves the correctness of the princi- ples on which it was given, and the knoAvn action of a medicine directly implies the nature of the pathological state that it relieves, as it shows that in aaay case of its successful administration the pathological state must have Taeen such as that known action would antagonize or correct. This reflected evidence has all the force of the fulfilment of a prediction, like the reappearance of HaUey's comet at the exact time that its discoverer foretold. My purpose in this chapter is to direct attention to the great efficacy and value, in the treatment of asthma, of certain drugs belonging to a class whose therapeutical action is very strongly marked, and about whose modus operandi there is no doubt, and which throw, therefore, a very clear light on the nature of the pathological condition that they relieve—the class of direct depressants or contra-stimulants. It is a class of remedies that exercises the most singular and powerful influence over the asthmatic condition, greater and more immediate than any other that I know, ex- cept, perhaps, mental emotion. As soon as their characteristic effect is established the dyspnoea ceases—completely ceases from that moment; no matter how intense the spasm may have been, the moment the sensations characteristic of collapse are felt it yields, the respiration is free, and the patient passes from ngony to ease. It is one of the most striking things to witness, in. the way of the effect of a remedy, that can be imagined. The three drugs of this class with whose use in asthma I am most fa- miliar are, ipecacuan, tartar-emetic, and tobacco. iNo doubt they all act in the same way—by lowering innervation, depressing nervous irritability, or whatever we may call it, and enfeebling the contraction of the bron- ITS PATHOLOGY AND TREATMENT. 99 chial muscle, just as they weaken the heart's action, or relax the grasp wherewith a strangulated hernia is constricted, or relieve urethral strict- ure, or the spasm of colic. With regard to their modus operandi in asthma I think a good deal of misconception very generally prevaUs ; they are thought by some to act as emetics, by some as so-caUed expectorants. I believe they act neither as the one nor the other, but as direct depressants, relaxing the spasm of the bronchial tubes in the way I have mentioned. In illustration of this I wUl just relate a case in which I had ample opportunity for some years of watching the effect of ipecacuanha. The patient was a youth who had been asthmatic from his infancy. His attacks had increased in frequency till, at the time to which I refer, they occurred with tolerable regularity once a week. His asthma gener- ally awoke him about four or five o'clock in the morning, and soon com- pelled him to sit up and wheeze in bed, or get out of bed and stand against some piece of furniture for support. In two or three hours he would be able to dress himself, and perhaps in the forenoon the severity of the dyspnoea would a little abate ; but toward the afternoon and even- ing it would deepen, and toward bedtime become so intense that with- out an emetic there was no chance of sleep. The emetic would be taken, and in half an hour he would be perfectly easy, without the slightest trace of asthma. He would then take a light supper, go to bed, sleep like an infant, and have no more asthma till that day week. In this way he would have fifty attacks, or thereabouts, in a year ; and cut them short at night with fifty emetics. If he did not take the emetic he passed a miserable, sleepless night, and was still bad the next day ; indeed, there was no defi- nite end to the attack without it. I think now that if he had taken it ear- lier in the day, or even in the morning, on first waking up asthmatic, he would have cut short the attack equally well, and have saved himself a great deal of suffering. I never knew it fail. TThe dose taken was always twenty grains of the ipecacuanha powdery, and although he repeated it so frequently, it neither lost its efficacy nor did him any harm. It was clearly not as an emetic that it acted, but as a depressant, for the relief took place before the vomiting. About ten minutes or a quarter of an hour after swaUowing the draught a sense of nausea would be felt, accompanied with a slight faintness, and dampness on the skin, and a profuse secretion of saliva which came from his mouth in a little, clear stream. It was then that the spasm gave way, before a single act of retching had occurred ; and his attendants would immediately know when the first sense of nausea was felt by the relief of the breathing that invariably accompanied it. Be- sides, the stomach was always perfectly empty ; there was nothing of which it could be reheved. ' \ The effect of tobacco is exactly the same, only the depression that it produces is more profound, amounting to actual collapse, and the relief, therefore, more speedy and complete. In those who have not established a tolerance of tobacco its use is soon followed by a well-known condition of collapse, much resembling sea-sickness—vertigo, loss of power in the limbs, a sense of deadly faintness, cold sweat, inabUity to speak or think, nausea, vomiting. The moment this condition can be induced the asthma ceases, as if stopped by a charm. In one case in particular I have fre- quently watched its effects. In the case that I refer to, the asthmatic for- tunately never established a tolerance of the drug, and twenty whiffs of a pipe, or half a cigar, would at any time induce a condition of collapse. I have known him begin to smoke when his breathing has been so difficult 100 ON ASTHMA : that he could hardly draw his pipe ; he would draw a feeble whiff or two and then stop to recover his breath, and then another whiff, and so on. By and by he would lay down his pipe with a look of intelligence at his attendant, as much as to say, " it's all right now ;" his face would become pallid and damp with perspiration, his limbs relaxed, his breathing long and sighing—but his asthma was gone. His object was to smoke just so much as to produce this condition, and no more, so that the moment he felt the sensation coming on he stopped. After this qualmy condition had continued for twenty minutes or half an hour, it would go off and leave him well—the attack cured. Sometimes, however, he would take a little too much, and then the operation of the drug would go on to vomiting; and sometimes he would overdo it altogether, and produce a deadly and protracted collapse, from which it seemed as if he would never recover. I have known his pulse hardly perceptible for nearly two hours, in spite of ammonia and brandy freely administered. It is this circumstance—the fear of this horrible and unmanageable collapse—that makes one so un- willing to employ tobacco ; it is, indeed, a dreadful remedy, almost as bad as thedisease ; but the asthmatic is wiUing to undergo anything to get quit of his sufferings. The following account, illustrative of the effect of tobacco, I have re- ceived from an inteUigent patient long subject to severe asthma: " I have always found perfect relief from smoking tobacco in the at- tacks of spasmodic asthma to which I have been liable. In describing my own experience, I should say that no relief is felt till the poison gives evi- dence of having taken effect by its disagreeable consequences ; and just in proportion to the sickness and faintness and other miserable sensations, is the relief of the difficult breathing. I never knew this remedy faU. As the use of tobacco was new to me it affected me very powerfully, and pro- duced the most miserable prostration and faintness. The cure of the asthmatic spasm was very speedy, and frequently it was forgotten alto- gether in the horrors of a sensation known to aU novices in smoking, so that I was often unconscious of its disappearance, or of the mode or time of its departure ; the asthma seemed supplanted by another condition, and cold perspiration and fear of collapse closed the scene. I am not aware whether this was followed by expectoration, and the presence of mucus in the throat removed by the usual process—the common action of ' clearing the throat,' as it is called—which invariably appears when an attack of asthma spontaneously subsides, and which always accompanies the slower cure resulting from the mild use of ipecacuanha, which, of late years, I have preferred to tobacco, as my asthma is not of sufficient inten- sity to require so violent and distressing a remedy. I imagine these more natural and ordinary symptoms of recovery would always accompany the use of ipecacuanha, and that an increased dose would only accelerate the process of recovery up to the interruption by vomiting. The difference between the characteristics of these two modes of cure appears to me to be strongly marked and very important. I conceive this to arise from the intensity of the depression caused by the poison of tobacco, which cannot be the case in the use of ipecacuanha, as it is a simple emetic, and I doubt if the same kind of sensations and depression could be produced by ipeca- cuanha, even if its effect could be carried on and the medicine were not rejected by the stomach, which is invariably the case when the effect is increased to a certain point. I have not gone beyond the stage of perspi- ration and a feeling of sickness, and I have always found the cure to re- semble the natural process of mucous discharge and clearing of the air- ITS PATHOLOGY AND TREATMENT. 101 passages, only more promptly induced and more rapidly performed. I have frequently had short spasms of asthma produced by laughing, light- ing a lucifer match, or some other special irritant, from which I have re- covered as rapidly as when under the influence of ipecacuanha, going through the stages of silent asthma, audible asthma, and the expectoration mentioned above, in about the space of ten minutes or a quarter of an horn-. The distinction between these two modes of cure or relief is worthy the attention of medical men and their patients, as much distress and per- haps injurious results might be avoided if the ipecacuanha is found to be as efficacious as tobacco. My only doubt is whether tobacco might not be preferable in desperate and suffocating spasms on account of its speedy and violent action." No doubt there is such a difference as that indicated above in the action of tobacco and ipecacuan. Ipecacuan, I think, could never produce such collapse as that caused by tobacco ; but that it does not always act as an expectorant or emetic, but as a direct depressant, is shown by the case that I related just now. "^The fact is, ipecacuan acts very differently on different individuals : in some, producing vomiting with little more irrita- tion than sulphate of zinc ; in some, producing collapse to a considerable degree. Moreover, by relaxing the bronchial spasm, it renders free cough and expectoration possible, which were previously impossible from inabh- ity to get sufficient air into the lungs to effect them ; so that the expecto- ration is the consequence of the relief, and not the relief of the expectora- tion, y^ In that mild but annoying form of asthma that accompanies the other symptoms of hay fever, and is known as hay asthma, tobacco pushed ad nauseam gives more relief than any other remedy. In a relative of mine, who is very much afflicted with this troublesome complaint, tobacco smok- ing is the only thing that gives any relief. During the hay season and aU the early hot summer weather he suffers (besides the sneezing and run- ning at the eyes, and tumid burning of the nose and throat, characteris- tic of hay fever) from paroxysms of a wheezing dyspnoea of the true asth- matic type, coming on exclusively at night, so as almost to deprive him of sleep. During the rest of the year he never smokes, as it is disagreeable to him, and in other respects prejudicial; but during this season he is quite dependent on his cigar for any degree of comfort or aUeviation of his symptoms. The foUowing graphic account of the relief he finds from tobacco I cannot do better than give in his own words: "There is no remedy during a paroxysm of hay asthma that has any- thing like the effect of smoking tobacco ; and though this is especially the case in the latter stage of the attack, when the asthmatic element of the phenomena is most developed, stiU in the earlier stage, when the lachry- mation, sneezing, and faucial irritation are most distressing, tobacco smoke has, in my case, a very marked influence in soothing and diminishing these symptoms. " No doubt any of those medicines which Dr. Pereira has called ' car- diaco-vascular depressants' would produce a somewhat sirmlar result; but none is of so easy application, or can be used so readily or pleasantly as to- bacco. During the hay asthma season—that is, in my case, from about the 15th of May to the 10th or 12th of July—I regularly smoke a cigar the last thing before going to bed, or perhaps more frequently after I am in bed. The effect is, that (excepting during the last fortnight in June, when I never get a night's rest) the sedative influence of the tobacco pre- vents the occurrence of any asthmatic spasm. If during this period I 102 ON ASTHMA : omit my cigar I seldom sleep beyond four o'clock ; usually three o clock finds me awake, hopelessly, though generally only slightly, asthmatic tor the rest of the night; tiU, indeed, about nine o'clock, when almost always the asthma completely leaves me. This night-cigar is taken as a preven- tive. But tobacco will cure the asthmatic spasm when it is fandyon ; only it requires a larger dose of the poison and in a stronger form The seda- tive influence of the cigar will usuaUy insure me a fair night s rest; but the powerful depression of strong shag-tobacco is necessaiy to cut short the spasm when it is established. Even when I do smoke my night-cigar I not unfrequently have to get up about three or four o'clock m the morn- ing and smoke ; and during the last fortnight in June this happens almost nightly. " Distressing as are the sensations of collapse from tobacco-poisoning, they are an unspeakable relief when contrasted with the impending suffo- cation of asthma. I shall never forget an attack which I once had, and the joy with which I hailed the approach of collapse from tobacco-poison- ing. It was late in July, many years ago. I had gone into Dorsetshire to stay with a relative in a country house. Immediately surrounding the house were grazing fields—not hay-fields—and they had not been mown. In these fields was a grass—Nardus stricta, I think—still blooming luxu- riantly ; for it is a grass which cattle wiU not eat; and thus, though past the usual time for hay asthma, I was accidentaUy surrounded by its most potent cause—grass in flower. The night came, and I had not been an hour in bed when I was attacked with the most violent asthma I ever ex- perienced. There were no cigars in the house ; but one of the servants had some rank shag-tobacco. I smoked one pipe, then another ; and as my face blanched, and my pulse faded, and the cold sweat stood on my forehead, miserable as were the sensations of coUapse, they were Paradise to the agonies of suffocation. I shaU never forget those moments of relief. " The story of this attack of asthma, by the way, is a very instructive one ; and I may just add it here, in brief,: I left my friend's house the day after this paroxysm, and went to the seaside, where I was as usual per- fectly well. Two days afterward I received a letter from him asking me to return, as he had had the grass in flower about his house cut down. I did so, and remained with him a fortnight, sleeping every night as placidly as an infant. The Nardus stricta had given me the asthma ; the scythe had cured it. " To return to the tobacco. A hay asthmatic should never smoke to- bacco but for his malady. Smoking should never be to him a habit or a meal, for it then ceases to be a medicine. Indeed, to him it should be as a deadly drug, for it is by poisoning that it cures." Not long ago I was conversing on the subject of his malady with a sur- geon of some distinction in this city who is grievously victimized with hay asthma, and on asking him what he found do him most good, he replied : " Tobacco; tobacco is the only thing; nothing does me any good but smoking ;" and he went on to teU me that whenever he finds his asthma very bad, and that he shaU get no sleep without it, he immediately resorts to a cigar. But the smoking does him no good unless it produces a con- dition of coUapse ; the mere sedative effect of it is of no use to him what- ever ; and having lost, from the habit of smoking, an easy susceptibUity to tobacco influence, he adopts the following device to secure its more po- tent effect: he fiUs his mouth with tobacco smoke, and then, instead of breathing it out again at once, as is usual in smoking, retains it in his mouth for several seconds, perhaps a quarter of a minute, then takes an- ITS PATHOLOGY AND TREATMENT. 103 other mouthful, and so on. In this way, he finds that the tobacco is more rapidly absorbed by the mucous membrane of the oral cavity, and that a state of collapse is speedily induced. The moment the faintness and sickness come over him the asthma ceases, he turns into bed, and has a good ni^ht The effect of antimony nearly resembles that of tobacco, and it acts in the same way, but the nausea and coUapse it produces are long and tedious. Of the three drugs, I should say ipecacuanha is the most manageable and entaUs the least suffering; tobacco the most speedy and effectual. There are one or two practical points on which I would add a few words. Kemedies of this kind, given with the view of cutting short the par- -^ oxysm, should be given as early as possible, and for two reasons: first, because it is much easier to break through the asthmatic condition when it is but just established, while the longer it is aUowed to go on, the more inveterate and uncontroUable it becomes, and the more difficult it is to arrest it; indeed, its giving way at aU may depend on the earliness with which the remedy is applied. \\ have known treatment powerless after the dyspnoea has continued for some hours which never failed if administered as soon as it declared itself. Just at starting, in the earliest stages of the paroxysm, a very slight thing wiU determine its advance or retreat, and in proportion as it advances and deepens, in just such proportion do reme- dies become inoperative. ~\ The other reason is that if the spasm does yield in spite of having been some time established, the recovery is not so com- plete as if the remedy had been applied immediately on its appearance. J, The longer the bronchial stricture lasts the greater is the arrears of breathing and the resulting pulmonary congestion ; and if this goes on unchecked and increasing for many hours the disturbance of the vascular balance becomes so great, the capillaries of the lungs so loaded, that it is a long time, many hours, or perhaps even days, before the balance is re- stored and the vessels recover their normal condition ; and although the bronchial spasm may completely give way there remains a certain amount of shortness of breath and an incapacity for exertion, and it is not until an abundant expectoration of mucus has taken place, by the pouring out of which the loaded vessels have relieved themselves, that the chest be- comes clear and the breathing free^' In asthma at once cut short there is no such accumulated congestion—no mucous exudation, and when the bronchial spasm ceases aU dyspnoea vanishes. If, on first awaking with the sensations of asthma, the asthmatic nauseates himself with tobacco, or smokes his nitre-paper, or keeps himself in a standing posture, or in any other way cuts short the paroxysm, he will be throughout the succeeding day exactly the same, with the exception of the sleep he has lost, as if nothing had occurred; but if he suffers the fight between asthma and sleep to go on long, and then on the first remission of the dyspnoea lies back and goes to sleep, he whl protract the asthmatic state, deepen the consequent pulmonary arrears, and not only postpone his recovery for many hours, but make it then slow and imperfectj I know an asthmatic who now never loses a day by his disease, in consequence of the prompti- tude with which he meets its first appearance in the early morning, but who formerly, from continuing to he in bed and trying to get sleep after the asthma had begun, protracted his sufferings during the day. He is at- tacked as often as ever, and at the same time—about three or four o'clock in the morning—but the moment he finds his asthma on him he takes measures to keep himself wide awake, stands leaning against a piece of 104 on asthma: furniture, and, if necessary, induces tobacco coUapse, so that instead of a day's asthma he has half an hour's, and, as far as aU the engagements of life go, has ceased to be an asthmatic. . It is a difficult thing for the asthmatic, I know, overwhelmed with sleep as he is, and generally with a peculiarly heavy drowsiness upon him, to leave his bed, or light and smoke his pipe ; but he must do it; he must rouse himself fairly up and adopt at once those remedies that in his par- ticular case are most efficacious. In fact the treatment of the asthmatic paroxysm should be so prompt as to be almost rather preventive than curative; in the treatment of no disease is the injunction " obsta prin- cipiis " of more vital importance. One is sometimes asked : Which is the best form of tobacco to use, a cigar or a pipe? I think a pipe has the advantage of more certain strength ; cigars vary so much, even the same sort. The tobacco that I generally employ is bird's-eye, as being a mild tobacco, and one by which you run little risk of inducing alarming coUapse. Shag, or any other of the strong tobaccos, should not be used by the uninitiated, as the coUapse they produce is apt to become protracted and unmanageable. For ladies and young children, a few whiffs of a mUd cigarette are quite sufficient.1 Of ipecacuanha I never give a very smaU dose ; it is uncertain and teas- ing. I would say, always give such a dose as wiU be certain to secure its own prompt rejection. I never give less than twenty grains, however young the patient may be : it never does harm. But ipecacuanha is a nauseous thing, and to those who have frequently taken it as an emetic it becomes almost intolerable. I have lately discov- ered that it may be taken very pleasantly and very efficaciously in the form of some strong ipecacuanha lozenges, made by Messrs. Corbyn, of 300 Holborn, London. They are about four times the strength of ordinary ipecacuanha lozenges ; three of them wiU produce prompt vomiting. They are very convenient, too, for keeping up a slight nausea ; and for children they are invaluable. If vomiting is desired, they should be bitten and ground up in the mouth and swallowed at once. There is one circumstance that greatly detracts from the utihty of to- bacco in the treatment of asthma, that practicaUy indeed almost destroys it. Our adult male population have so habituated themselves to its use, that they have lost the susceptibility to its fuU influence, and cannot in- duce complete coUapse by any amount of smoking. Now adult males con- stitute by far the majority of the subjects of spasmodic asthma ; and thus the habit of smoking has rendered powerless, in a large number of cases, what I think may, without any qualification, be caUed its most potent remedy. 1 In an old number of the Lancet (vol. ii., 1837) I have met with the following no- tice of the beneficial administration of tobacco in asthma in the form of a tincture: In disordered respiration tobacco obtained the well merited confidence of the older physicians in cases where no organic alteration had occurred. It has, however, nearly fallen into neglect, from which state it will most probably revive, for it has lately been tried to a very great extent, and with no small success, under a false name. At the time that the Lobelia inflata was the subject of great panegyric, and that clinical lectures appeared in the periodicals, extolling its virtues in asthma, there was not a particle of it in the drug market. One firm, at the head of which was a shrewd, in- telligent, practical man, had formerly had great experience of tobacco, and he pro- claimed that his house was the sole mart for lobelia; he made a spirituous tincture of tobacco, which he supplied to the trade, pretty freely, and it became a great favor- ite of the profession. My own experience led me to its frequent employment; nor did I discover for some time the artifice which had been practised. It, however in- duced me to place great reliance on an ethereal tincture of tobaceo to mitigate' the paroxysms of spasmodic asthma. ITS PATHOLOGY AND TREATMENT. 105 CHAPTER IX. TREATMENT OF THE ASTHMATIC PAROXYSM {continued).—TREATMENT BY STIMULANTS. Theory of the modus operandi of stimulants.—Illustrated by coffee.—Alcohol.—Cura- tive influence of violent emotion.—Its action analogous to that of stimulants.— It acts also as a " nervous derivative."—Cases. One of the commonest and best reputed remedies of asthma, one that is almost sure to have been tried in any case that may come under our ob- servation, and one that in some cases is more efficacious than any other, is strong coffee. To the question, " Have you tried strong coffee ? " the asth- matic is pretty sure to answer, " Yes; " and he is also pretty sure to add that it gives him relief. About the modus operandi of this remedy I was long puzzled ; I could not make it put; and it is only lately that I think I have stumbled upon it. The rationale of its efficacy is, I think, to be found, on the one hand, in the physiological effects of coffee—the particular nervous condition that it produces—and, on the other, in a feature in the clinical history of asthma which I have long observed, and of which I think the efficacy of coffee is highly corroborative. This fact is, that sleep favors asthma—that spasm of the bronchial tubes is more prone to occur during the insensibUity and lethargy of sleep than during the waking hours, when the senses and the will are active. I have already referred to this in the Chapter on the Clinical History of Asthma, in describing the phenomena of the paroxysm, and in explaining why the attack invariably (or almost invariably) chooses the hours of mid-sleep for its onset. Let me just refer to this subject again ; for it is both interest- ing and important, as it explains a curious and very constant phenomenon in asthma—the hour, namely, of the attack—is highly illustrative of its pa- thology, and furnishes the key to some of its treatment. "y I think, then, that sleep favors the development of asthma in two ways— First.—By producing insensibility to respiratory arrears. Second.—By exalting reflex action. That sleep does exalt reflex nervous action there can be no doubt._)„It is a fact so abundantly inculcated by the history of disease as hardly to re- quire illustration or proof. The phenomena of epilepsy, cramp, lead tre- mors, and other examples of deranged muscular action, all teach it.'f It is just as sleep comes on, just as the will is laid to rest, or during sleep, that these different forms of involuntary muscular contraction most commonly occur.! Any one, to convince himself of it, has only to fall asleep sitting on the edge of his chair, in such a position that it shall press on his sciatic nerves. As long as he is awake his legs wiU be motionless ; but the mo- ment he falls asleep they will start up with a plunge and suddenly wake him. As soon as he is awake they are quiet and stiU again, with no dis- 106 ON ASTHMA : position to start tiU he again falls asleep, and that moment they start again and wake him ; and so he may go on as long as he likes. He changes his position, sits back in his chair, and they start no more. I need not explain what so clearly explains itself. I heard, some years ago, of a case of what might be caUed chronic traumatic tetanus, in which the source of irritation —the excito-motory stimulant—was extensive disease of the hip-joint. The moment the patient fell asleep he was seized with opisthotonos, which, of course, immediately awoke him. On awakening the tetanus vanished ; on again faUing asleep it reappeared ; and this alternation of faUing asleep and waking continued for weeks, if not for months, the patient getting no con- tinuous rest, till he was quite worn out. As long as he was broad awake the tetanus never appeared.1 Hosts of simUar facts, illustrative of the same truth, might be cited. Anything that exalts reflex nervous action increases, of course, the po- tency of reflex stimuli. Now, I have elsewhere endeavored to show that the phenomena of asthma are, in almost every case, those of excito-motory action, and that the exciting causes of asthma are, in the great majority of instances, such as act by a reflex circuit. They would, therefore, on the asthmatic's faUing asleep, immediately acquire a potency they did not be- fore possess, just as the pressure on the sciatic nerve did in the illustration I have given. \ Thus it is, we see, that the asthmatic may gorge himself with unwholesomes, and yet, as long as he keeps himself awake, suffer no con- sequential asthma ; the irritant is there, the undigested food is in the stomach, but as long as he is awake, as long as the will is dominant, it is inadequate to the production of reflex phenomena. But let him fall asleep, and in an hour or two the paroxysm whl be established. And not only wiU sound sleep determine, by this exaltation of reflex susceptibility, the production of asthma, by its exciting causes, but a small dose of the same condition—sleepiness, drowsiness—wiU favor the super- vention of asthma in a proportionate degree. Not only is drowsiness a premonitory sign of an attack, but a powerful predisposer to it; and the asthmatic knows that he yields to it at his peril. I have often noticed in asthmatics that the sleepiness that is so apt to come on after dinner will be accompanied by a slight asthmatic oppression and wheezing: as the drowsiness deepens, so does the asthma, and in this way it may settle down into an attack; but if the patient rouses himself, or if anything occurs to engross his attention so as to wake him up, broad awake, the asthma quickly vanishes. It is in this way, I think, that is to be explained the fact that asthmatics can dine out late and unwholesomely with impunity, while if they dine, at the same time and in the same way, at home, asthma is sure to come on. At home they want that excitement which at a dinner- party keeps the animal functions in a state of exaltation and the mind viv- idly awake, and effectually banishes the least approach to drowsiness. Of the fact there is not the slightest doubt. I know an asthmatic who can, with impunity, dine out at seven o'clock, as dinner-eaters of the nineteenth century are apt to dine—shirk nothing from soup to coffee—walk home at eleven o'clock, a distance perhaps of four mUes, with the wind of a deer- stalker—go straight to bed, and get up the next morning scathless; but if he were to dine at home at six, or even at five o'clock, he would be wheez- ing at nine, and by four the next morning downright asthmatic. 1 I was further informed, respecting this case, that, after everything else had failed, sleep was procured, with an immunity from the tetanic spasms, by putting the patient into the mesmeric state. In this way he got rest, and greatly improved • bu; what was the ultimate issue of the case I do not know. ITS PATHOLOGY AND TREATMENT. 107 I believe a certain amount of the curative influence of fright, or other strong mental emotion, is to be explained in the same way. j "But why," it may be asked, "all this round-about digression? What has aU this to do with the curative influence of coffee ? " I believe it is simply its explanation. - vFor, what are the physiological effects of coffee ? They consist in the production of a state of mental activity and vivacity, of acuteness of perception and energy of vohtion, weU known to those who have experienced it, and to a certain extent very pleasurable, and which is the very reverse of that abeyance of will and perception which, in drowsi- ness or sleep, so favors the development of asthma. In sleep, whl and sense are suspended ; after taking strong coffee they are not only active, but exalted. It produces rapidity of thought, vivacity of spirits, clearness of apprehension, greatly increases the working powers, and altogether in- tensifies mental processes. Not only is there no disposition to sleep, but sleep is impossible: the thoughts hurry one another through the mind ; the bodily movements are energetic and rapid ; and if the effects of the drug are pushed far a very unpleasant condition is produced, something like that of delirium tremens, minus its haUucinations. Now, if the sus- pension of the wiU, or its depression, favors the production of excito-motory phenomena, and thus favors the development of asthma, is it unreasonable to suppose that its exaltation should prevent or cure it ? It must do so—if not positively, at least negatively, by removing the predisposing condition. And bearing in mind this marked physiological effect of coffee—that this exalta- tion of the animal nervous functions is exactly what it produces —it cer- tainly does seem to me reasonable to suppose that this is its modus operandi. And if of coffee, then of strong tea, and alcohol, and ammonia, and Indian hemp, and ether, and other stimulants of undoubted value in asthma. To show that this is the rationale of the cure of asthma by stimulants, I do not think it is necessary to show that it is only when the asthmatic is drowsy, or has been sleeping, that they do good. If anything that rouses the asthmatic to a state of wakefulness will put a stop to asthma that was creeping on him while he was sleeping or sleepy, d fortiori, anything that carries him beyond a state of mere wakefulness—that gives him an active, not a mere passive wakefulness—wiU be still more efficacious, and wiU be adequate to the checking of an attack that, in spite of his being broad awake, was gaining on him. The very frequency with which coffee gives relief makes it hardly worth while for me to narrate the history of any cases. I should think, from my own experience, that coffee relieves asthma in two-thirds of the cases in which it is tried. The relief is very unequal, often merely temporary, and sometimes very slight: sometimes it is complete and permanent. It is often taken in the morning; and patients will tell you that previous to taking their coffee they are not fit for anything, can hardly move about, but that the taking of it is immediately followed by freedom of breathing and an ability to enter at once on their daily occupations. J^ y\ There are two or three practical hints with regard to the administration of coffee that are worth bearing in mind. First.—It cannot be given too strong. Unless sufficiently strong to pro- duce its characteristic physiological effects it does no good, but rather harm; moreover, if given very strong, it need not be given in much bulk, and quantity is a disadvantage—its effect is less rapid, and it oppressively distends the stomach. Second.—I think it is best given without sugar and milk—pure cafe noir. Third.—It should be given on an empty stomach; if given on a fuU 108 on asthma: stomach it often does great harm, by putting a stop to the process of di- gestion ; indeed, so much is this the case that I consider coffee, accompany- ing a meal, especially late in the day, so peculiarly apt to induce asthma, that it deserves to be classed among its special provocatives. I have men- tioned elsewhere the case of an individual who never dared to take the usual after-dinner cup of coffee—it would make the simplest dinner dis- agree with him. But the same asthmatic found, in strong coffee, on an empty stomach, one of his most valuable remedies.1 Fourth.—For some reason or other, I do not know why, it seems to act better if given hot—very hot. Alcohol is another stimulant, of the value of which I have often seen ! most striking instances. The first case that brought this before my attention was that of a Scotch lady, who consulted me in May, 1862. She was fifty-five years of age, and had had her asthma for thirty years. She had been under the care of many physicians, but all the ordinary remedies of asthma had completely failed. The following is a list of some of the things she had tried, and their results, as I have recorded them in the notes I took at the time : "Nitre-paper—no good ; ethers—no good ; stramonium, in piUs— no good ; strong coffee—no good ; lobelia—no good ; chlorodyne, head- ache, no relief ; emetics—no good." But there was one remedy to which this otherwise uniformly unfavorable verdict did not apply, and that was whiskey. For some time past this lady had been in the habit of taking this stimulus (how long I do not remember), and it had never failed. She took it with hot water, and began with much smaller doses than she ultimately reached ; but at the time I saw her she would frequently take three doses, in rapid succession, of an ounce of Scotch whiskey each, very little diluted. Her sister told me it sometimes produced a very decided effect upon her—I mean, that it decidedly affected her head. It was a great distress to her to have to resort to such a remedy, and in such doses ; but, as she said to me, what could she do ? She could not go on in such horrible sufferings, knowing that she had immediate relief at her command; and nothing else reached her symptoms, whUe this never fahed, let the paroxysm be as bad as it might. It was merely a question of quantity: if the spasm was very severe, she required more ; if it was slight, less would do ; but if the whiskey were only pushed far enough the asthma could never withstand it. I saw her three or four times, but with the uniform result of all the remedies that I suggested failing ; and she left my care, as she came under it, with whiskey the sole remedy of her disease. 1 Since writing the above I have received the following account from an asthmatic gentleman, singularly confirmatory of my own observations. " I used to think," writes my informant, '' strong coffee the best of all remedies. I remember one in- stance especially, only a pattern of many others, but more striking when told. With bent back, high shoulders, and elbows fixed on the chair-arms, I had been laboring for breath all the afternoon. About five o'clock I had two breakfast-cups of strong coffee. The hard breathing disappeared rapidly and completely. My sisters were dancing in the next room, and in less than an hour I was dancing with them, quite free from asthma. Of late, coffee has often had an opposite effect upon me. The after-dinner cup of coffee, to which I have been for several years habituated, now produces a sen- sation of stuffing of the chest, and incapacity of moving about. 1 believe this is be- cause it stops digestion; and the reason 1 did not suffer from it for some years I take to be, that my originally most excellent and enduring stomach could stand it so long, and no longer. Coffee, on an empty stomach. I still deem a most valuable remedy. I do not share the prejudice against putting milk and sugar into cofff e that is used as a medicine, provided that it remain cafe noir, and be not made cafe au laiV ITS PATHOLOGY AND TREATMENT. 109 The second case was also that of a lady, forty-five years old, who had suffered from asthma fourteen years, and had tried literally everything— nitre-paper, emetics, stramonium smoking, tobacco smoking, chlorodyne, chloroform, ether, hyoscyamus, ipecacuanha, squhl, strong coffee, iodide of potassium, tonics, etc., with hardly any benefit. She was recommended by a lady with whom she was residing to try gin, as it was "very good for asthma," and she asked my consent, which of Course I gave her, and she took a dose—two .teaspoonfuls in a wineglass of water. The effect was immediate, and the relief complete. From that time she resorted to it under all circumstances, and always with the same result. No remedy that she had ever tried had produced such effects. The dose gradually increased, and the frequency of taking it also increased, tiU, instead of tak- ing two teaspoonfuls, she would take two wineglassfuls ; a smaller dose was insufficient. Sometimes she would take this as much as three times 'in the twenty-four hours. I have seen her decidedly under the influence of alcohol. She herself had a great horror of it, and used to tiy to do without it, but nothing else would give her relief ; and, after trying other things in vain, she would be at last compeUed to resort to this her disa- greeable, but always efficacious, remedy. In the autumn of 1862, I sent her to Malaga, to escape the bronchitis which had nearly killed her the winter before, and she was able there to leave off the gin. But, on return- ing to this country in May, 1863, she found she was obliged to take to her gin again. She has never found it do her any harm. It has a strong diuretic effect; but the relief does not depend upon this, as it is immedi- ate, and occurs long before the kidneys begin to act. She always takes it with water, as hot as she can bear it. If she took it with cold water, she thinks she might take any quantity, and that it would do her no good ; for, if she lets it stand till it is cool, and then takes it, it is useless. If, too, she takes it when suffering from bronchitis as well as asthma, or when the asthma is due to cold on the chest, it gives either very imperfect re- lief, or none at all. The third case is that of a gentleman at the present time under my care. I think I may say, without exaggeration, that his case is the most severe I have ever witnessed. I have never seen or heard of spasms so violent, or that seemed to threaten so nearly to put life in peril. His most intense spasms he calls " screaming spasms," from the strangling cries that the want of breath compels him to make. At the time of which I am speaking, he lived in the same street with myself, and though his house was half the length of the street from mine, his nurse has often assured me that if the doors had been open I could have heard his screams in my house at night. His case was as much characterized by intracta- bility as severity. I may simply say that everything had been tried, and that nothing did him any good worth speaking of. The only thing that gave him any relief was chloroform, and that only lasted as long as he was under its influence; as he emerged from the state of unconsciousness, the spasm returned. All other remedies failed absolutely. One day his nurse, who had seen benefit derived from hot spirit-and- water, in the case of an asthmatic lady on whom she had attended, recom- mended him to try it. He was at first afraid to do so, thinking it could do him no good, and might, possibly, do him harm. He, however, took some, and was at once relieved by it. He was so convinced of the relief it gave him, that when, a few hours after, the difficulty of breathing was coming on again, he again resorted to it, and with a like effect. He took it a«-ain and again, each time to meet the spasm, and each time with the 110 ON ASTHMA '. same result: the spasm stopped almost as soon as the brandy-and-water was swallowed. It was made very strong and hot—two-thirds brandy and one-third boiling water. In this way he took a quart of brandy m the first twenty-four hours that he tried it (at least so his nurse afterward assured me), and went on in that way for two months, during which time he took twelve gaUons of brandy. The spasms were so fearful and the relief so complete, that I gave my consent to this treatment, although I was appaUed by the quantity of brandy he was taking. Indeed, I think that no prohibition of mine, if I had thought it right to prohibit it, would have been of any avail, so eagerly did the poor man cling to anything that gave him relief. On many occasions, the nurse has told me, he became quite intoxicated, but be was so imperious in his demands for the spirit that she was afraid to refuse him. For the last five months the " spasms" have left him, but he has, instead, what he calls a "thickness"—tight constricted breathing—two or three times in the night, and sometimes by day; and this he finds equally relieved by the brandy—equaUy, but not so instantly reheved : the relief begins at once, but it is often ten minutes or a quarter of an hour before it is complete, and sometimes half an hour before he lies down and goes to sleep. He takes it twice in the night, or three times, but none by day. The quantity now consumed in the twenty-four hours is about five or six ounces. It now never produces any effect on his head. But though he takes it in such reduced quantity, it stUl must be taken hot and strong; to use his own expression, "the water should be boUing—as hot as you can get it down : warm water is of no use." He believes himself that the brandy acts by favoring expectoration; but this cannot be, as the relief begins prior to the spitting. I believe the order to be the reverse, and that the expectoration comes in conse- quence of the relief. This is a remedy that one would, and properly, feel great reluctance in commencing. Alcohol is a thing the use of which is much more easily begun than left off. Moreover, it requires to be given in constantly in- creasing doses. Besides, if given as a remedy for a chronic affection, it has far more likelihood of becoming habitual than if taken for any other reason ; for, since the circumstance that requires it constantly recurs, its administration also constantly recurs; and thus that which was given in the first place in small doses, and for a mitigation of suffering, is ultimately taken in excessive quantities, and becomes a necessity of itself. Still, in face of the horrible sufferings of asthma and the inoperativeness of every other remedy, I think we are justified in giving it. I would go so far as to say I do not believe we should be justified in withholding it. Only our patient should be clearly made aware of the tendency of the remedy, and that it is one that can only be administered for a certain time. If the paroxysms are of frequent occurrence, and the dose of alcohol required to subdue them is large, its unlimited continuance would only exchange the uncer- tainties of asthma for the certainties of kidney or liver disease, or delirium tremens : the common-sense rule of choosing the least of two evils would be enlisted against its use. I admit that this consideration, however strik- ing the effect of the remedy, greatly diminishes its practical value. Still, in the cases I have related I have been very glad to avaU myself of it, and the poor patients themselves have felt thankful that there was at least one remedy on which they could fall back in their extremity. It is a great point gained to stop the paroxysm in any way whatever; and the clinical history of asthma is so capricious that it is always possible that before any ITS PATHOLOGY AND TREATMENT. Ill remedy has been continued prejudicially long, it may, on the one hand, cease to be necessary, or, on the other, may cease to be efficacious. The theory of the action of alcohol in asthma is, I think, very much the same as that of coffee and other stimulants—it acts as what I call, for want of a better term, a " nervous derivative;" it puts a stop to the asth- matic state by the establishment of a new nervous condition; it gives a sort of shock or shake-up to the nervous system; in the language of the French semi official press, it " profoundly modifies the situation." We know that an inceptive epileptic fit may be stopped on exactly the same principle. Such a theory has nothing in common with the treatment of acute inflammatory and other diseased conditions by alcoholic stimulation. In carrying out this treatment the following rules, very similar to those Z- to be observed in the .administration of coffee, must be borne in mind: That the alcohol must not be given as a diet—that is, not given as a part of a meal, or sipped gradually. That it must be given in quantity sufficient to produce the physiologi- cal effects of the drug. That the most concentrated forms of alcohol are the best—brandy, whiskey, gin; the weaker being inoperative in proportion to their dilution. That for some reason or other—probably because it increases the stimulation—it is best given hot; not warm, but hot. That its continued use requires that the dose should be constantly in- creased, in order to produce the same effect. J--" I adverted just now to the influence of mental emotion on asthma, and stated my belief that its modus operandi was, like that of coffee and other stimulants, by producing an exaltation of sense and wiU—an intense activity of the intellectual part of nervous action—and proportionately lessening the tendency to excito-motion ; and this it does to a much greater degree than stimulant remedies, and its effects are, therefore, proportionately more sudden and complete. It was, indeed, the curative influence of violent emotion, and the observation that it and coffee-taking alike banish that condition, in which asthma is most prone to come on, that first suggested to my mind the theory of the action of stimulants on asthma that I have endeavored to propound. I think, too, that mental emotion acts, if I may so express it, as a nervous derivative. There are many phenomena, both in health and disease, that seem to show that only a certain amount of nervous activity can be in operation at a certain time, and that if a nervous action of one kind comes into operation, another that had been previously going on is immediately depressed or arrested. Such is the explanation of the weU-known experiment of the two dogs, one of which was taken hunting immediately after a meal, whUe the other was allowed to sleep. In the one that was taken hunting, digestion, on its re- turn, was found hardly commenced; in the other, it was completely over, and the stomach empty. In the sleeping dog the wThole vital dynamics, not being otherwise employed, were appropriated by the function of diges- tion ; while in the hunting dog they were entirely taken up by its energetic locomotion, and drafted away, as it were, from that nervous superintend- ence of digestion without which the function cannot be carried on.1 The power of strong emotion, or hard study, in retarding digestion, is an analo- gous fact. Just in the same way, I think, the extraordinary activity and exaltation of thought and perception, that characterize the state of mind 1 See Dr. John Reid's experiments, in Todd's Cyclopaedia of Anatomy, vol. iii., p. 899; also those of Bernard and of Bischoff, in Miiller's Archiv, 1843. 112 on asthma: that the taking of coffee, ether, Indian hemp, and other stimulants pro- duces, act as a nervous derivative in asthma, and divert from the nervous system of the lungs that morbid activity which engenders the spasm of the bronchial tubes.1 The cure of asthma by violent emotion is more sudden and complete than by any other remedy whatever ; indeed, I know few things more striking and curious in the whole range of therapeutics. The remedy that stands next in speed and efficacy—tobacco pushed to coUapse—takes time, a few minutes at least; but the cure of asthma by sudden alarm takes no time; it is instantaneous, the intensest paroxysm ceases on the instant. This is a fact so little known, as far I can see, and yet so practically impor- tant and theoretically interesting, that I think it wiU not be unprofitable if I endeavor to impress it more deeply by the narration of some cases OT lf"S OP0U1TGI1C6 Case I.—A gentleman suffering an unusually severe attack, so bad that he had been unable to speak or move all day, was suddenly alarmed by the Ulness of a relative ; he ran down two flights of stairs and up again, and administered the restoratives he had procured, and then observed, to his astonishment, that his asthma was gone. This gentleman tells me that, on many other occasions, different forms of mental emotion have cured his asthma. Case H.—C. B., a confirmed asthmatic, states that when he was suffer- ing from an unusually severe attack a fire occurred just opposite his house. Previous to the occurrence of the fire he was in bed, breathing with the greatest difficulty, and unable to move. When the excitement of the fire was over, he found that he had been standing in his nightshirt, looking with others out of the window, and that he had forgotten all about his asthma. His breath was not quite well the rest of the day, but nearly so. On another occasion, when he was suffering from an attack, some sudden anxiety arose about two of the members of his famUy being out late: the alarm from which he suffered relieved his asthma, but not so suddenly as in the case of the fire. On another occasion a sister of his was seized with sudden Ulness that seemed to threaten suffocation: he was suffering se- verely from asthma at the time, and was in bed ; he jumped out of bed in great alarm, and found then that his asthma was perfectly cured. He was sufficiently well to run for a doctor, and continued weU throughout the day. Case HI.—Not long ago I was informed by a patient at the'hospital, who had suffered greatly for many years, that however severe an attack might be, venereal excitement would almost invariably cure it. He told me also, that, when a youth, he had been guilty of the practice of onanism, and that the unnatural excitement thereby produced had just the same curative effect on his asthma. Indeed, he pleaded this effect of it as a sort of excuse for the practice ; and assured me that when his breath was very bad at night he used to resort to it for the purpose of curing it. I have known two or three cases in which sexual excitement has had just the same effect. Case TV.—The following account of the curative influence of mental excitement I have received from a medical friend, who has suffered from 1 The case of a lady, who related to me that whenever she felt her asthma coming on she was in the habit of stopping the attack by going to the piano and playing, ad- mits, I believe, of the same explanation She was an enthusiastic musician; and the practice of her accomplishment so exalted her cerebration, that it placed her ner.oua system in a state the least disposed to excito-motory action. ITS PATHOLOGY AND TREATMENT. 113 asthma all his life : " On one occasion I was sitting with fixed elbows on a sofa, breathing hard : a lady came into the room whom I knew very well, and whom I had not seen for several years. I got up to receive her, and sat down again on a music-stool; with no especial purchase, therefore, for the respiratory muscles, and yet with comparative ease of breathing. This ease lasted for about an hour, and then the difficulty of breathing came on again. I attribute the temporary amendment to the diversion of nervous energy. Just the same thing has happened to me more than once. On another occasion I was suffering a good deal at a farm-house. I got on horseback with some difficulty, and an anxious hope that the horse would go quietly, to fetch myself an emetic from a town three TnUes off. The horse ran away with me. I pulled in, at first weakly and almost despair- ingly, but the need of exertion brought the power: after a run of about a mile I succeeded in pulling up, and was delighted to find my asthma gone. Another time I was breathing very hard, and a friend engaged me in an argument. At first I could only get out a sentence in successive gasps ; but gradually, as I got excited, the hard breathing went off, and I could talk fluently." 1 Fromlhe foregoing observations, then, I think we may conclude— TkaCsince the abeyance of the will favors, in proportion to the degree of that abeyance, the development of asthma, and since the effect of stimu- lants is to dispel such suspension or depression of volition and restore the will to its wonted (or even an unwonted) activity, it is by thus exalting the will, and so disfavoring the development of excito-motory action, that these remedies relieve asthma. That thus strong coffee, alcoholic stimulants, and mental excitement, although apparently so different, belong to the same category of remedies for asthma. i % ____________________^__________;_______________________________ 1 For additional cases of the cure of asthma by mental emotion, I must refer the reader to Chapter II., on the Pathology of Asthma. 8 114 on asthma: CHAPTER X. TREATMENT OF THE ASTHMATIC PAROXYSM {continued).— TREATMENT BY SEDATIVES. Their number and value.—Tobacco.—Chloroform : its varying efficacy.—Caution with regard to its use.—Opium.—The objections to it.—Stramonium: its unequal value—Cases.—Its various preparations and modes of exhibition.—Practical rules. —Lobelia.—Indian hemp. —Ether. The recognition of the nervous nature of asthma ; of the paroxysmal char- acter of its symptoms ; of the fact that the air-passages were in a state of spasm ; that a part, at least, of its essential pathology appeared to be a morbid susceptibility to certain stimuli; that many of its exciting causes were such as exalted nervous irritability ; that the subjects of it were com- monly individuals of quick and mobile nervous systems ; these, and analo- gous considerations, long ago suggested the use of sedatives both for the prevention and aUeviation of the asthmatic paroxysm. The modus operandi of sedatives, both in the cure and prevention of asthma, is doubtless by allaying nervous irritability; destroying for the time that morbid sensitiveness of the pulmonary nervous system that con- stitutes so essential a part of the disease. \ And while, on the one hand, it * is the nervous theory of asthma that has suggested the use of sedatives, their efficacy, on the other—the immediate and perfect rehef that foUows the use of some of them—is among the best proofs we have of the correct- ness of this nervous interpretation of the phenomena of the disease. Of aU the classes of remedies used in asthma I think that sedatives con- stitute the most numerous. I wish I could say that they exceUed others in efficacy as much as they do in numbers. But they are of very unequal power ; for while one or two of them are of very great value, others appear to be of little worth, and some even prejudicial. Z Chloroform, for example, is, in my opinion, one of the most valuable remedies for asthma that we possess ; the inhalation of its vapor putting a stop to the asthmatic par- oxysm more speedily and more certainly than even tobacco. Opium, on the other hand, I have found, as far as my experience has gone, positively worthless. \ Moreover, with regard to sedatives, asthma exhibits very strongly its characteristic caprice ; stramonium smoking is, to some patients, an infal- lible cure, while others might just as well smoke so much sawdust, and not only receive no benefit, but experience no result of any kind from it. The principal remedies of this class are : I. Tobacco, in sedative doses; H. Chloroform; HE. Opium ; IV. Stra- monium ; V. Lobelia ; VI. Indian Hemp ; VH. Ether, in sedative doses, y Of most of these I have now had considerable experience. I wiU speak of them in the order in which I have enumerated them. I. Tobacco.—I have, in a previous chapter, spoken of tobacco as a de- pressant. But tobacco as a sedative is quite another thing. The dose is ITS PATHOLOGY AND TREATMENT. 115 different; the physiological effects are different; the principle of the cure is entirely different. In smoking, with the view of producing depression, the individual must be unaccustomed to the drug, or the tobacco very strong, or the dose very large ; in smoking for sedation none of these is necessary. y\ For tobacco to cure asthma, as a depressant, it must produce coUapse ; as a sedative it merely produces that composing and tranquiUiz- ing condition with which smokers are so familiar. As a depressant, it ren- ders spasm impossible by knocking down nervous power (doubtless by poisoning the nervous centres); as a sedative, by temporarily effacing a morbid sensitiveness to certain stimuli, and inducing a normal indifference to and tolerance of them. >Any one may experience the sedative effects of tobacco, and all smokers do habitually ; but the production of its full de- pressant action is almost impossible in those who have long accustomed themselves to its use; in others, however, as in women and chhdren, it is so easy that the difficulty is to prevent sedation from running into depres- sion. It is for this reason that it is necessary, in administering tobacco as a sedative only, to the uninitiated, the delicate, or the young, to give the very mildest form, in carefully measured quantities, and to insist on its slow and deliberate exhibition. Asthmatics are very commonly smokers, and many of them find in the habit an almost unfailing antidote to their disease. But in almost aU the cases that I have met with, it is rather as a prophylactic that it is used— to secure immunity when under dangerous circumstances, or to meet the first threatenings of an attack—than as a veritable curative to cut short spasm. II. Chloroform.—The inhalation of chloroform is, beyond doubt, one of the most powerful methods of the treatment of the asthmatic paroxysm that we possess, as it is also, necessarily, one of the most recent. Many patients have an objection to it, and there is the practical difficulty of the necessity, or the supposed necessity, of the presence of the medical attend- ant for its safe administration ; and, therefore, in a great many of my cases, patients have preferred using other remedies, and have not tried it. But I have notes of thirteen cases in which I have watched its employment, in none of which was it inoperative ; in twelve it did good, in one it did posi- tive harm. But I believe this last case is extremely rare, and that not in one case in fifty or a hundred would chloroform increase the asthmatic spasm : of aU the cases in which I have known or heard of its being given, I have never heard, except in this case, of its increasing the asthma. A more common fault of it, and a very serious fault, is that the relief which it gives is transient, and in many cases merely coextensive with the insensibility that is produced. Indeed, it is the rule for the beneficial effect of the chloroform to pass off, in a greater or less degree, with the in- sensibility. This, however, is not always the case, for in some instances when the insensibility passes off the asthma does not reappear ; in some the relief is produced without any insensibility whatever ; and in some a very smaU dose is sufficient to give relief, the patient immediately passing into a tranquU sleep, which may continue for hours, and from which he will wake with the asthma gone, although the original dose was far short of enough to produce the true chloroform sleep. There can be no doubt, I think, that chloroform dissipates the asthmatic spasm by relaxing muscular contraction, just as it will dissipate hysterical contraction of the rectus abdominis, and thus disperse a phantom tumor, and that it acts through the general nervous system. But I have seen one case, which I shall relate, in which it seemed to act directly on the bron- 116 on asthma: chial muscle. I conclude this to have been so because I think the effect was too immediate for it to have taken place via the circulation and the general nervous system : the first act of inspiration was accompanied with a sensible relief long before the blood charged with the chloroform could have reached the nervous centres. Patients and their friends have often asked me if there is not danger in giving such an agent as chloroform in the height of an asthmatic paroxysm. And truly, looking at the alarming state of semi-asphyxia to which the asthmatic paroxysm often amounts—the turgid face, the small pulse, the struggling respiratory muscles, the almost absolute stand-still to which both respiration and circulation are brought—one would be apt to think that it would take very little more to stop both the one and the other, and that it was not exactly the condition for which to administer a drug hav- ing so depressing an influence on both these functions. I can only say, however, that I have given chloroform in the very agony of the worst at- tacks ; that so far from fearing it under such circumstances, it has been to relieve the intensest asthma—that which nothing else would reach— that I have most given it; and that I have never seen any bad effects from it. Indeed, the immediate and direct effect of the chloroform is to remove that which is the whole cause of the asphyxial stoppage—the bronchial spasm—and to set the pulmonary circulation free. No sooner does it en- able the patient to fill his lungs than the loaded right heart disburdens itself, the lividity and venous turgescence disappears, and the pulse regains its normal volume. The intensity of asthmatic apnoea, so far from being a reason against the administration of chloroform, is the great reason for its immediate employment. I grant that if the same amount of lung-stop- page depended on any other cause than bronchial spasm (at least on any cause that chloroform would not relieve) its administration would be highly dangerous. I may add that my experience does not induce me to believe that the presence of valvular disease, or muscular weakness of heart, adds any- thing to the danger of chloroform, unless these conditions exist to such an extent as materiaUy to affect the circulation. I believe that chloroform may be as safely given to a man with an aortic bruit as to one without one, provided there be no symptoms proper. I believe the circumstance that determines whether chloroform shaU exercise a fatal influence on the heart's action is, not the presence or absence of organic heart disease, but some idiosyncrasy of nervous organization. I shaU not easily forget the first case in which I administered it. A poor woman was brought into King's College Hospital at the time that I was house-physician there, supposed to be dying by those who brought her in. She was quite unable to move, and could barely speak: but it was easy to perceive, from the violent action of the respiratory muscles and the loud, wheezing that accompanied it, that the suffocation from which she was suffering was of the asthmatic kind. I at once administered chloroform. After a few whiffs the spasm began to yield, and before I had given her enough to make her insensible, it had quite subsided and her breathing was free. In ten minutes after entering the hospital she left it—well. Even in asthma with bronchitis I have known it, if carefuUy admin- istered, of great service, by getting rid of the asthmatic element of the dyspnoea, and so putting a stop to one of the sources of suffering, and one of the causes of pulmonary congestion and bronchial exudation; and at the same time, by relaxing the constricted air-passages, facihtating the ITS pathology and treatment. 117 discharge of the accumulated mucus. In chronic bronchitis I have seen at least half of the dyspnoea vanish on its administration, showing how much of the symptoms were due to spasm. I think its usefulness in these cases has been overlooked, and that if carefuUy and tentatively given it might be tried in them without risk. Certainly for the time the patient is placed under much better circumstances, even as far as the bronchitis goes. The sooner it is given after the commencement of an attack the better, for if the spasm has existed for some time it is apt to recur as soon as the influence of the chloroform passes off. The plan recommended by Dr. Russell Beynolds, of recurring to it at the first indication of an attack, is, I think, a very good one, for the spasm yields with much greater facUity, and is cut short whUe it is in so incipient a state that the treatment is virtually prevented. He mentions the case of a young lady (Lancet, October 29, 1853) who, by inhaling a few drops on her handkerchief whenever an attack threatened, at once averted it, and was thus virtually cured of her troublesome complaint. As in aU other cases, so in asthma, the patient should never administer the chloroform himself. Dr. Todd's remarks on this point are so judicious, and enforced by so striking an example, that I cannot forbear quoting them. "In the administration of chloroform," he says, "I would give you this twofold caution: first, to give it gradually and cautiously, and not in a full dose —not to produce insensibility. Secondly, to impress upon your patient that he must never give it to himself. The following case was related in the papers the other day : A person who was in the habit of curing his attacks of asthma by inhaling chloroform, when administer- ing it to himself one day, and when in a state of half subjection to its in- fluence, in order to produce the fuU effect placed his handkerchief on the table and buried his mouth in it; his insensibUity became deeper and deeper, till at last he was too far gone to raise his head. He therefore continued inspiring it; his coma became more and more profound ; and a short time after he was found in that position quite dead."—Medical Gazette, December, 1850. The foUowing cases very well illustrate the power of the remedy, its varying operation in different individuals, and the symptoms that result from its continued and excessive administration. Case I.—F. E., aged sixty-three, engaged in the practice of the law, a sufferer from asthma of many years' standing, first began to take chloro- form at the end of 1861, two years and nine months ago, most probably at my suggestion, to relieve the violent attacks from which he then suffered. The dose in the first instance was smaU, and the effect always satisfactory and immediate. Not more than fifty minims was given on each occasion, and probably it was some time before that dose was reached. It never failed. One effect noticed then, which has been remarked ever since whenever the chloroform is given in full doses, was that it always made him feel chUly wdien recovering from its influence. It was applied on a handkerchief twisted into a hollow cone, into which the chloroform was dropped. The time at which it was exhibited depended entirely on the time at which the asthma was sufficiently bad to require it. and that was generaUy in some part of the night. The effect was at that time im- mediate ; after a breath or two had been drawn the spasm was felt to be giving way, and within a minute it was entirely gone ; and consciousness was gone with it. At this time the effect was not only immediate but final; the asthma 118 ON ASTHMA : was over for that bout, and the quantity necessary to finish it off was cer- tainly never more, as has been stated, than fifty minims, probably not more than thirty. After having had an attack of asthma cured by chloro- form, he was in the habit of considering himself " good for a week." Since that time the asthma has gradually changed its character, and the attacks, instead of occurring in paroxysms of great severity, at long in- tervals, have occurred more and more frequently and in a milder and milder form. As a result of this the chloroform has been more and more frequently called into requisition, and again, as a result of this, has gradu- aUy lost its power. Thus the dose required to relieve the spasm has con- tinually increased. The quantity required at different times would be very various ; some- times ten minims would produce a complete and marvellous effect—com- pletely stop the asthma, and send him off in a tranquil sleep for two hours; at other times dose upon dose would produce no effect, or next to none. On one occasion he took three ounces of chloroform between one o'clock in the morning and nine o'clock in the evening. The reason of the differ-, ence at different times seemed quite inscrutable. I have observed it in other cases. From the beginning, the taking of chloroform was foUowed, many hours afterward, by two symptoms—nausea, and a copious secretion of viscid saliva from the mouth. If, for instance, he took the chloroform at the usual time, say four o'clock in the morning, he would have no nausea at the time, nor in the morning on taking his breakfast, which was gener- ally a most substantial one, nor at chambers. But almost immediately after leaving chambers, at half-past four p.m., as soon as his mind was relieved from the preoccupation of his duties, he became conscious of the nausea. On his way home it would become very troublesome, accompanied by this profuse secretion of saliva, which was so great that, to his infinite disgust, he had constantly to get rid of it in the street. It was frothy and viscous, so that sometimes he had great difficulty in getting his lips clear of it. On reaching home the nausea was sometimes so bad that he could take no dinner ; generally he could and did, and usually found that the act of taking food relieved the sensation. Sometimes, however, after having taken a good dinner, it all came up again. For the rest of the evening he was hors de combat—could do nothing; sat in his arm-chair in a state of exhaus- tion, with a basin by his side ; and this would continue till it drove him early to bed at eight or nine o'clock. The next morning, on waking, supposing he had no asthma or chloroform, he would stiU feel the nausea, but in a diminished degree ; often, however, so much that he could take no breakfast. On reaching chambers all sense of nausea would vanish, and would not be felt tiU business was over ; then it would be felt again, but in a still less degree. And so it would go on till the second or third day, the flow of saliva and the nausea both graduaUy decreasing, when they would both finaUy cease. If, however, he took chloroform the second night, the nausea at breakfast-time the next morning would be still stronger, and would last longer—go on an additional day. Besides these effects of the chloroform, which may be caUed the pri- mary and immediate ones, certain more remote results graduaUy developed themselves in proportion to the length of time that the habit had existed, and the increased quantity taken on each occasion. These secondary ef- fects of the prolonged use of chloroform, as shown in this case, were__ 1. Insomnia. 2. Deafness. ITS PATHOLOGY AND TREATMENT. 119 3. Apathy. 4. Tremulousness of hands. 5. An increase of the asthmatic tendency. The most strongly marked and the most distressing of all was the in- somnia. It came on very gradually, and for a long time the cause of it was not suspected. The patient was habitually a good sleeper, and the wake- fulness that gradually showed itself was a strange and unaccustomed thing. In spite of all he could do, the hour at which he fell asleep became later and later—two, three, four o'clock, tiU at last it was six or seven. Indeed, he may be said ultimately to have had no sleep at all; two or three hours in a week was all he would get, and it became a wonder both to him and to me how he could exist with so little sleep, and not only exist, but pur- sue professional labors involving a great deal of close attention and mental wear and tear. When he went to bed he lay perfectly tranquil; there was not the slightest restlessness, but it seemed as if all tendency to sleep was abolished, as if he had no sleep in him, and never should want to sleep again: he was tranquiUy wide awake. Finding sleep hopeless, he spent the chief part of his nights reading. Everything that could be thought of in the shape of a sedative was tried. At one time it was thought that In- dian hemp was giving him sleep, but it turned out afterward that it was the remission of the chloroform that allowed him to sleep, and not the In- dian hemp that was making him sleep. The dependence of the insomnia upon the chloroform was discovered in this wise : The first exhibition of the Indian hemp was accompanied by a remission of the asthma, and therefore with a cessation of the chloroform. After it had been given a night or two it was observed that the patient was sleeping a little toward morning, and night by night the time at which he fell asleep became ear- lier and° earlier, tiU at last he would be so sleepy at ten o'clock (or even nine, I- think) that he could not keep himself awake, but was obliged to go straight to bed. The Indian hemp had been given early, at seven o'clock, in order that its influence might come on the sooner ; it was now, therefore, given later, just before bedtime, but so great did its soporific effect appear to be, so immediately did an irresistible sleepiness come on, that the dose was reduced, and great was the credit that the "bhang" re- ceived as an invaluable hypnotic. The sleep was everything that could be wished, and the neck of the insomnia was supposed to be broken ; the In- dian hemp had done its work, and was left off. But now came asthma, and with it chloroform, and within a few days the insomnia difficulty reap- peared ; sleep came on later and later. The " bhang " was again resorted to with confidence, but this time without success; the sleeplessness be- came worse and worse, till it was as bad as it had been before the hemp was given. The murder was now out: it was clear that it was the chloro- form that produced the insomnia ; that its former cure had depended on the remission of the chloroform, and not on the administration of the In- dian hemp, and that now that the chloroform was keeping it up, the hemp was powerless. It was very curious to see, as the chloroform continued to be given, the gradual way in which the time that sleep would come on was postponed, just as previously, when the chloroform was left off, the time at which sleep supervened was a little earlier each night. I may here mention that, in confirmation of this view, the return of sleep has again followed the remission of the chloroform. My patient has now, at the time that I am writing these notes, left off the chloroform for twelve days, and he has, in the same gradual way as before, recovered his power of sleep, and this time without the use of the Indian hemp. I am not aware that this ten- 120 on asthma: dency of the protracted use of chloroform to produce insomnia has ever been noticed before. Another effect was deafness. My patient has long been a little deaf, but after he had taken the chloroform for some time this deafness was greatly aggravated, and became a matter of much inconvenience to him- self and his friends. His mind also seemed to be affected ; his inteUect- ual powers were as good as ever, but he seemed to.have lost the disposi- tion to use them, and he wTould sit for hours in a sort of apathy, neither writing, nor reading, nor conversing, although naturaUy a man of, great mental energy. He noticed, too, that his hands were tremulous, and that he had not his customary steadiness in delicate manipulations with them. There cannot be a doubt, too, I think, that, although the chloroform never failed to relieve the asthma at the time, it tended to increase the asthmatic tendency in the long run, and this probably by rendering the nervous system more susceptible, shaky, and irritable. Certain it is that the longer the cldoroform was given the more frequent and obstinate did the asthma become, and the more transient was the control that the chloro- form exerted over it. Slighter things, too, would bring it on: the pa- tient has told me that he is sure that an attack of cough which, now that he has left off the chloroform, has no power to bring on the asthma, would infallibly have done so at the time he was taking it in such quantities. At that time, too, phlegm coming away would secure no immunity. A good deal of this " induced " asthma, however, was not " the genuine article," but a spurious imitation. I was sent for one night in great haste to see him, and was told of the immense quantity of chloroform that had been taken, and the persistent recurrence of the asthma in spite of it. But on closely watching my patient I soon discovered that what he was suffering from was not true asthma at aU; there was no real distress about the breathing, and I believe no narrowing of the bronchial tubes. The differ- ences between this " induced" and true asthma are that it is rather a rapid and panting than a tight, constricted breathing ; that, though loud, it is unaccompanied with wheezing ; that it will suddenly cease sponta- neously, remain absent from two and a half to three minutes, and then suddenly reappear; that whenever he speaks it ceases, or whenever any- thing emotionaUy excites his attention. On the occasion in question I re- fused to give any more chloroform for the mitigation of this spurious dysp- noea, and in a quarter of an hour it was gone. I believe that by keeping up the chloroform condition it might have been indefinitely protracted. From that time my patient and his attendants have been able"to recognize the difference between true asthma and this spurious dyspnoea. And the recognition of the difference is practically important, as the chloroform, although so effectual in relieving the true asthma, is not only useless against the spurious form, but inevitably keeps it up. Such, in this interesting case, were the secondary results of the pro- longed use of chloroform. They are such as I think offer a very serious bar to the further use of the drug. It was impossible to observe the shat- tered condition of my patient, and not feel that the further pushing of the remedy would entail a worse condition than the asthma ; that of the two evils it would be the choice of the greater. And, with this case in view, I should, on any future occasion on which I might advise the use of chloro- form, look forward to the possibility of having to prohibit its further em- ployment, lest a worse thing than asthma came upon my patient. Chloro- form-taking is like other dram-drinking, gains the same hold upon the patient, and leads to the same results. Indeed, it is impossible not to see, ITS PATHOLOGY AND TREATMENT. 121 in the case that I have related, a veiy close resemblance between the symp- toms and those of chronic alcoholism—the vomiting, the hand-tremor, the mental enervation, the insomnia. It is a good rule, and of universal ap- plication, that we should be slow in ordering the habitual use of any rem- edy whose ultimate effects are deleterious, especially in cases in which the dose is likely to become large. And just as I should be chary of commenc- ing the habitual use of alcohol or opium in any case of a chronic nature, so should I that of chloroform. Case H.—L. B., a lady aged forty-nine, who has long been a victim to asthma, is accustomed to get relief from her symptoms in the following way: About seven or eight o'clock in the evening, when she feels she could go to sleep, she pours ten drops of chloroform on a pocket-handkerchief, and inhales it. In two minutes her asthma is gone, and partly, probably, from the cessation of the fatiguing efforts of breathing, and. partly from the effects of the chloroform, she is sound asleep ; sleeps, perhaps, for six hours, and wakes breathing quite freely. On one occasion when I was called to see her in a very bad attack, knowing that so small a dose of chloroform as ten minims would stop an attack in the way I have described, I determined on administering it, in the confident expectation of giving her immediate relief. What was my surprise, however, to find that, al- though each dose that I administered gave her temporary ease, as soon as the effect of the chloroform passed off the asthma returned. I continued dosing her for about an hour, having given her in that time three or four drachms ; when, however, the effect of the last dose passed off, her asthma returned as severely as before I had administered any. It was quite clear that I was gaining nothing, and that for permanent relief the chloroform was worthless. I therefore desisted. Subsequent experience has cleared up the mystery, and shown that chloroform only gives her permanent relief when it sends her into a con- tinuous sleep ; and that it only sends her into a continuous sleep when she takes it at such a time as she would, if free from her asthma, be likely to sleep continuously—as, for example, near her ordinary bedtime. Given at any other time, it produces just as much momentary rehef, but the state of sleep being transient—the chloroform sleep not passing into natural sleep—the asthma returns with the consciousness. This curious fact is consistent with another fact in this lady's case and probably depends upon it—that she never has asthma when she is asleep, and that if she has asthma and can in any way get to sleep her asthma is sure to cease ; so, on the other hand, she is never awoke by asthma, like other asthmatics, but wakes free, her morning asthma appearing immediately after she is awake, and the time that it comes on depending entirely upon the time she wakes. The correct interpretation, therefore, of the cure of this lady's asthma by ten minims of chloroform is, that the chloroform temporarily relieves the asthma and sends her to sleep, and that the sleep prevents the recurrence of the asthma. I have repeated the chloroform experiment in this case on several occa- sions, and always with the same result. Any quantity is valueless to give more than a transient relief unless given just at the time when sleep is dis- posed to supervene ; but given then, ten minims is just as potent to cure an attack now as it was formerly. The incompatibUity of sleep and asthma which characterizes this case is quite peculiar ; indeed, it is the veiy reverse of what one ordinarily sees, sleep being commonly one of the most powerful predisposing conditions of asthma. However, it is a peculiarity that is very fortunate for the pos<- 122 on asthma: sessor of it, for it evidently imparts to chloroform, in her case, a power that it would not otherwise possess. Case HI.—One of the most suffering of asthmatic sufferers that I ever saw writes to me respecting the effect of chloroform, as foUows : "And now about chloroform. I can hardly teU you much about it, as I have tried none since I left Surrey Street; and there, and elsewhere before, I only tried it once or twice at a time. It struck me, however, that its bad after-effects were greatly in excess of the short relief I obtained by the stoppage of the paroxysm. Latterly I inhaled from half a drachm to forty minims during the height of a paroxysm. In a few minutes I began to feel queer, but a delightful sort of queerishness ; the paroxysm disap- peared, and I could lie back half asleep, and breathing, as it appeared, naturally. But this effect wore off in half an hour or so, and the paroxysm would begin again, aggravated by a very distressing sort of feeling. I have not tried it in repeated doses, the first after-effects being so bad ; in fact, it acts very like any preparation of opium does on me, but quicker, and the rehef does not continue so long ; the paroxysm returns sooner, and the distress is greater than after opium ; but it does not make me so un- weU the next day." Case D7.—A medical man, formerly a patient of mine, and in whose case chloroform was the only thing that gave any relief, thus describes, in notes that he sent me, the effect that it produced on him, and the method of its administration : " The effect of the chloroform was not immediate in subduing the paroxysm, but was instantaneous in giving temporary relief by relaxing the spasm of the muscles of the bronchial tubes ; if, however, I ceased its inhalation the symptoms returned in unmitigated force. As to the time I had to continue its use, that depended upon the severity of the paroxysm; and as to the quantity, I can scarcely give you a correct estimate, as Mrs. H. poured about a teaspoonful upon a handkerchief, and this was repeated as soon as the chloroform had evaporated, and continued untU the urgency of the symptoms was removed. The effects were always accompanied by an acceleration of the pulse ; and after the dyspnoea was relieved I usually went off to sleep." I might multiply such narratives as these to a great extent, but I have given enough to show the value and efficacy of the remedy, and to iUus- trate some points of its physiological action. On the whole, my experience of chloroform induces me to conclude— That it holds a high place among the remedies of asthma; that there is probably no one agent that relieves in so large a number of cases. That it operates with very various completeness in different cases. That even where it does not cure, it is of great value by affording a temporary respite. That no amount of asthmatic apncea or dyspnoea is any bar to its use. That if given constantly, however, in large doses, for a long period, a state of things arises which does, in my opinion, constitute a bar to its continuance. HI. Opium.—To opium in asthma I have myself a great objection. I do not mean to impugn the correctness of those who profess to have seen benefit derived from it; all I would say is, that I am not certain I have ever seen it do good, that I have often seen it do harm, and that I should have antecedently expected, from its known physiological action, that it would be prejudicial, and tend to increase the very condition for which it is given. I have endeavored to show that sleep favors asthma; that it does so on account of the ascendancy that excito-motory action then ac- ITS PATHOLOGY AND TREATMENT. 123 quires; that the heavier and more oppressed the patient is the intenser does the asthmatic spasm become ; and, on the other hand, that the wider awake and more vigilant he is— the more exalted sense and wUl—the more readUy does it yield, so that often simple rousing is enough to stop an attack that was graduaUy creeping on the sleeper. Anything, therefore, that soporizes aggravates the asthmatic tendency. Now this is exactly what opium does. What we want in asthma is a seda- tive that, like stramonium, sedates but does not narcotize ; or one that, like chlojteform, goes much further, and produces universal muscular re- laxation. \And not only does opium act prejudicially, by tending to exalt reflex action in proportion to the drowsiness and lethargy it produces, but by lowering sensibUity it prevents that acute and prompt perception of respiratory arrears which is the normal stimulus to those extraordinary breathing efforts which are necessary to restore the balance. Ju But, beyond this, opium seems to have a specific tendency to excite in- voluntary muscular action and induce a tendency to spasm. The exact explanation of this wiU depend upon the theory of muscular contraction that is adopted ; and into this at present disputed physiological question I wiU not enter. If, then, I had been asked, antecedently to all experience, whether opium would be useful in asthma, I should have replied, on the strength of the spasm theory of the disease, that it would not. But I would not let any theoretical objection run counter to clinical evidence ; and if experience said " give opium," no theory should prevent my recommending it. My own experience, however, coincides with these objections ; and I am disposed to think that the frequency with which it is given in asthma depends upon an unthinking foUowing of routine and a want of close and exact observation. Not only have I often seen asthma worse for it when given during the fit, but I have seen it brought on when it did not previously exist. An asthmatic gentleman, in whom I have often watched this, and who is frequently obliged to resort to opium on account of colic, never takes it without being rendered more or less asthmatic by it, however free from the disease he may have previously been. I would say, then, prefer any other sedative to opium ; and, unless there is some special complication that indicates it, never give it at aU. I must admit that since the publication of the first edition of this work I have seen cases in which opium has been of signal service. But they were cases in which there was bronchitis as well as asthma, and in which I believe the asthma was kept up by the irritation of the inflamed bron- chial membrane. And I believe it was by allaying this irritation that the opium acted beneficially—just as it allays bronchitic cough. But with regard to the use of opium in pure asthma, unaccompanied with any bron- chitis, I have not seen any reason to alter my original opinion. IV. Stramonium.—The smoking of the datura as a remedy for asthma was introduced in 1802, from India, by General Gent, and soon obtained, as new remedies are apt to, the reputation of being specific and infallible ; everybody with any shortness of breathing was smoking stramonium. Its use, however, has illustrated the general inapplicability of any one remedy to all cases of a disease, and the special caprice of asthma; and time has shaken it into its proper place and assigned it its true worth : that its original reputation greatly exaggerated its merits, but that it has undoubted, though very unequal value, and will probably always maintain its place among the real remedies of asthma. Perhaps no drug has been given with more contradictory results, and perhaps in no way is the caprice of asthma better illustrated than by its: 124 ON ASTHMA : effects in different cases. In some it is the remedy; in the majority of cases, as ordinarily used, it does some good, and in some few is positively injurious. " Sometimes," writes Dr. Watson, " it calms the paroxysm like a charm. The late Dr. Babington told me of a patient of his, who had been griev- ously harassed by asthma for a series of years, but who declared to him, after he had made a fair trial of stramonium, that he no longer ' cared a fig' for his asthma, which he could always stop in a moment. So, a Mr. Sills, in a collection of communications relative to the Datura stramonium, published in London in 1811, states that he had been a great sufferer from asthma; that the fits continued, with short interruptions, from thirty-six hours to three days and nights successively, during which time he had often, in the seeming agonies of death, given himself over, and even wished for that termination to his miseries. But, having at length discovered the virtues of stramonium, he uses this strong language: ' In truth, the asthma is destroyed. I never experience any Ul effects whatever from the use of the remedy ; and I would rather be without life than without stramonium.' " Among several striking cases of the efficacy of stramonium, communi- cated by Dr. Gooch, of Croydon, I wiU quote the following: " Mr. L., twenty- two years old, for the last four years has had great difficulty in breathing, attended by wheezing and cough, which attack him suddenly, when in bed or at meals, disabling him from his business, and sometimes continuing more than a week. It occasionally seizes him so violently that he is unable to speak, and appears to be threatened with instant suffocation. He has had much medical advice, without receiving material benefit. He now smokes the thorn-apple, swallowing the saliva and smoke ; by these means the fit terminates in a few minutes. He smokes every day, even when the fit does not occur. Sometimes it attacks him while dining in company ; in which case he retires, smokes a pipeful, and returns to his friends breathing freely." I might go on quoting cases ad libitum, but must con- tent myself with referring the reader to many very interesting and striking ones in the seventh and eighth volumes of the Edinburgh Medical and Sur- gical Journal, the twenty-sixth volume of the Medical and Physical Journal, and the various medical periodicals published at the early part of the present century. In most of the cases that I have personaUy witnessed it has given only temporary relief—mitigated rather than cured the spasm ; but, in a case recently communicated to me, its effects appear to be nearly as striking as in the cases I have just quoted. The patient was what is commonly termed a "martyr to gout," and suffered most severely from asthma. He could not walk in consequence of the gouty state of his legs and feet; and one of his amusements was to pick the chalk-stones out of his fingers with a knife ! "I remember," writes my informant, " one day, when I was at his house, he came home in his little hand-carriage, in which it was his wont to be wheeled about, and, on being helped into the parlor, he was in such a state from a violent attack of his asthma that he could not speak, but made signs to his daughter, by pointing to a cupboard, that she should reach him his pipe of stramonium. She lighted it, and, after he had taken a few whiffs, the breathing became relieved, and he was able to speak ; and, after a few more, the spasm and oppression so completely vanished that he could converse as well as usual." On the other hand one is frequently being disappointed with it; in some cases it does no good at aU, and in some has been said to prove in- ITS PATHOLOGY AND TREATMENT. 125 jurious, and in a few instances fatal Dr. Bree tried it in eighty-two cases ; in fifty-eight of these it had no permanent effect, and in the remaining twenty-four it acted injuriously. I must say, however, that my own expe- rience of its use has been much more favorable than this, as wiU be seen by a reference to my tables. In the majority of cases I have found it give some relief, and it rarely gives rise to discomfort. To what are these contradictory results to be attributed? Partly, doubtless, to the caprice of the disease, which behaves in the most irregu- lar way to all remedies; but partly, I think, to the mode of preparation and drying of the drug. An asthmatic patient of mine informed me that whUe he received great benefit from stramonium grown and dried by a relative of his, that which he gets at the shops does him no good whatever. He sent me a specimen of this home-prepared stramonium, and certainly it was a very different thing, both in appearance and smeU, from what one commonly sees : it had not lost its fresh greenness, nor the genuine sola- naceous smell. I think, therefore, asthmatics would do wisely to grow and prepare their own stramonium. Part, too, may depend on the time at which it is administered; stramonium, hke other remedies, wiU cut short an incipient spasm, while over one that has been long established it has but little power. The great thing is to give it in time ; and for that purpose, since the patient in general is awoke from his sleep by the parox- ysm, he should put his pipe, already fiUed, with the means of lighting it, by his bedside over night, so that, on awaking with the dyspnoea, he might immediately use it. My friend Dr. Buller, of Southampton, tells me that he has seen benefit from the inhaling (not the mere smoking) of stramonium smoke. "A year ago," he writes, " I met with an old asthmatic, who had cured himself and relieved mauy others by using cold stramonium smoke. He smoked the stramonium as you do tobacco, then puffed the smoke into a tumbler, and then inhaled the cold smoke into his lungs. I am now attending an asthmatic lady who could not inhale the hot smoke, but who inhales the cold smoke this way with great relief." The same plan of inhaling I find mentioned in a very interesting case in the Edinburgh Medical and Surgical Journal, as far back as 1811. The patient says: " The way in which I employ this remedy is thus: I fill a common tobacco-pipe with the stramonium cut in small pieces, and inhale the smoke as much as possible into the lungs, which causes heat and pain about the fauces and throat, and I am obliged to breathe once or twice before I can inhale it again, when I draw in the smoke ; and so on alter- nately till the herb is consumed, which occupies about half an hour, once a day. The saliva I swallow." Now this is introducing the drug in a dif- ferent way, and certainly a more powerful one than by simply smoking it, and one weU worth trying. B}r ordinary smoking absorption takes place by the oral surface only; here it is introduced into the lungs themselves and absorbed by the respiratory surface, whose absorbent powers exceed those probably of any other surface of the body. Besides, it has the ad- vantage of being applied to the very part affected. There are several species of datura in use, of which that commonly employed in this country, the Datura stramonium, appears to be the least powerful. The Datura ferox, which was first introduced by General Gent, seems to be much stronger. The Datura tatula, from which what are caUed stramonium cigars are made, appears also to be stronger. The seeds are much more powerful than the other parts of the plant; their analysis yields more than three times as much of the active principle, 126 ON ASTHMA: daturia. My friend Dr. Alexander, of St. Helena, where spasmodic asthma appears to be rather common, informs me that whUe he has found the smoking of the leaves almost worthless he finds the smoking of the seeds a most efficient and powerful remedy ; and that whereas he was disposed before he tried the seeds to regard the reputation of stramonium as a myth, he has since their employment come to the conclusion that it is one of the most satisfactory of the remedies of asthma. He states, however, that the effects of the seeds are so powerful that great care is necessaiy in their administration: they should be smoked in very small and graduaUy in- creasing quantities, and their effects closely watched. ^He has seen, on two or three occasions, alarming symptoms supervene on their use. I have not yet tried the experiment of smoking the seeds, but I shall certainly do so. I do not see why the leaves should not be steeped in a decoction of the seeds, dried, and then smoked, so as to administer by smoking a reliable preparation of an uniform strength. Exhibition by smoking certainly appears to have some advantages; absorption by the oral surface, especially if combined with inhalation, is sufficiently rapid, and at the same time gradual and more easUy regulated than by the stomach. One would rather either take or give any prepara- tion of the Solanacece by smoking than by swallowing. One feels, with regard to such ticklish remedies, the fuU force of the facilis descensus and its alternative. Nevertheless, I frequently give the extract, made from the seeds, and often with marked benefit. It should be commenced, I think, in quarter-grain doses, graduaUy increased to a grain. The Edinburgh preparation—an alcohohc, and not a watery extract—is the best and most reliable, the active principle, daturia, being veiy soluble in alcohol, but very sparingly so in water.l The tincture may also be given in from ten- minim to twenty-minim doses, every four hours, graduaUy increased till it occasions some obvious effect on the system. I may say, in conclusion, with regard to this drug, that its great value in some cases would, in spite of its too frequent impotence, always induce me to give it a trial in cases in which it had not been tried ; that I do not believe it is attended with any danger except from the most egregious over- dosing ; that since the common fault is want of power, I should prefer the stronger forms, the ferox and tatula, giving them tentatively and carefully; that inhalation of the smoke and swallowing the saliva may be advanta- geously combined with the ordinary method of smoking ; and that it can- not be given too early in an attack. I think it does more in the way of prevention than cure; I think I have seen better results from the long- continued practice of smoking a pipe of it the last thing at night, whether an attack of asthma is threatening or not, than by waiting untU a paroxysm comes on. I have seen this nightly pipe, the last thing before going to bed, apparently keep the disease at bay for an indefinite time, as long as it was continued, but followed by its immediate reappearance as soon as it was left off. The stramonium seems to leave for some hours a state of nervous system in which the asthma is not likely to come on ; and since the attack is almost always at night, the use of the stramonium at bedtime conducts and guards the patient through the critical time. I should say, then, let this always be one part of its administration ; and keep up the practice of smoking it the last thing at night for some months after the disease appears to have yielded, so as to completely break through the habit. 1 The alcoholic extract is now adopted in the British Pharmacopoeia. ITS PATHOLOGY AND TREATMENT. 127 I cannot dismiss the subject of stramonium-smoking without remarking that there is one circumstance that greatly reduces the value of smoking in general as a remedy for asthma—namely, that the severest asthma ren- ders the act impossible ; the patient cannot draw sufficient air into his mouth to keep the pipe or cigar ahght; he makes one or two ineffectual attempts at a whiff, and then his pipe is out and has to be lighted again ; when you proffer him the pipe he shakes his head in despair, and cannot even make the attempt. V. Lobelia.—I formerly had very little faith in this remedy, so little that at one time I almost ceased to prescribe it, having repeatedly tried it and found it fail. Of late years, however, I have very much altered my opinion respecting it, and I am convinced that my former want of success, and the want of success that has generaUy attended its use in this coun- try, has depended upon not giving it in sufficiently large doses. I had never given it in larger doses than from fifteen minims to half a drachm ; but I found that in America, where it is much more used than in this coun- try, and has a high reputation as an almost unfailing specific in spasmodic asthma, they gave it in vastly larger doses ; they consider half an ounce a full dose, but recommend two drachms every two or three hours till some decided effect is manifested. In many successful cases on record it has been given in smaU anti-spasmodic doses ;' but I believe, as I have said, its great success among the Americans, and in Dr. Elliotson's hands, and in my own since I have used it more fearlessly, depends upon its having been given in doses producing the characteristic depressant action of the drug. In fact, the condition that a large dose produces is such as I should think no asthma could resist; it is almost identical with to- bacco-poisoning—giddiness, faintness, sickness, cold sweat, and complete muscular relaxation. I have the most perfect faith in its value in asthma when producing such symptoms as these ; but they are not the symptoms one likes to produce in one's patients, and cannot be considered devoid of danger. I have for some time adopted Dr. Elliotson's plan of giving fre- quent and gradually increased doses. He recommends ten minims every quarter or half hour, increasing each dose a minim till the disease yields, or the drug seems to disagree with the patient. If this last should be the case, and vomiting and headache come on, the medicine must be left off for a time, and continued when the headache and other symptoms are re- moved, not increasing the dose beyond the last given. One circumstance that makes it the more necessary to be careful of overdosing a patient, and that strongly inculcates commencement with small doses, is that different individuals tolerate it in such different quan- tities. Dr. EUiotson states that in some instances a single minim produced sickness, while in other cases, on the contrary, sixty or even ninety drops were taken for a dose. He mentions a young lady who, being subject to spasmodic asthma, always carried with her ninety drops of the tincture in a small vial; this dose she swallowed whenever an attack of the disease came on. He. mentions, also, the following extraordinary and almost in- credible case: "A medical man, suffering from asthma, having failed to obtain his usual relief from his usual dose of the tincture, increased it to 1 " I have, for upward of two years past, been afflicted with inveterate asthma, which deprived me of natural rest, and the spasmodic effects of which were frequent and most distressing. When I found these paroxysms coming on I took fifteen drops of tincture of lobelia, which invariably gave me immediate relief, although pre- viously to my using this remedy the violent fits often lasted for hours."—London Medical Gazette, vol. iii. jog on asthma: fifty-minim doses, which he took every hour for twenty-four hours. Ex- periencing but little relief he added a minim to each dose tiU it reached seventy-five minims ; this he took for forty-eight hours, and the disease was relieved. His pulse was becoming intermittent, perspiration broke out over the body, and he became languid ; small doses of ammonia soon re- stored him to his usual state. In the last four days this man must have taken twelve ounces of the tincture."—Lancet, vol. ii., p. 144. Another circumstance that makes it the more necessary to be careful not to administer this drug in undue quantities is that different specimens of it differ so much in strength. Dr. Elliotson complains of this, and as- signs it to faulty preparation. But the Americans say that the plant itself varies very much in strength, this difference depending chiefly upon the situ- ation in which it has grown ; that which has grown in damp situations being rank and strong, while that which has grown in dry places is almost inert. The plan that I have now, for some time past, uniformly adopted in the administration of this remedy, is to give it in repeated doses every half hour, increasing the dose five minims each time, tUl some result is obtained. By " some result " I mean either that the physiological action of the drug is established (faintness, sickness, etc.), with or without relief, or that re- lief is obtained without such symptoms. The moment the patient begins to feel sick, or giddy, I order him to stop, whether his asthma is relieved or not; the same, of course, if the asthma yields without any sickness. I very commonly find that no relief to the asthma takes place tUl the charac- teristic symptoms of lobeha-poisoning show themselves, and that then the spasm immediately yields. Any amount may be given, short of producing these effects, without any relief whatever. The quantity required to es- tablish the physiological action of the drug is a matter of individual idio- syncrasy, and differs in each case. GeneraUy when fifty or sixty minims are reached the characteristic symptoms are felt Sometimes my patients have reached doses of a drachm and a half without producing any effect. When once the necessary dose has been ascertained in this way, I order the patient, on the next occasion, to start with that dose, which generaUy has the desired effect at once. VI. Indian Hemp.—The Indian hemp, Cannabis sativa, is much given in India as an anti-asthmatic, and among the natives has a great reputation. I can easily imagine from its physiological action that its reputation is well deserved. It is at once a stimulant and a sedative. I should be inclined to think it would act best in small stimulant doses. Given in this way it produces the same effects as coffee, only in a more marked degree—it exhila- rates, imparts great activity and intensity to the intellectual faculties, and exalts the functions of animal life. In any case in which coffee is useful I should expect that Indian hemp would be so in a greater degree. I think in large doses it might even do harm, from its hypnotic tendency. In this respect there is the same objection to it as to opium. I can say but little of it from my own personal experience. I have not often prescribed it, and in the great majority of the cases in which I have it has been a complete failure. VH. Ether.—Ether is mentioned as a remedy for asthma by almost all writers on the disease. I have never seen but one case in which it did any good, though I have given it in scores of cases. In that case it acted, and always had acted, like a charm. I cannot say that in any other case I ever saw it do a particle of good, and think I have often seen it produce a dis- agreeable oppression, and even increase the spasm. Others speak weU of it; but the result of my experience is as I h:we stated it. ITS PATHOLOGY AND TREATMENT. 129 CHAPTER XI. TREATMENT OP THE ASTHMATIC PAROXYSM {continued). Treatment of asthma by the inhalation of the fumes of burning nitre paper.—Cases. —Practical remarks. At a time when a more advanced pathology and physiology are inducing us to discard much of our inherited therapeutics, when the numerical method is giving us results so subversive of our faith in particular reme- dies, when the tendency of the professional mind is to trust more to treat- ment and less to medicines, and when the disposition to question the re- sults of past experience has given rise to a medical free-thinking almost akin to medical scepticism, it is some comfort to be able to fall back upon accessions to our materia medica of unquestionable value, about whose worth the mind feels no doubt. And when these remedies are those of a severe and intractable malady the satisfaction is stiU further augmented. The subject of this chapter is a remedy of this kind, of whose beneficial effects I have met with in innumerable instances ; and although the treat- ment is now not new, its effects are so striking and its value so frequently unknown, that I think it worth while to give in detail some of the cases which have come under my observation in which it has been successfuUy employed. This remedy consists in the inhalation of the fumes of burning nitre- paper—bibulous paper which has been dipped in a saturated solution of nitre, and dried. How or by whom it was discovered, or exactly when, I know not; but I find from the references made to it by different authors that it must have been in use for nearly twenty years, and its great valiA and efficacy are now beyond question, although for some time past it seems to have hybernated, and never to have attained a general notoriety. Let me first briefly relate some of the cases that have come under my observa- tion in which it was successfully employed, and then offer a few remarks on the method of administering it and the rationale of its operation. Case I.—P. K. W., a young lady, aged twenty, who has had asthma ever since her fourth year, at which age the disease appeared with the symptoms of an ordinary cold; in a very brief time these passed into what was supposed to be a severe attack of bronchitis, but the suddenness with which all the symptoms disappeared at once made it evident that the at- tack was of a spasmodic rather than an inflammatory character. She was immediately taken to the sea-side, and for four months had no return of the asthma. From that time, however, the attacks became much more frequent, so that it was impossible for her to leave the house during the winter, and this for several years, and indeed one winter she was scarcely able to leave her room. As she advanced in years the attacks became more distressing; change generaUy produced temporary relief, but three weeks scarcely ever passed without an attack more or less severe. Of the 9 130 on asthma: results of treatment her father, who is a medical man, writes thus: « Of treatment I can say but little. In the earlier part of her life I gave her the benefit of consultation with a physician connected with one of the London hospitals, and subsequently with other medical men ; but, to be candid, I must say that I cannot look back to any of their treatment, or my own, with a belief that it lessened the frequency of the attacks or miti- gated their severity when they occurred. But, though she derived no benefit from any medicines, I must not omit to state that she has always (save in those attacks which resulted from inflammation of the mucous membrane of the bronchi) experienced very great relief from burning bibulous paper, previously soaked in a saturated solution of nitrate of potass, and then dried. The room became almost instantly filled with a dense smoke, and that which was pretty nearly death, or at least the great- est inconvenience, to others, was to her a source of the greatest comfort, always mitigating and sometimes completely relieving the spasmodic con- dition of the air-tubes. The most striking instance of its efficacy was during the worst attack of asthma that I have ever witnessed. My daugh- ter, on the night to which I refer, had retired to her room with gloomy forebodings—the frontal headache, the tightness of the chest, the wheez- ing respiration, aU foretold the coming attack. About seven in the morn- ing the paroxysm was at its height, and as I entered her room the sight was indeed most pitiable : the livid, distressed countenance, the body thrown forward with the hands firmly pressing on the bed, the shoulders raised to the ears, the noise of the air passing through the narrow tubes, so loud as to be heard in the lower part of the house, aU showed too plainly the fearful struggle for hfe, and were the more distressing from the entire failure of every means which had been used to alleviate her suffer- ings. For a few minutes slight relief seemed to foUow the quick and regu- lar passing of the hand along the course of the spine. I had left the room for a short space. Alone with her maid it seemed to both as if the contest could be continued no longer ; in her agony she was just able to gasp out, ' Try the paper again.' Taking a large sheet the servant quickly filled the room with a cloud more dense, if possible, than a London fog. Scarcely had two minutes passed when, changing her position, she re- clined her head on the shoulder of her attendant; two minutes more and the was lying back supported by her heap of pillows; and conceive, if you can (for I cannot teU you), my surprise and joy when, on entering her chamber Avithin ten minutes of leaving it, I found her breathing as quietly, as noiselessly almost as a sleeping infant. A change so sudden, so com- plete, I never before witnessed. You wiU not wonder that nitre-paper has become an indispensable adjunct to the family medicine-chest, or that my daughter should be loud in its praises and grateful for its benefits. The attacks have much diminished both in frequency and intensity of late ; but the paper still maintains its high position as a remedial agent, and many have been the assaults warded off or repulsed by filling her room with its smoke when first she retires to rest." Case H.—G. T., aged forty-seven, has alwa}rs had asthma," his first attack dating from cold in infancy. The frequency of the attacks is about once every three or four months, and their time of access about two or three o'clock in the morning. The only thing that he has found do him any good is the inhalation of the fumes of burning nitre-paper, which, however severe his asthma may be, enables him to breathe easily. On the approach of a paroxysm he lights two or three sheets of this paper, which soon fills his room (rather a small one) with dense fumes. He describes ITS PATHOLOGY AND TREATMENT. 131 the first effect as being somewhat oppressive and suffocating; but this is soon foUowed by a mitigation of the dyspnoea, and then its entire disap- pearance. This is invariably the result; and the rehef is not temporary, but permanent—the attack is cured. Case HI.—E. P., a lady, aged thirty-five, married, having previously enjoyed excellent health, and never suffered from any thoracic affection, was seized with what was thought to be severe inflammation of the lungs supervening on exposure to cold ; but the urgency of the dyspnoea, the suddenness and completeness of its departure, and the repetition of the attack soon after, showed it to be asthmatic. From that time the attacks were frequent—every month or so. Every remedy was tried that could be thought of, but with no beneficial result. At length, happening to see in an American paper an account of an asthmatic who, having used aU his tobacco, had on an emergency filled his pipe, in default of it, with the match-paper (paper soaked in a solution of nitre) with which he was ac- customed to light it, and to his surprise had experienced more benefit from this than from his tobacco, and wished to know " the reason why," she was advised, by way of experiment, though little expecting benefit, to give it a trial. To her surprise she experienced great relief, and in her after-trials still more, because she managed it better than she had at first, and was more familiar with its manipulation. From that time she found it an un- fading remedy. Its effects were rapid and complete, and never failed. There was, however, one exception to its efficacy, and that was whenever the asthmatic attack was brought on and accompanied by bronchitis, in that case the relief it gave was trifling—it did indeed hardly any good: the fact was that it only relieved the bronchial spasm—only put a stop to the asthmatic portion of the dyspnoea, whUe the bronchitic portion per- sisted; and, moreover, there was in the inflamed condition of the bronchial mucous membrane a permanent exciting cause that probably restored the bronchial spasm almost as soon as relieved. At first the paper was used only every month or so, as the attacks were rarer; but as the disease became more severe the attacks occurred more frequently, and at last the paper had to be resorted to every day. Always at night, before going to bed, she burnt it in her room; indeed without it she could not have gone to bed, or got any sleep. It invariably had a marked sedative effect and sent her off to sleep in a few minutes; she could not resist the drowsiness that it gave rise to —she was quite overpowered by it, and was obliged to be watched lest she might faU forward, or drop the burning paper on her dress. When she felt her drowsiness overpowering her she would give warning, that the burning paper might be taken from her, and that she might put herself in a position from which she could not faU, as she had not power to save her- sslf. Even by day, and when not previously sleepy, it would put her to sleep, as well as cure her asthma, in ten minutes ; but if at all sleepy, as in the evening, she would be quietly asleep in three minutes. Now, we know that many remedies that relieve asthma are immediately foUowed by sleep in consequence of their removing that laborious dyspnoea which is the cause at once of the wakefulness and the weariness. But that this was clearly not the way in which the nitre fumes acted, but that they acted as a positive sedative, was shown by the fact that if this lady's asthma awoke her at night and prevented her sleeping, the burning of the paper had the same speedy sedative effect. As soon as her asthma awoke her she would strike a light and burn her paper, which she always kept by her bed-side, and get immediate relief, and so quickly and suddenly would the sleeping come on that, though quite independent of her husband in the commence- 132 ON ASTHMA : nient of her operations, she was always obliged to wake him that he might take the paper from her when the drowsiness overcame her. In three minutes after lighting the paper she would be sound asleep; sometimes her husband could hardly take the paper quick enough, so sudden were its sedative effects. Now here she was awoke from sleep to relapse again into sleep in two or three minutes; there had been no accumulated want of sleep, no weariness from protracted laborious dyspnoea. So uncertain was the time at which an attack might occur, and so certain was the effect of the nitre-paper, that this patient never went anywhere without taking some of it with her in her pocket. H an attack came on at any time she would resort to it. Sometimes when making a morning caU she would find her asthma coming on; she would bear the increasing dyspnoea as long as she could, and then, when she could bear it no longer, she would ask to be al- lowed to retire to some room to use her remedy, and in ten minutes return to her friends as well as ever. Case IV.—H. H., a gentleman residing in a country town, has suffered from asthma for twenty-five years. At first it occurred regularly every third night, but of late years has been less regularly periodic; the usual time for the attack to come on is twro o'clock in the morning. Of the effect of nitre- paper in his case this gentleman has given me the following account: "I certainly have great faith in the fumes of nitre. I have used it for twenty years, and when the difficulty of breathing is purely spasmodic I am sure to get relief by its use. I use it in the foUowdng manner : When I feel my breathing uneasy I burn a piece of the saturated blotting-paper in my bedroom on going to bed, and, by lying high at head, I am almost cer- tain of getting a good night, and of leaving my room in the morning free from the paroxysm. I use blotting-^vqier, but a friend in London teUs me that he uses £isswe-paper, which is thinner and does not smoke so much. I think this is an improvement, but there is more difficulty in saturating it, in consequence of its thinness." This gentleman adds : " Some time since I heard of a very bad case at Sturminster MarshaU. I sent the poor man some papers, and requested to be informed, in the course of a few days, what effect they had upon him. I enclose the poor feUow's answer; he is only a farm laborer." The answer was, verbatim et literatim, as foUows: "June the 20, 1855. " Honored Sir I have made a trial of your Goodness what you sent to me Sir and I am Happy to inform your Honor that it is the Best advice I ever had at aU for I went to Bead at 7 at night and never a woke untill 5 the next morning and that is more than I have done for this 10 weeks past Honored Sir I do not know how to express my grattitude to you a nogh for your great and merciful kindness to me Honored Sir I return you Sir most Humble and Hartery thanks for your goodness to me Sir I re- main your obedient and oblided servant J Christopher." Case V.—The foUowing account of the influence of nitre-paper in the case of a young asthmatic, aged fourteen, who has been asthmatic from the age of two, was communicated to me by his father, a well-known phy- sician in London : " For above six years nitre-paper has been burnt every night on his going to bed. When formerly omitted, on occasions when he appeared and felt perfectly weU on bidding us good-night, he had so fre- quently become asthmatic after being in bed for an hour or two that the paper is now invariably burnt the moment he hes down. His sleep is ITS PATHOLOGY AND TREATMENT. 133 generally sound and tranquU from nine p.m. tiU between three and five in the morning, when a slight disturbance in his manner of breathing, a sort of sonorous interrupted sigh, announces an approaching attack, which would in a few minutes distress him to such a degree as to compel his sitting up in bed but for the nitre-paper, which is instantly lighted, and which never fails to restore his usual breathing within five or ten minutes. He rarely awakes under these circumstances, but sleeps on quietly tUl seven o'clock, not aware how imminent the approach of his enemy has been." Case VI.—Even now, while I am writing, another case has come under my knowledge. It is that of a gentleman, an asthmatic from infancy, but who has of late years enjoyed an almost perfect immunity from his disease in consequence of residing in London. But whenever he goes into the country he is sure to be assailed by his old symptoms and cannot pass a night without asthma. Moreover, there is exhibited in his case that dis- position to habitude which so often characterizes asthma—that tendency to maintain, like other periodic diseases, the rhythm of its recurrence when once it has been established—so that when once his disease has been ex- cited by going into the countiy, it still continues on his returning to the place and to aU the circumstances and conditions of hfe in which, before, he had been free from a trace of his disease. Two or three weeks ago, when in perfect health, he went into the country, and suffered from his asthma as usual. On his return it stiU continued—hung about him ; hardly a night passed without its awaking him, and as it went on for sev- eral weeks without subsiding in the usual way he determined to try the nitre-paper. It was tried at once and was perfectly successful. He burnt two or three pieces of the paper in his room just before going to bed, slept without waking tUl about seven o'clock in the morning, and then awoke with his breathing perfectly free. He repeated it for several nights with the same effect. He then thought he would put it to its trial, so he took a late and not particularly wholesome supper, a thing very apt to bring on his asthma, then used his nitre-paper, went to bed, and had as good a night as ever. He then omitted it, and during that night his symptoms reappeared. He recurred to it the next night and for several foUowing, and then on leaving it off suffered no return of his disease ; the disposition to the nocturnal recurrence of the paroxysm had vanished—the speU was broken. He has not used it since, and probably wiU not tUl another visit to the countiy sets him wrong again. I might multiply cases to almost any extent; hardly a week passes without my meeting one or more. Within the past week I have met with two, iu one of which the nitre-paper was the only thing that did any good, in the other its efficacy was shared by stramonium. It has been suggested to me that if the nitre is dissolved in a strong infusion of stramonium instead of water, the result is still more satisfactory, but of that I have not made trial. The value of nitre-paper in any given case is, in my opinion, in propor- tion to the purity of the asthma in that case—the cure it effects is only complete where the asthma is of the pure spasmodic type and free from organic complications. In three of the cases that I have related, and others of which I have not preserved notes, it was of very little use when the at- tack was complicated with bronchitis. In such cases the dyspnoea is the result of two causes—the asthmatic spasm and the bronchial inflammation. The nitre-paper appeals to only one of them, and leaves the other un- diminished ; its effect is therefore but partial. Moreover, the bronchial inflammation is an abiding excitant of the spasm, and immediately re-hghts it as soon as the effects of the nitre-paper fumes have passed off. 134 on asthma: Let me, in conclusion, give a few practical hints with regard to the making of the nitre-paper. And this is not an unimportant point, for patients wiU find it more convenient to prepare the paper themselves, and unless it is properly made it wUl not produce its beneficial results. The object is to have as much deflagration of nitre and as little combustion of paper as possible. For that purpose the paper must not be very thin, or it wiU not take up sufficient nitre ; nor very thick, or it wiU make the fumes too carbonaceous; but it must be moderately thick, and very porous and loose in its texture, so as to imbibe a sufficiency of the solu- tion. The strength of the solution should be saturate at the ordinary temperature. If a saturate solution is made with warm water, and the paper is very bibulous, it becomes too much impregnated with nitre—too strong a paper, and burns too fast, with a sudden, explosive flame. There should be no brown smoke in its combustion, but light, clear, white fumes. Those who have a good deal of experience with this remedy teU me that they find the red blotting-paper, of moderate substance, the best. Some blotting or filtering papers appear to have a good deal of wool in them; they are loose, thick, and coarse. They should be particularly avoided, as they yield, on burning, a smoke of a particularly irritating and offensive kind, with a smeU something like that of brown-paper smoke, only worse. The nitre-paper, when once made, should be kept in a dry place, and then wiU not be the worse for any amount of keeping; but if it gets damp it does not burn with sufficient freedom, and should then be dried before using. The foUowing is the way in which an asthmatic gentleman teUs me he has been accustomed to make a paper that answers perfectly weU : " Dis- solve four ounces of saltpetre in half a pint of boding water ; pour the liquor into a small waiter, just wide enough to take the paper ; then draw it through the hquor and dry it by the fire ; cut it into pieces about four inches square, and burn one piece in the bedroom on retiring to rest at bedtime." I have tried this method of preparing the paper myself, and find that it burns perfectly weU and is very efficacious; but I think two such pieces are not at aU too much to burn at once. \ ITS PATHOLOGY AND TREATMENT. 135 CHAPTER XII. DIETETIC AND REGIMINAL TREATMENT OF ASTHMA. Facts showing the connection between the stomach and asthma; illustrative cases.— Practical rules a3 to the quantity and quality of food, and the time of taking it.—Special vitanda.—Summary. In no direction is asthma more accessible than through the stomach. Of aU forms of prophylactic treatment, none, with the exception of change of residence, is more successful than that which is regiminal. This depends on the close relation existing between the stomach and the lungs. > The intimacy of this relation is shown in asthmatics in various ways. a. Asthmatics are generally dyspeptics. Not that they are apt to suffer from the severer forms of ordinary indigestion, but their stomachs are generaUy irritable, their digestion capricious and irregular, and their die- tary restricted. It is very rare to see an asthmatic with a perfectly sound, strong stomach, about which he has never to think, and in the histoiy of whose case dyspepsia finds no place. Sometimes the dyspeptic symptoms exist in a very aggravated form, and they are frequently such as to imply that the stomach disturbance is one of deranged innervation—that its sen- sibility, or its movements, or the nervous superintendence of its secretion, is perverted. In these cases the stomach and lung symptoms are part of one morbid condition; the whole thing is deranged pneumogastric inner- vation, the dyspeptic symptoms being the manifestation of the gastric por- tion of this deranged innervation, and the asthma of the pulmonary portion of it. The foUowing is, as I interpret it, a good example of this association of stomach and lung disorder: A little girl, living in the viUage of Selborne, in Hampshire, began to suffer, when about eight years of age, from extreme irritability of the stomach. It was intolerant of anything ; the moment' food of any kind was swallowed it was rejected. There was no pain, no tenderness, no feel- ing of sickness at any other time. The vomiting was not violent; it was the simple and immediate rejection of anything put into the stomach. Before the chUd had half finished her breakfast she would have to rise from the table and run to the garden. There an act or two of vomiting would empty the stomach, and she would return to the house quite weU. The same with other meals; the same with any httle thing, such as blackberries, that she might eat between her meals: indeed her friends and playfeUows used to know where she had been, and which way she had walked, by these vomited blackberries and other things at the side of the pathway. This went on for many years, and the only way in which she appeared to suffer from it was from weakness and extreme emaciation. All sorts of remedies were tried without any effect, and the only treatment that did her any good was the plan of feeding her with nothing but milk, in teaspoonfuls at a time, frequently. This smaU quantity of this bland material the stomach 136 on asthma: would tolerate, and in this way some nourishment was able to be retained. I heard nothing of her for some years, and then, upon inquiry, I was told that her vomiting had ceased, but that its disappearance had been accom- panied by the appearance of another disease, spasmodic asthma, which had apparently supplanted it. With my previously conceived notions about the pneumogastric pathology of asthma, this was particularly interesting to me, and this interest was increased by my further inquiries ; for I found that not only had the vomiting ceased when the asthma appeared, but that when the vomiting had again appeared, as it had more than once, the asthma had ceased. In this way they alternated, the vomiting always com- ing on when the asthma was better. I regret to say that the intensity and persistence of the asthma have been such as to inflict on the lungs, by emphysema and thickened bronchial tubes, irremediable mischief, and to change the dyspnoea from paroxysmal to constant. Now, I do not think that I am giving way to fanciful speculation in be- heving that the malady in this case was throughout one and individual— morbidly exalted pneumogastric irritabUity, and that the supplanting of the vomiting by the asthma—the stomach contraction by the bronchial contraction—merely indicated the transference of this perverted innerva- tion of the pneumogastric from its gastric to its pulmonary portion. In another case of asthma violent paroxysms of pain in the epigastrium, clearly depended on cramps and irregular peristalsis, occurred at irregular intervals of two or three months apart. They were at first thought to be colicky, but were afterward clearly proved to have their seat in the stomach, and, I believe, depended upon a strdng hour-glass contraction, or spasm of the pylorus, through which the cardiac portion of the stomach was in vain endeavoring to drive its contents. It certainly so happened that when this patient was freest from his asthma he was most apt to be attacked with these paroxysms of pain, and vice versa, and that he never had the two together. In this case, however, the vicarious relation of the stomach- cramp and the asthma is not so clearly marked as in the preceding, and I would not press that interpretation of the symptoms. In the foUowing case, however, I think this vicarious relation is indis- putable. I wUl give as much of it as relates to this subject in the words of the gentleman who communicated it to me : ". . . . About three years since, the disease became very much modi- fied; the attacks were less frequent and less severe, and tiU this period the case appeared to be one of genuine spasmodic asthma, unmixed, I think, with any other disease. At the time to which I have referred my patient lost a sister, a year younger than herself (seventeen years), her constant companion in sickness and health. I mention this as it is somewhat curi- ous that from that event the asthmatic attacks very nearly ceased, but in the place of them she has been subjected to attacks of dyspepsia, frequently causing her as much suffering and inconvenience as her previous asthma. During the past winter and (with an intermission of a few weeks in the spring and early part of the summer) up to the present time, this dyspep- tic malady has rather increased than diminished. A leading symptom, as weU as a most inconvenient and distressing one, is that for many weeks together every particle of food, no matter of what kind, the moment it reaches the stomach induces what, for want of knowing how better to de- scribe it, I may caU & flatulent hiccough. This is soon succeeded by an extraordinary generation of flatus, which continues frequently for eight or nine hours, and has not been amenable, I think, to any treatment that has been adopted; though I may just remark that I am now giving her strych- ITS PATHOLOGY AND TREATMENT. 137 nine, and I fancy the symptoms are somewhat lessening. It is remarkable that this large generation and accumulation of air in the stomach has never induced an attack of asthma, although previous to this change at- tacks of asthma were frequently brought on by indigestion." Such cases as these are exceedingly interesting, and weU worth close attention. b. Another way in which this connection of the stomach with asthma is shown is the frequency with which attacks of asthma may be traced to errors in diet—a debauch, a late dinner, a heavy supper. In many asth- matics the most scrupulous care is necessary in all that relates to food, and a late dinner or a heavy supper wiU at any time infallibly bring on an attack. c. Another illustration of the same fact we see in the tightness of breath- ing that in some persons with asthmatic tendency foUows every meal: as certainly as food is taken, so surely, in an hour or two, does tight, dry, asthmatic oppression succeed. During an attack of asthma this tendency of food to embarrass the breathing is very much exalted, so that the suf- ferer is obliged absolutely to starve as long as the attack is on him. As the appetite is not affected in asthma this starvation adds greatly to the sufferings of the disease ; but the intensity of the exacerbation of the dysp- noea that foUows the taking of even a small portion of food is so terrible that the craving hunger is willingly endured. I have known more than one case in which, at each attack, the patient dared not suffer a particle of food to pass his lips for thirty-six or forty-eight hours. In one of these cases the attacks were weekly, and the patient had to starve himself from an early dinner on the day previous to the attack to breakfast on the day succeeding it. d. Another example of the same thing may be recognized in those gas- tric symptoms that are so often premonitory of an attack, that constitute, in fact, its first stage—flatulence, hiccough, and such hke. In aU these ways we see this one fact—that there exists between the state of the stomach and asthma a very close connection. From this fact we draw, on the one hand, instructive pathological teaching, and, on the other, important practical rules. To these practical rules let me now turn. One of the most important rules to be borne in mind, in the dietetic treatment of asthma, is the time of day at which food is given. The follow- ing case very weU illustrates this point, and also the part that sleep plays in favoring the induction of -asthma by food: A youth, residing in the country, had been subject to asthma from chfldhood. When quite young he ate and drank like other chUdren ; but as his malady became more severe he found that his attacks depended very much upon his previous day's eating; indeed that that was the one circum- stance which regulated them. If he ate late in the day (in other words, went to sleep soon after taking food) he was sure to be awoke the next morning at four or five o'clock with his asthma. At first he was obliged to give up suppers, and to make an early tea his last meal; then he was obliged to give up even that, and take nothing after an early dinner. He might drink, but could take no solid food. And for years two o'clock was the latest time at which he could with impunity suffer solid food to pass his lips. He made a good breakfast at eight o'clock, always taking some ani- mal food, and a good dinner at two, and from that time tiU eight o'clock the next morning he never took a mouthful. In this way he managed, in a great degree, to keep his disease at bay; but if he ever transgressed he knew the penalty he should have to pay, and which inexorably awaited him 138 on asthma: the next morning. He had a very good digestion and a ravenous appetite, and as evening advanced his hunger became so great that it amounted to a craving almost irresistible ; but he dared not gratify it. _ Sometimes, not daring to trust himself, and yet knowing the painful price at which he would transgress, he used to make vows, that it might be impossible for him to eat. But on the rare occasions on which he yielded to temptation and ate supper, it was never tiU he had been asleep an hour or two that the dyspnoea came on ; and if he did not go to sleep—as for example, if he stayed up dancing half the night, or sat up reading, or took a very long walk—the asthma did not come on at all. This gentleman has of late years almost completely lost his asthma; but if ever he gets it now it is after eating late the previous evening ; a late dinner-party, or a supper, is always the corpus delicti. By going to bed later than usual, however, and thus throwing a certain number of hours between taking food and sleep, he is able to render his dinner or supper innocuous; so, when he has been dining or supping out he sits up a little later than usual, and no harm comes of it. He knows by his feelings when digestion is over and his stomach empty ; and then he may go to bed in safety. The simple explanation of these phenomena is this: The taking of food (either by its mere presence in the stomach, or by the process or re- sults of digestion) acts as an irritant to the morbidly irritable pulmonary nervous system. The affair is excito-motory ; the food is the immediate or remote irritant, the nervous circuit involved is the pneumogastric, and perhaps in part the sympathetic ; and, in obedience to the common law of reflex action, the potency of the stimulus is increased, or, in other words, the reflex nervous irritability is exalted, by the condition of sleep. I need hardly recall to my readers' minds analogous phenomena in various dis- eased conditions—the frequency with which epilepsy affects the hours of sleep, or that debatable land between sleeping and waking ; the restriction to sleep of the cramps and jactitations of those whose systems are im- pregnated with lead, and which cease the moment the sufferer from them is broad awake ; the grinding of the teeth in children affected with worms ; and various other similar phenomena. So, in the case of asthma, the food may be in the stomach, but unless the wiU is suspended and excito-motory action exalted by sleep no results foUow. Now, to what does aU this practicaUy point ? To this simple rule, which of aU the dietetic treatment of asthma is the most important—let no food be taken after such a time in the day as will allow digestion being com- pleted and the stomach empty before going to bed. \ Of course the time at which the last solid food should be taken will depend upon what the bed- time is ; if ten or half-past ten, I would say let three or four be the dinner hour ; after that take no solid food, or a mere scrap of bread and butter at tea. But I would rather insist on no sohd food whatever being taken. As the day advances digestion becomes less energetic and rapid, and I am sure six hours is not too long to allow between the last meal and bedtime ; a dinner is not got rid of so rapidly as a breakfast. Moreover, the diges- tion of asthmatics is often very slow. But the rapidity of digestion, and therefore the time after dinner that sleep may be safe to the asthmatic, will depend upon two other circum- stances—the quality of the food and its quantity ; and these are two very important points. With regard to the quality of the food there are two kinds of articles of diet that should never be given to the asthmatic—those that are generaUy indigestible, and those that are specially provocative of asthma. These are ITS PATHOLOGY AND TREATMENT. 139 not necessarily coincident; for though, as a rule, it may be said that the foods that are found to be the most disposed to bring on asthma are those that are the most generaUy indigestible, yet there are some articles of diet that appear to have a special disposition to induce asthma quite out of proportion to, and in excess of, their general unwholesomeness. With regard to the first, we should act upon the same rules as we should in ordinary indigestion ; the food should be plain, well cooked, and con- taining the proper proportion of animal and vegetable elements. I am sure it is a mistake in asthma, as in other diseases in which it is desirable to give a peculiarly digestible aliment, to cut down the diet to too rigid and monotonous a simplicity—bread and mutton-chop, bread and mutton- chop, in eternal repetition. The stomach of man requires a certain amount of variety, and wearies of, and refuses to digest pleasantly, anything, no matter what, that is offered to it incessantly over and over again. Bearing this in mind, and bearing in mind that as the asthmatic only eats twice a day his food should be as nutritious as possible, the diet that I should prescribe as the best, in a case of asthma, would be, in detaU, something as foUows : For breakfast, a small basin, or breakfast-cup, of bread-and-mUk, and besides this, an egg (two for a strong man with a good appetite), or a mutton-chop, or some cold chicken or game. As a drink, if any is re- quired besides the bread-and-milk, I think tea is better than coffee, cocoa better than tea, and mUk-and-water better than either. For dinner (not before two or after four o'clock), let mutton be the staple meat, beef or lamb but rarely, pork or veal never. A httle succulent vegetable and potato should be taken ; and a little farinaceous pudding, or stewed fruit, or the fruit of a tart, should conclude the dinner. Only one helping of either meat or pudding. I believe, unless there is some special reason to the contrary, that water is the best accompaniment to an asthmatic's dinner. No cheese, no dessert. A great sufferer from hay asthma teUs me that a httle boiled fish and brandy-and-water have the least tendency to bring on his asthma of anything he can take; he can take this when a dinner of butchers' meat would be certain to be followed by difficult breathing. With regard to the brandy-and-water I will not speak positively of its advantages in hay asthma, but in ordinary asthma I do not like stimulus of any kind. With regard to the fish there can be no doubt that it is less of a diet, yields more readily and rapidly to digestion, than butchers' meat, and is, therefore, less provocative of any evil depending on prolonged and laborious digestive effort.1 And here let me observe that butchers' meat is of aU foods (with the exception of those particular articles of diet which are specially offensive to asthma, and to which I shaU refer presently) that which is most apt to aggravate asthmatic dyspnoea, and it is because dinner is a meat meal that it is necessary to take it so early. From any occasional late meal that convenience, or circumstances, may force upon the asthmatic, butchers' meat should always be excluded. In two cases in which an attack came on every day an hour after taking dinner, I succeeded in completely preventing the fit by forbidding the patients to take meat. They were in the lower ranks of life, and dined every day at one o'clock. At two, or a few minutes after, on came the 1 In regard to this fact, common experience accords with Dr. Beaumont's observa- tions. He found that while beef and mutton required from three hours to three hours and a half for digestion, most fish was digested in two hours, and salmon and trout in an hour and a half. 140 ON ASTHMA : attack. But on substituting their ordinary butchers' meat by bread-and- butter and a cup of tea, or some farinaceous mess, they were as completely free from any subsequent difficulty of breathing as if they had taken noth- ing at aU. And now let me say a word or two about those particular articles of diet that have a special tendency to oppress and tighten the breathing of those liable to asthma. They are not the same in all cases ; but those that I have found have this tendency most commonly are the foUowing: Any- thing in any way preserved, especiaUy if strongly impregnated with antiseptics, whether condimentary or saccharine, such as potted meats, dried tongue, sausages, stuffing and seasoning, preserved fruits, such as one gets at dessert, e.g., preserved ginger, candied orange-peel, dried figs, raisins—especially almonds and raisins (a vicious combination). Cheese is bad, especially if old and decayed; nuts are worse. With regard to cheese, I remember hearing an asthmatic remark that there was " as much asthma in a mouthful of decayed Stilton as in a whole dinner." Meat pies are very " asthmatic " and so, in a peculiar degree, for some reason or other, are beef-steak-and-kidney puddings. I have known more than one asthmatic condemn them as being very bad. Coffee, although of great benefit in some cases as a stimulant, is, from its indigestibUity, especially if taken strong, and with sugar, so bad for asthma that it deserves to be classed among its special provocatives. I know the case of a gentleman whose dinner making him asthmatic or not entirely depends on his taking, or abstaining from, the customary post-prandial cup of coffee. Heavy malt liquors, especiaUy those containing a good deal of carbonic acid gas, as bottled stout and Scotch ale, are of all drinks the worst for asthma. It will be seen that almost aU the above fairly belong to the category of " unwholesomes." I beheve their indigestibUity depends on their im- pregnation with antiseptics ; that which makes them " keep "—i.e., opposes putrefaction—out of the body, opposes digestion in the body. The asth- matic should never touch one of them.1 But the quantity of food taken at a time is also very important. When asthma is brought on by eating (especiaUy if it comes on independently of sleep) it is almost always after a large meal: a heavy dinner wUl inevitably be followed by asthma when a light dinner, on the same articles of diet, and at the same time of the day, will as certainly not. And why is this ? It is a very general belief that the true explanation is a mechanical one— that bulk of food induces asthma by pressing upon the lungs through the diaphragm, and preventing the descent of the one and the expansion of the other. I do not believe this. Much less do I believe that the dispo- sition of food in general to bring on asthma independent of its bulk, the 1 It is not always, however, as I have already stated, that articles of diet specially provocative of asthma are also specially indigestible; sometimes the contrary is the case, and they are of the most wholesome kind, as the following curious case, com- municated to me not long ago by my friend, Mr. F. Bailey, of Liverpool, will show : " The child about whom I write to you is the member of a family in which the disease seems almost to be hereditary, for several of its members have suffered from it. The mother consulted me one day with regard to the propriety of the child's taking milk, for whenever he did, although perfectly well at the time, asthma was sure to come on. Her own medical attendant had laughed at the idea, but being in Liverpool she asked me my opinion on the subject. Of course I recommended that milk should not be given. The child is twelve years old, and very rarely has his asthma at any other time, except when he has taken a very severe cold. This will be one more instance of the sympathy existing between the stomach and lungs, and of the power of certain articles of food to produce asthma.'' ITS PATHOLOGY AND TREATMENT. 141 tendency of recumbency to induce asthmatic breathing, and the relief that foUows an emetic, have the same mechanical explanation, as is so commonly believed. I believe that a bulky meal is an asthmatic meal be- cause it is an indigestible meal; and it is an indigestible meal in two ways —because the demand on the powers of digestion will of course be in pro- portion to the quantity to be digested, and because, beyond a certain amount, increase of bulk of food directly diminishes digesting power by over-distending the stomach and so paralyzing its movements, and by being altogether in excess of the secreting powers of the gastric mucous membrane. If the mechanical were the true explanation of asthma coming on after meals, the tendency of food to induce it would be in direct proportion to its bulk, but such is not the case. An asthmatic may fill his stomach with arrowroot and gruel to any amount, but he will have no asthma ; he may drink water ad libitum, but he wUl have no asthma. Moreover, in most cases asthma does not come on immediately after finishing a meal, when its bulk is greatest, but an hour or so afterward, when it has already been considerably reduced in bulk by the absorption of the more fluid portions of it. Again, the relief by an emetic is clearly not mechanical, as it comes on the moment the nausea is felt, before any vomiting has taken place ; moreover, an emetic affords relief even when the stomach has been previously empty and contains nothing to be vomited. But although I cannot accept the mechanical explanation of the rela- tions of food to asthma, yet, for the reasons that I have mentioned, the tendency of food to induce asthmatic dyspnoea depends very much upon its bulk. An asthmatic's meals should therefore always be compact and small. As a corollary to this, they should be of highly nutritious mate- rials, for if he eats but little that httle must, for adequately maintaining the nutrition of the body, be rich in plastic materials ; whUe, for the reasons I have before mentioned, it should be very plain and digestible. We thus arrive at the three qualities essential to the diet of the asth- matic—that it should be small in quantity, highly nourishing, and of easy digestion. It is less necessary to bear these rules in mind at breakfast than at any other meal; indeed, at breakfast the asthmatic may do pretty much as he likes. I have known asthma brought on by every other meal, but I never knew it brought on by breakfast: I have never known breakfast foUowed by even that slight straitness of breathing (without any decided attack) that so commonly foUows the taking of food in asthmatics. The tendency of eating to induce asthma is in direct proportion to the lateness of the hour at which the food is taken: it is slight after luncheon, worse after a late dinner, worst of aU after supper; but breakfast seems entirely free from it. I do not see any reason to beheve that this depends on any increased disposition to asthma as the day advances, but rather on the diminution of digesting power which the stomach experiences as its resources are ex- hausted by succeeding meals, and which requires a night's rest for its restoration. Breakfast is therefore the great meal for the asthmatic, and as he may at that time eat what he likes with impunity, and has had a long fast from the previous day's early dinner, he should eat as much as his appetite prompts him to, and of the most nutritious materials. He should take this opportunity, too, if any, of gratifying his palate, as the chances are that nothing he takes at breakfast will disagree with him. Of course there is a limit to this latitude, and of course his food should not be so indiges- tible as to become innutritious. Since, too, the interval from an early 142 on asthma: dinner one day to breakfast the next is so long, it is advisable that the breakfast hour be as early as possible; if the asthmatic rises at seven, let him breakfast at eight. The rules, then, for the dietetic treatment of asthma, and the reasons for them, may be summed up as foUows : First.— The tendency of food to produce asthma is greatly increased by the state of sleep ; therefore nothing should be taken after such a time, as digestion and absorption may be completely over in the stomach and smaU intestines, and even the lacteals quite empty before bedtime. Second.—This long fast before sleep involves a long period of inanition; therefore the asthmatic should break his fast early and heartily. Third.—The quantity of food the asthmatic takes should be small; therefore it should be highly nutritious. Fourth.—As a rule, the tendency of food to produce asthma is in direct proportion to its general indigestibUity ; therefore the asthmatic's diet should be of the simplest and plainest kind. Fifth.—But there are some articles of diet that have a special tendency to produce asthma ; therefore from these the asthmatic should exercise the strictest abstention. ITS PATHOLOGY AND TREATMENT. 143 CHAPTER Xni. ON THE THERAPEUTICAL INFLUENCE OF LOCALITY. Special curative influence of London air.—The air of great cities in general curative of asthma.—Exceptional cases.—Caprice of asthma in respect to the effect of local influences.—Subtle and inappreciable character of the influences.—The asthmatic tendency not eradicated by them.—Adequacy of locality to develop asthma.— Change of air, per se, prejudicial. I think I cannot better introduce the subject of the cure of asthma by local influences than by relating the case that first directed my attention to it. D. M., a confirmed asthmatic from chUdhood, came to London at the age of twenty. Previous to that time he had always lived in the country, either in a small provincial town or the complete country, and had never been in any large town. From his infancy his asthma had been gradually getting worse, its intervals shorter, its attacks more severe. The intervals were rarely prolonged, but for a year or two before he came to London they became less regular. He had the characteristic physiognomy and physique of asthma; he was spare, rather high-shouldered, and with a feeble circula- tion. The only effect of change of air was that at most places he seemed worse than in the smaU provincial 'town in wliich he habitually resided and in which he was born. With the view of improving his health he had been to many places near to where he lived, but none did him any good, and from many he was obliged instantly to return, as he could not breathe in them. He had tried aU sorts of remedies—stramonium, tobacco, opium, lobelia, ether, camphor, henbane, squill, ipecacuan, tonics—in fact the whole list of ordinary asthmatic remedies ; but nothing had done him good, and nothing relieved the paroxysms at all except emetics. He suffered an at- tack about once a week, and it disabled him for two days, so that he was ill a third of his time. His case was looked upon as a hopeless one ; his education was impaired ; his prospects were marred ; and he came to Lon- don to pursue indefinite and preliminary studies, as it was doubtful if he would ever be fit for any profession. No sooner, however, had he arrived in London than his asthma ceased—completely and at once—he had not another attack. And not only had he no regular attacks, but he lost aU asthmatic feehngs ; so that after two or three years he said he had really forgotten what the sensation of asthma was ; he ceased to be an asthmatic. He could take any liberties with himself, do anything he liked without fear, eat what he liked and when he liked, go to bed and he flat on his back after a hearty supper ; whereas in the country he had never dared eat after two o'clock in the day. He gained flesh ; his looks improved; he was able to join in the business and pleasures of others ; life became a different thing to him ; for the first time he had a future. For fifteen years this effect has continued. He has had occasional reminders, just to show him that the tendency to asthma is not lost, and there are circumstances, 144 ON ASTHMA : to which I shaU refer by and by, that show that it is living in London, and that alone, that keeps his malady at bay. Such an occurrence as the following is, I believe, not uncommon : I have been told by one physician that he has known several such. An asthmatic resolves to come to London to get "the first advice ;" and he comes to town over night that he may make his visit to the sacred regions of Brook Street, or Harley Street, in the morning. But on waking the next day he is surprised, and almost disappointed, to find his asthma gone; for he wanted the doctor to see him when his disease was on him, in order to form a correct judgment of it. So he waits tiU the next day, hoping he may then be able to show his doctor what his attacks are hke ; stUl, to his surprise, no asthma. He cannot think how it can be ; London—smoky, foggy, damp, dense London, the worst place in the world for breathing; he would have thought he would have hardly been able to hve in it. He waits tUl the next day, and the next; at last he is tired of waiting and comes to the agreeable conclusion that his asthma has taken its final conge, and that, like the horse who died just as he had learned to hve on a straw a day, it has chosen to depart of itself just as he was going to get the best advice for it. But no sooner does he get back into the country again than he is just as he was before he went to town. This is more vexatious than anything ; so back he goes again to London. But again he is weU. And then the light breaks in upon him. Now this, I have been assured by one physician, has happened several times within his own knowledge ; and I believe that many cases of asthma have been permanently cured by London residence, from finding, on coming to consult some metropolitan physician, that London air was a specific for them. Since writing the above, the foUowing apt and most illustrative case has come under my knowledge : G. C, a confirmed asthmatic, a native of a city in Scotland in which he resided, having been a sufferer for many years, came to London in 1838 for the sake of receiving the best medical advice. He took apartments in the centre of the city of London, somewhere near St. Paul's. His inten- tion was to wait for an attack, and as soon as one came on to present him- self to his physician that he might witness it and have a clear idea of the state he was in. He waited six weeks, much to his mortification, in ex- pectation of an attack coming on, not only without experiencing one, but without any difficulty of breathing whatever; his health altogether im- proved, he slept well and gained flesh. Being tired of waiting he went back to Scotland without having seen his physician at aU, and, to his great disappointment, he had not been in his native city many days when he was attacked in the usual way, and continued to suffer just as before his visit to London. Subsequently, finding it necessary, on matters of professional business, frequently to visit London, he experienced the same result on aU occasions as at his first visit—perfect immunity from his disease. To use his own expression, " he felt in London like a renewed man." On his first arrival in town he was in a miserable state ; he could not move without feeling his shortness of breath distressingly, he got no rest at night, and was seldom able to lie down in his bed. But in London he could do any- thing—eat, drink, sleep. The consequence was, he gained flesh and strength, and went back to Scotland looking quite a different person. This was the invariable result. He used to joke about it, and say that going to London was better than seeing a physician. Unfortunately, his professional engagements did not permit him to make London his perma- nent residence. ITS PATHOLOGY AND TREATMENT. 145 Some time after this (1850) a Scotch lady, traveUing to London to get advice for her asthma, heard of this case, and had her expectations raised that she might experience the same relief. On coming to London she took up her abode in Lombard Street, that she might have the most genuine city air, and to her great delight experienced the same happy results—her asthma ceasing from the moment of her arriving in town. Now here we see, in these cases, confirmed and apparently incurable asthmatics suddenly and completely losing their disease on a change of residence—not experiencing a partial relief, a mitigation of their symptoms, but ceasing to be asthmatics altogether, becoming like other people. But we see something more. It wiU be remarked that the cases I have men- tioned have been cured by coming to London. And this is not from an accidental or purposed selection of cases; it is the rule. I believe that three-fourths or seven-eighths of cases of asthma would be cured by coming to live in London; indeed, I believe a larger percentage than this. I do not speak unadvisedly, or from narrow data ; for years past I have had my attention directed to this subject, and have made a point of asking aU pro- vincial asthmatics "if they have been in London, and if they have ever had an attack of asthma when there." Their answer is almost invariable—in- deed, I do not know that I remember a single exception ; they aU say, " No, never ;" and some of them with surprise, as if they had never thought of it before: "Dear me," they say, " now you come to, mention it, I re- member thatl never have." (Of course, in speaking thus of this large percent- age of cures by London residence, I am excluding the cases of natives or permanent residents in London who have become asthmatics whUe residing there.) The foUowing are a few striking examples of some of these cases, of which I have taken notes, or of which I have been furnished with notes by my friends: The Kev. Mr. V. was a martyr to asthma during the many years he was at Cambridge, as a boy (for it was his birthplace), coUege-student, and Fellow of King's in residence ; but, however bad it might be, it was always quite well directly he got into London. "I have heard him say," writes my informant, Dr. Dyer, of Bingwood, " that he has sat up night after night at Cambridge, ' living at the top of his breath,' unable even to speak; and in this state would accept an invitation to a dinner in town, weU knowing he would be quite free of his disease directly he arrived." R. D., aged twenty-nine, a solicitor living in the country, began to suffer from asthma at the early age of two, and is liable to attacks at the present time. Up to the age of eighteen he lived in the country ; from eighteen to twenty-one in London ; and from twenty-one to the present time again in the country. While in the country, both before and since his residence in London, he has been in the habit of having an attack every few weeks ; but during the three years that he was in town he did not have a single attack. Among many interesting cases communicated to me by my late friend Mr. Macaulay, of Leicester, the foUowing are iUustrative of this fact. But I must mention that Mr. Macaulay's own experience had induced him to adopt an opposite conclusion, and to believe that the greatest number of cases of asthma would be relieved by a residence in a high and open local- ity, and that close, confined situations are especially prejudicial. Although a large number of carefully observed and lucidly recorded cases, which I shall relate at a future part of this chapter in Mr. Macaulay's own words, would appear to warrant his conclusions, I cannot say that I agree with him ; and indeed some of his cases, as the foUowing, teU the other way. 10 146 on asthma: After expressing the above opinion, Mr. Macaulay goes on to say : "It is nevertheless impossible to predict, excepting by actual trial, what air wiU suit an asthmatic. The late Dr. John Heath, head master of St. Paul's School, could not breathe at Rugby, and his life was apparently saved by his appointment to St. Paul's, where he never had an attack, although they returned upon him from time to time in various parts of the countiy. He lived in London until the age of eighty-two. It is rather curious," contin- ues Mr. Macaulay, " that I picked up two more cases yesterday, in Ulustra- tion of my position that every patient may, if he tries perseveringly, find an anti-asthmatic locahty, in which he wiU be able to breathe freely and en- joy his health. Speaking on the subject at the Infirmary yesterday to Mr. Paget, he mentioned the case of a Mr. P., some years ago living at Not- tingham, in an open, airy place called ' The Park,' on very high ground, who suffered severely from asthma for many years. Business compelled him to go to reside in London, and he took up his residence in Thames Street, in fear and ti-embling ; but he soon experienced a very remarkable immunity from his old enemy, which, in fact, speedily disappeared. As long as he kept to Thames Street he was weU ; but whenever he went to Nottingham, to see his friends, he was sure to be attacked, and a return to Thames Street as certainly cured him." The other case I shall mention presently. I could multiply such cases if it were necessary, for I have met with very many. Indeed, it is the rule, as I mentioned just now, on putting to provincial asthmatics the two questions—Have you ever been in London ? Did you ever have the asthma there ?—if an affirmative answer is given to the first, to receive a negative answer to the second. So that I always put the questions with the confident feeling of what answer I shall get, and rarely am I disappointed. I know many asthmatics who are wheezing about the country, passing suffering hves, and getting emphysema and dilated right hearts, who, if they would come to London, ■would enjoy perfect health. Some Of them know it; but professional engagements, or famhy ties, or a dislike of London, prevent their migrating. Now, are these remarkable effects of London residence on asthma to be attributed to anything peculiar and individual in London, as London, and that exist nowhere else, or to those conditions which characterize London as a thickly covered, densely populated, smoky city, and which ^are common to all other simUar cities ? This question is approximatively ■answered in favor of the last supposition by the fact that the same results are observed in all our large, densely peopled, manufacturing cities, and that, as a rule, asthmatics are benefited by a change from a rural to any ■urban residence. The foUowing are cases in point: A. B. was a gentleman of fortune, living in the neighborhood of Glas- gow. He had a fine estate and mansion within six mUes of that city ; but he had the asthma. He could not sleep a single night in his own house. He was quite weU by day, but if he attempted to he down and sleep at night he was immediately attacked by his disease. In Glasgow, however, he go home to L----on the Saturday after school (which ended at one p.m.), returning on the Monday. Invariably, as weU as I can recoUect, I was seized with a fit of asthma the first night of my return. About midnight my mother was sure to be attracted to my bedside by certain sounds from my breathing resembling the mewing of a cat, and I would get up and go through the stages of a fit, from which I would be sufficiently recovered on the Monday morning for my return to Newry. I soon came to expect a fit as an inevitable attendant upon my visit to my father's house. If I re- mained four, five, or six weeks at Newry, the asthma kept away, but when- ever I went home to L----, there I was sure to find the tormentor awaiting me. I think I was never longer than six or seven weeks without making a visit to L----, during aU my stay at Newry school, which ended with my entering Trinity CoUege, Dublin, in my sixteenth year. But before leav- ing Dr. H.'s finally, I had several slight attacks there too, of an asthmatic kind, though none of them as bad as at L----. These occurred in the last year of my residence there. Most of these were so slight as merely to oblige me to get out of bed and move away to a sitting-room, where I seated myself close to a table, on which, after a time, I was able to rest my arms to support my head, and thus to fall gently asleep. In the morn- ing my breathing would be good enough again. I may mention that it was on my removal to Dr. H. 's that I first perceived myself able to lie on either side in bed. TiU then, I think I used always to lie on the right side only. At Dublin I stayed only eight or ten days on the occasion of my enter- ing college. I was to be an externe student. My health during the visit was robust and my enjoyment of life seemed boundless and exhaustless. As yet I was scarcely more than a boy, my time of puberty coming late, and I did not reach my height tiU perhaps twenty-two. During the four years or upward of my college life, I lived nearly altogether at my father's house, going up to Dublin about four times a year for examination, and staying there about a week or fortnight each time. At Dublin my health was sure to be perfect. At home the fits seemed to grow more severe, and 13 194 APPENDIX. the effect upon my general health more injurious. They occurred pretty regularly every fortnight or three weeks, lasting for two nights at least. I used to go to R----on a visit now and then, and there was free from asthma. So it was with any other visits I made, as to a friend's house in Newry, to Armagh, to Belfast. Abroad I was sure to be well, but always I must expect a bad fit on the night of my return to L----. I began during this period to adopt various measures, partly by advice of doctors, partly from my own experience, in hope of preventing the attacks, or of alleviating their severity. As to regimen, it soon became plain to me that the best was strict temperance in eating (unless when I happened to be on an excursion, wThen I had brisk exercise and cheerful excitement), avoidance of rest in damp clothes or chilled feet, being much in the open air, being always in good temper. Naturally I was of a very cheerful disposition ; but some things that do not much affect people in general were afflicting to me ; for instance, the_ crying of infants. This, or other things no more important, depressed me so much sometimes as to bring on a fit. For food, I pre- ferred strong coffee for breakfast, with a boiled egg and bread-and-butter. Chops, or steaks, or broiled fowls were best for my dinner. Salt meat I found not good for me. Potatoes, if dry and simply dressed, were digestible and safe. So were young peas well boded. Carrots and parsnips were admissible, but not to be recommended. Cabbages, beans, cauliflowers, and most other garden vegetables were bad. In fact, it was best for me to cat hardly any vegetables. Riding I found exceedingly salutary; and often when miserably weak after two or even three days' suffering in the fit, I felt immediate ease on being put on horseback. Sometimes I mounted to ride away from an approaching fit when I was fully aware of its approach, and sometimes the flight procured my safety ; particularly as I always went to some of those houses where I had the habit of being always free from the disease. As to medical treatment in the fits, what I came to con- sider as the best was to take an emetic immediately on perceiving the acces- sion of the fit. After the operation of the emetic I would sip at a mixture of the strongest coffee with laudanum—about thirty to fifty drops of laudanum in a large teacup of strong coffee without cream or sugar. When this treatment was adopted promptly enough, it sometimes shortened or lightened the fit. But it was difficult for me to know of the actual coming of the fit till it was already upon me. I had a strange feeling of reluctance to admit the fact of the approach of the disease even to myself, and when the symptoms were manifest to others. This strange reluctance against admitting or believing the actual coming of the fit possessed me all the years of my asthmatic life. I have observed the same feeling in my friend Mr. M., who became asthmatic when he was about twenty-five years old. Sometimes, when I felt my digestion disordered and my head loaded with blood, symptoms which often preceded an attack, I took a dose of calomel (four to six grains) with Dover's powder (six to ten grains), and I now and then thought it beneficial. It seemed to me injudicious to take purgatives often, or indeed any drugs at all, and yet my general health grow so bad that I used to dose myself a great deal. At the age of twenty-two I was about five feet eight inches high, one hundred and twenty-six to one hundred and thirty-three pounds in weight, a pretty good walker, and not readily tired either on foot or on horseback, and of average strength and activity for my height and weight. My com- plexion was florid and my temperament sanguine, though at the same time I was of very sensitive nerves and physically timid—what is styled a nervo-sanguineous temperament, I think. I was an early riser, and my APPENDIX. 195 habits were simple and temperate. My time was a good deal occupied in books and in sedentary idleness. The disease had certainly gained ground against me since my boyhood. The period of my life in which I suffered most from it was from about my seventeenth to my twenty-sixth year, and during that period the violence ;nd duration of the fits, though not their frequency, kept slightly increas- ing, while the intervals of health began to be marked by symptoms of con- stitutional derangement. In my boyhood the fit generally lasted a single night and day, seldom more than two nights and a day. When once it was gone I was immediately quite well—I could eat, run, enjoy myself as if nothing had ailed me, and I did enjoy the recoveries so greatly that they far overpaid me for the trouble of the fits. Even when I was a youth of sixteen or seventeen, I remember that the fits sometimes passed away at once so completely that I began to jump over stools and chairs, in gleeful triumph over the enemy that had just taken flight. But after my twentieth year the fits often lasted, with slight intermission or relaxation of the symp- toms, for three nights and days, or more probably three nights and two days. And in the intervals of health apoplectic symptoms often appeared, such as fits of giddiness. I could not lie a minute on my back, or with my head on the same level with my trunk ; the least tightness on my throat was a trouble to me ; a sudden run would give me a feeling as if heart and brain were bursting their cases ; I felt as if there was too much blood always in my head and neck. During my boyhood I had been (in the intervals) a good runner, and quite equal to healthy boys in general of my age at shinnie, prison-bars, and other games that tried the soundness of respiration, and I could climb a mountain right well. Now I became afraid to run, because of the palpitation and feeling of oppres- sion that any lengthened quick movement produced in me. In climbing a mountain, too, I was distressed tiU after profuse perspiration had relieved me. And this inability to make, without preparation, a quick movement of many minutes, or to ascend a steep of many furlongs rapidly, has continued with me even during those years when the asthma was utterly defeated and hors de combat. To be sure, in Van Diemen's Land I could run, etc., with but slight preparation, the wonderful dryness of the climate and my habits of life keeping me, as it were, in constant training ; but even there I was distressed (more than other men so little encumbered with flesh) in the beginning of a mountain ascent, though nobody could pass me in run- ning down it. It was during that period (from my seventeenth to my twenty-sixth year) that the fits became marked and aggravated by a tendency to coma, which was often, during the latter part of the fit, so obstinate that my attendants had trouble in keeping me awake. I never quite lost conscious- ness, but I was every minute dreaming heavily and waking up again. Awake I must be kept, to make the continual efforts needed for getting breath. When the paroxysm had at length subsided, and I had got the refreshment of a sleep, there still remained, for a day or more, debility more or less, and even a tendency to asthmatic breathing at night. This latter was especially the case when there had been catarrhal symptoms at the beoinninf of the fit, a complication or modification which now became of frequent recurrence. I would be afraid to lie down in bed, and toward the latter part of the period I used to sleep for many nights in succession sitting on a chair, with my head rested on pillows placed on other chairs at each side of me (I mean, resting on one of them at a time). In the period from my twenty-sixth to my thirty-sixth year the attacks 196 APPENDIX. were more and more characterized by the complication with catarrh and bronchitis, while the apoplectic symptoms diminished in gravity. The fits often passed into tedious attacks of bronchitis, with asthmatic breathing, gen- erally with more or less remission in the day, and lasting sometimes three, four, or five weeks. I have been more than once in my asthmatic life six entire weeks without going to bed; and during aU the years from about my twenty-fifth to my thirty-sixth, while living at L----, I spent more of my nights on the three chairs with the pillows than in bed. It was ordi- narily upon my right side that I leaned, always with head and shoulders elevated considerably ; but ever since I had been sent to school at Newry I had been able to sleep occasionaUy on the other also. Thus, I would describe my asthma as having graduaUy changed its character, or rather considerably modified it, so that the history of my case may be divided into three periods, corresponding with the three periods of boyhood, youth and early manhood, and mature age: 1st, purely spasmodic or nervous ; 2d, the spasmodic, with pressure on the brain, over-fulness of blood, and great derangement of the circulation; 3d, spasmodic bronchitis. Not only, however, did those periods succeed each other by such insensible degrees that I could not say precisely when one ended and the other began, but in any of the periods there would occur cases classed by me in some other period. Thus a bad cold has sometimes resulted in a fit in the time of my youth, and then there would be coughing and expectoration at the end of the fit; or imprudence in diet, or extreme vexation and depression of spirits, may have brought on a fit in the latter years of my case or bronchitic period, and then there would be no expectoration or catarrhal symptoms, but a fit almost purely spasmodic. I shall now endeavor to describe an ordinary fit of that period during which I suffered most from the disease, that is, from my seventeenth year to about my twenty-fifth. It commenced by awaking me from a slumber, generaUy close after midnight. I was impelled to rise out of bed instantly, and seat myself with my elbows on my knees and my head in my hands. It was sometimes a labor for me to put on my trousers and slippers, and a loose coat or dressing-gown, particularly the latter, on account of the rais- ing of my arms to get them into the sleeves. Everything about me must be loose. Very often there was a disturbance of the bowels at the very first, but this seldom recurred during the fits. Excessive action of the bladder commenced early in the fit, and grew worse as the fit advanced, and this was a torment. I had to empty the bladder perhaps every half- hour, or oftener, and that at a time when the slightest exertion or move- ment was beyond what I could afford, all my energies being needed for the terrible toU and struggle of the respiration. The urine was quite limpid and in considerable quantities. My mother, or my sister, or a ser- vant, were sure to hear me, and come to attend me as soon as I could per- mit. I must get away from the bed-room, the presence of the bed seeming to me an oppression on my breathing. I moved to a sitting-room, and there (winter or summer) a fire was lit, and this must be done without smoke or dust, both of which would distress me. The skin was dry, and remained so till the crisis of the fit. The head generaUy ached. Except the headache there was no other pain, the suffering consisting in the vio- lent, incessant, exhausting labors of respiration. The balance seemed quite destroyed between inspiring and expiring. In spite of myself I was forced to keep tugging in the air with all the muscles and joints of my body, while it seemed as if it hardly went out again at all. A cough, as an APPENDIX. 197 expiration, was a relief, but a relief that seldom came in those fits tiU near the end. As the paroxysm advanced, my head became hotter, fuller, and heavier ; the veins felt bursting fuU on my neck; my eyes were rose-colored sometimes ; my feet were icy cold. My hands, too, were sometimes cold, but not always. But the coldness of the feet was such that the rubbing with warm hands and wrapping with warm flannels, which the attendants sedu- lously employed, could but slightly remedy it. This coldness of my lower extremities often mounted above my knees. The blood seemed to stay in my head and chest. The pulse was generaUy quickened some ten to twenty beats, weak and irregular. Besides the peculiar asthmatic sound of respiration, I used to accompany almost every tug for breath with a sort of groan, which (I imagine) helped me hke the hech of the axe-man, or served, as it best might, in place of an expiration proper. There was in the earher stages of the fit a profuse flow of saliva (at least generaUy) and also a slight mucous discharge by nose and mouth, and this mucous discharge I was ac- customed to feel as a relief. I could not walk but with my spine arched, so that my head was nearly on a level with my flanks—that is to say, such was the way I did always walk in the bad fits—and any movement was toilsome and difficult to me. My work was the breathing, and quite enough I found it. At the worst of the fit the comatose symptoms required the constant tentations of those around me. When, perhaps, two days' toiling for breath had almost exhausted my strength, and the imperfect aeration of the blood weighed heavy on the vital powers, the tendency to coma was very great. At last came the turn. Generally it appeared in the gradual subsidence of the more violent symptoms, a greater facUity of keeping warmth in my feet and legs, a moistening of the skin, and a gentle slum- ber—quite a different thing this from the comatose slumber, which was horrid nightmare. My attendant could distinguish between them, and I myself still kept conscious enough to feel the difference. It was very often between midnight and daybreak that the favorable crisis came. Li my earlier years the crisis was unmistakable; but later, from about twenty- five, there might be two or three attempts at the critical slumber before the real one came. A word now as to the treatment generaUy adopted in such fits, and its effects. As soon as convenient after the fit declared itself, I took an emetic, generaUy sulphate of zinc in a dose of twenty to thirty grains. If this was taken early enough, I think it generaUy proved beneficial. But the fit advanced so fast that the emetic seldom was taken early enough to be of essential service. It seldom brought any discharge of food from the stomach, or anything but itself, and sahva, and bUe. After the operation of the emetic I sipped a mixture of the coffee and laudanum which I have already mentioned, fifty or sixty to a hundred drops of laudanum in a large cup of the strongest coffee ; of this I sipped a teaspoon- ful every half-hour or so, or perhaps the whole day. As weU as I remem- ber, no other medicine served me in the fit during this period. And it was but seldom that the attack was shortened or lightened by any treat- ment whatever ; though I had an idea that if the emetic were administered instantly on the appearance of the fit, or if possible sooner, and the coffee and laudanum employed after free evacuations of the emetic, the effects would be valuable. I remember that during my boyhood, when the fits were purely spasmodic and nervous, a patent medicine caUed Wear's Asthma Tincture several times relieved me. I think its chief ingredient was tincture of myrrh. After a year or less it lost its good effect. In my boyhood, also, I was sometimes reheved by lavender whiskey—that is, 198 APPENDIX. whiskey in which a great quantity of flower-stalks of lavender have been steeped. But this, too, lost its power after some time. During the period of those bad fits with the apoplectic symptoms I was never bled, though I remember I often felt a desire to have the temporal artery cut, or to have the nape of my neck cupped. In later years, after I had studied medicine, I sometimes felt in the fit that bleeding would relieve me ; but I never had the nerve to open my own vein myself, and the doctor lived five miles away.- Besides, I felt, as well as my friends, that it would take more blood than my body contained to stand bleeding once a fortnight or three weeks, which was the frequency with which the fits generally occurred in the second period, at least whUe I lived at L----. Almost all the " anti- spasmodics " of the Pharmacopoeia were tried in the years between my twen- tieth and my thirty-fifth. None of them seemed to do me any good worth mentioning, and generally they rather added to my sufferings. Ether (sulphuric ether, I think) certainly did. I remember the violent symptoms were aggravated by a weary sickness it caused any time I used it largely. I have remarked, too, in the case of an asthmatic friend, a serious aggravation of the fit from the exhibition of ether. It seemed to lower the vital power, and so lessen the forces needed for keeping up the struggle for breath. Sulphate of zinc seemed the best emetic for my case. In later years, when it became rather difficult to excite vomiting, I sometimes added powder of ipecacuanha, and this combination served weU enough, particu- larly, as I think, because the apoplectic symptoms were decreasing, and the catarrhal or bronchitic ones increasing in gravity. Tartar emetic proved quite inadmissible as an emetic in my fits ; I think I used it but twice ; but both times its relaxing effect on the muscles, and the general feeble- ness, or rather exhaustion, it caused were such that I felt as if I must die —a feeling which you probably have remarked hardly ever arises even in the most violent fits, and when bystanders suppose death inevitable. I remember that it operated on the bowels as well as on the stomach, and that in the movement which this necessitated, it was agony for me to sup- port my weight on my limbs, and my head was lowered almost to my knees as I crept along. I think there were cases (but seldom) when a fuU dose of purgative medicine prevented the fit, or postponed it. Dover's powder became a favorite medicine with me in the bronchitic period. I used to take it in doses of two or three grains (or even one to two grains), repeated every half-hour or hour for several times. If the stomach and bowrels were clear, it generally proved of some advantage. Very many other medicines and remedial measures were tried by me, but (exclusive of the grand measure of change of place) none of them were attended by results important enough to demand notice in this ac- count of my case. I propose now to finish the history of my asthma by relating the cure of it, which seemed to result from change of climate, of occupation, and similar circumstances. Could I effectively perform this part of my task I might supply valuable indications for the treatment of the disease ; but in one's own personal case one is prone to omit or slur over important facts, just because of one's perfect famUiarity with them. There were two things which my experience had taught me. One was that towns clearly agreed with me better than the country ; I made APPENDIX. 199 frequent visits to Armagh, Belfast, Dublin, and Downpatrick, and at aU these places my health was much better than at L----. The other fact was that the fits were always worse and more frequent in summer than at any other season.. A damp summer affected me worst of all. The best seasons seemed to be early spring and late autumn. Winter was not bad for violent fits. Dry weather suited me best. In my boyhood and early youth I had the impression that if I had the fortune to be well at the commencement of a frost, I was secure against a fit as long as the frost continued, even should that be for several weeks. After graduating at coUege, about my twenty-first year, my health at L----was so very bad, the fits recurring sometimes weekly for months together, and each fit lasting nearly three days, that I became exceedingly anxious to leave home. I rather think that about this period of my life my health was injuriously affected by the state of my spirits. All through my life I have remarked that cheerful employment, above all, such as exer- cises both the body and the mind, and chiefly in open air and with brisk movements, gives the greatest protection against the disease. On occasions of exciting and pleasant excursions I might eat and drink hke healthy people, and with impunity. But even strict abstinence, and precautions against damp and cold and the like, could not ward off a fit if my spirits were very low. In my twenty-third year I determined to go and study medicine at Dublin. To this I was impelled chiefly by the desire of escaping from the grievous persecutions of the disease at L----. My medical studies occupied two years ; but I visited L----■ in the summer for a couple of months or longer. In Dublin my health was perfect. I never had a fit or an attack worthy of the name all the time of my residence there. My constitution, too, seemed to strengthen under the influence of such con- tinued good health. I had a fine florid complexion, and considerable vigor of body, and a person ignorant of my asthma would have supposed me the picture of health. Yet my weight (I think) never got above one hundred and thirty-three or perhaps one hundred and forty pounds. In my twenty-fifth year I began to keep a house of my own, and adopt the occupations of farmer and smaU country gentleman. The house in which I established myself was in L----, about a mile distant from my father's. It was situated on the slope of a hiU. These features of the resi- dence, together with the cheerful occupations of a farmer in easy circum- stances, the feehng of responsibilities and duties that were easily and agreeably fulfilled, the early rising, open-air exercise, and active habits of my new life, all operated favorably upon me. The improvement in my health consisted mainly in the lengthening of the intervals between the- bad fits, but they still occurred as often as ten times a year. In the course of the first two years of my farmer life I made tours to London, to Dublin, to Scotland, and other places. At London I have never had an attack, though at one time I spent about seven weeha there. At the end of those two years, when I was about twenty-seven, I madj a voyage to America. On the passage, which lasted sixteen days, I was free from sea-sickness, as I have been all through my life. The weather was very boisterous, the ship crowded, and my sleeping accommodation very bad. However, I had no fit on board. On arriving at New York I was perfectly well, and so I continued to be for the week I spent there. I then proceeded, by the Hudson and raUroad and lake steamers, to HamUton, at the western extremity of Lake Ontario, and thence by stage 200 APPENDIX. to London, some eighty miles to the westward. Great part of the journey was made over corduroy roads (which may you never travel over in a springless wagon, as I did !). My health was good enough tUl I reached the end of my long journey—my sister's log-cabin in the backwoods. There, the night after my arrival, commenced one of the most violent fits I ever suffered. It passed away completely after a couple of days, and my health remained perfectly good, at least entirely free from asthma, for all the time that I spent in America afterward, which was ten months. I attributed this fit to the accumulated effects of aU the fatigues of my long voyage, but most of aU to the tortures of the corduroy road, which surely were as bad as ordinary rack practice in the dungeons of the Inquisition. It is likely that the season of my arrival in the Canadian backwoods was peculiary favorable, and also the weather which prevailed that year. It was the end of September, the beginning of the Indian summer, which was remarkably fine that year. The temperature was dehciously mild, the air calm and dry; the sunlight, coming from a cloudless sky, was tempered by the peculiar dry haze of that season ; there was neither rain, nor fog, nor damp of any kind. It was a luxury to me to breathe, the air felt so pure and light, and my lungs in such fine working order. The Indian summer lasted tUl the first or second week in December, when it was succeeded at once by a winter of snow and frost. Bright sun, hard frost, and the calm clear weather of winter lasted tiU the beginning of March, when there were alternations of thaw, and frost, and rain ; and at last the spring suddenly appeared one lovely morning, with newly arrived singing-birds in her train. In the spring there were showers and rainy days, but yet the asthma never made a sign. Summer came fast after the spring, and there were terrible thunderstorms; the heat became almost intolerable, and the vegetation was ranker than the Irish. But stUl the asthma kept away from me. In the course of the spring and summer I made some long tours down the lakes and the St. Lawrence as far as Montreal, and by New York, Philadelphia, Washington, across the AUe- ghanies into Ohio, and to the lakes, Ontario, and Detroit. The weather during my tour in the States was the hottest I had ever experienced, and I felt a good deal of inconvenience from it, and even some feverish Ulness. But there was no symptom of asthma. I returned to Ireland the following year (1840), and resumed my former life. Again my asthma returned, but the character of the fits was modified, as I have described in a former part of this paper: they often degenerated into bronchitis with spasmodic breathing, and sometimes lasted, or rather lingered, for two or three weeks. When I fell into a lingering state of disorder, such as prevented me for weeks together from going to bed, I used to get away to Dublin, on arriving in which city I was quite weU at once. Such was my state of health when, in the summer of 1848,1 bade adieu to home and went to live in Dublin. My occupation there was of the most exciting and absorbing kind (patriotic struggling as a writer and editor —i.e., Anglice, seditious and treasonable proceedings). In the fourth week of my residence I was imprisoned, and was kept in one or other of two jails for eleven months. During that time I suffered from fever and dys- entery, which reduced me to extremity. At the end of that period I was taken from jail and sent on board ship to be transported to Australia. A feehng of pride and indignation had grown strong enough in me to coun- teract the depression of spirits which had attended my first knowledge of the desperate condition of my country. It may seem wild, but I mention APPENDIX. 201 it as what I still believe a reality—I must have died then but that I was de- termined not to die so. But all this time I had no fit of asthma. We reached Sydney in ninety-three days from the Cove. After lying in Sydney harbor for ten days or a fortnight I was sent to Hobart Town (eight hundred nhles), where I arrived about November 1, 1849, and I was sent ashore the day after. All the time I was at sea my health was excellent. I can remember the delight of breathing the air in the latitude of Madeira, the luxury it felt to me. Not only was I free from asthma and symptoms of asthma, but in all respects I was quite well and sound. In Van Diemen's Land I was sent to a distance of forty-five miles from the sea at Hobart Town, and about twelve hundred feet above the level of the sea. The country there is a forest of gum trees, in which the under- growth is kept down by the browsing of the flocks and herds. It is a mountainous countiy, with some great lakes on a plateau of vast extent which occupies the centre of the island. The sun was very fierce, and the heat of the summer weather often very great (generaUy in the middle of the day as much as 90° Fahr. in the shade); but this heat was not nearly so sensible to me as a far lower degree would be in Ireland. The extreme dryness of the air, and something peculiar in its electrical condition, may account for the fact. I lived a very active life at first, walking and riding many miles every day. Often I would ride fifty miles a day, besides walk- ing a good many more, rowing a boat, etc. My health was superb. Not only did asthma totally disappear, but coughs and colds, and everything like the smallest derangement of any part of the organs of respiration. I grew active, and strong, and hardy. My weight increased to one hundred and forty-seven pounds, though I was taking violent exercise nearly every day. I remained in Van Diemen's Land from November, 1849, to July, 1854. After the first year the seasons were never so dry, the excitement of novelty died away, I grew subject to fits of depression, and my health was not so perfect as during the first year; but there was never the least symptom of asthma for all the five years of my stay in Australia. I think I had not even a bad cold but once. I left Austraha in July, 1854, voyaging by Ceylon, the Red Sea, and Egypt, to France. I suffered greatly from the heat, but no asthma. I lived in Paris from October, 1854, to June, 1856. I had some severe colds on the chest, but still no asthma. In June, 1856, I went back to Ireland and remained there till October following; stiU I remained free from asthma. I returned to France in October, and spent the winter and spring at Pau, under depressing circumstances. There I was revisited by my old enemy in two or three unmistakable fits, besides frequent slight affections of the breathing. A change of chamber, however, and some easy precautions, drove him away, and for the last four months of my so- journ there I was free. In Paris, from the end of May, 1857, till the beginning of September, I had no asthma. In September I went to Ireland, where I remained till December. Travelling through the country I had an unmistakable fit (of only one night) at Killarney. Except about two regular fits at Pau, and several slighter attacks, and one fit and a few threatenings in Ireland, I have had no asthma since the year 1818, i.e., ten years. 202 APPENDIX. CASE vn. Spontaneous occurrence at the age of eighteen.—Gradual increasing intensity of the disease.—Haemoptysis.—Extreme asthmatic deformity.—Death. William Burr, aged thirty, an emaciated man, speaking short, with the most marked asthmatic deformity I have ever seen.1 He was quite well up to twelve years ago, when he met with an accident—fell down from a loft on his back, on some flagstones. From this he did not seem to suffer at the time ; he appeared pretty well the day after the fall, went to his work, that of a groom, as usual, and did not think any more about it. A month after this, early in August, and in very hot, thundery weather, having gone to bed perfectly weU, he woke in the night about twelve o'clock, " all of a perspiration, and as if he had been running fast, and could not breathe, with a load at his chest and a wheezing in his throat." He got out of bed and sat on the side of it, and obtained a little ease, and then was able to return to bed again and go to sleep. He awoke in the morning, at six o'clock, as well as usual, and went to his work, and thought no more about the difficulty of breathing he had experienced in the night. He had no cold at this time, there was no cough, and no expectoration. A month or six weeks after this, about twelve o'clock in the day, when he was dress- ing a horse, being in all respects in his usual health, he was seized with difficulty of breathing, which became so severe in twenty minutes that he was obliged to leave off his work altogether. When the dyspnoea was at its height he was suddenly seized with coughing, and found that what came up into his mouth was hot, and on spitting it out discovered it to be blood ; the difficulty of breathing and the blood-spitting lasted about three hours, and then went off together—as soon as the breath got easy the hemoptysis ceased. The cough was very slight; the blood was about half an ounce in quantity, not pure, but mixed with mucus. The disappear- ance of the dyspnoea at the end of three hours was complete. He felt weak, however, and did no work for a week, and on returning to his duties found that on attempting any brisk exercise, or the laborious occupation to which he had been accustomed, his breath became short, so that he was obliged, after a fortnight, to give up his situation. As on former oc- casions, he had neither expectoration, cough, nor symptoms of cold. He then went to a silk mill, where his work involved no exertion ; on going to work, however, morning and evening, his breath would some- times trouble him and oblige him to stand and rest, which he generally did in a stooping position, resting his hands upon his thighs. At this time he was able to play with other youths, and romp and run as well as ever. One night, after he had been at the mill about six months, he was seized about twelve o'clock with an attack of the same nature as the first; he got up and sat in a chair, resting his head forward in his mother's lap (who, alarmed at his condition, had come to his assistance), and in this position he went to sleep ; in about an hour he was able to return to his 1 This is the case that I referred to at p. 92 ; a photograph which I had taken of the subject of it, and which was to have shown to what a pitch asthmatic spinal curva- ture may reach, was unfortunately lost. The deformity was most extraordinary, and equalled that which one commonly sees as the result of organic spinal disease, although it had the distinctive asthmatic characters referred to at pp. 91-93, and beyond a doubt was not in any way due to primary organic disease of the spinal column. It was as if the back had set in that stooping deformed shape which we not uncommonly see in the intensest asthmatic paroxysm. APPENDIX. 203 bed, and when he got up in the morning at six o'clock, he felt no traces of his attack, and went to work as usual- He went on then for a twelvemonth, working every day, and during the day feeling no dyspnoea, but frequently a little night and morning, obhging him to walk to and from his work slower than the rest; and then, at the usual time of the night, twelve o'clock, he was seized with an unusually se- vere attack, which did not go off as before, but left him with an unusual amount of dyspnoea and incapacity for exertion throughout the day. About one o'clock on this day, breathing tolerably easily whUe he was still, he went a short distance with a message, and, though only creeping, very much increased the difficulty of his breathing; this obliged him to stand still, and while thus resting himself he began spitting, and again found that what he expectorated was blood. This time he spat nearly a pint; it poured out of his mouth and nose, making quite a puddle in the road, and he was carried home in a very weak state. He was unable to resume his work for a month, and during this time whenever he spat there was a little blood with the mucus. After this the blood only appeared when the breath was unusuaUy difficult, as on violent exertion, or in the morn- ings, or on the occasion of an attack, and after lasting on and off in this way for two years entirely ceased, and for the last eight or nine years he has seen none. From the time of this severe attack with haemoptysis he never returned to his regular work at the miU, but did little odd jobs, kuife- and boot-cleaning, etc.; his morning dyspnoea increased and became quite regular, and sometimes of an evening, too; but he slept weU, and had no very violent nocturnal attack for a twelvemonth. He now found food increase his dyspnoea, and often for a month together he would have a slight attack every day after dinner, lasting for two or three hours (that is, during the time that digestion was going on), so that he has sometimes gone without his dinner to avoid the attack; then, for three or six months, perhaps, he would be free from these after-dinner attacks, and then they would come on again. Sometimes they would come on after supper, but he rarely ate supper, because he found that if he did so he was worse the next morning. Sometimes his breath would be very bad of an afternoon and then clear up in the evening, and he would have a good night; some- times he would be quite well throughout the day and bad at night; but always the same for many days and weeks together—the habitude, the diurnal rhythm, always strongly marked. For some years he went on in this way by day, with occasional intense attacks at night, occurring at from six to' twelve months'. interval, always coming on, and waking him from his first sleep, about twelve o'clock, and going off at about three, or four. Sometimes the attack was not so severe as to oblige him to get cut of bed, but he would turn round and kneel up in bed toward his pillow, with his hands resting on his knees, and in this way, in an hour or two, get sufficient ease to lie down. Sometimes, with leaning forward on his elbows on the bed, or on other pieces of furniture, his elbows would be quite sore and the skin rubbed off. After some years, however, now about three years ago, the attacks ceased to leave him in the morning, but lasted on through the day, at first only a little in excess of the ordinary time, going off in°the forenoon, then lasting the entire day, then not leaving him at all, but keeping him up a second night; sometimes it would come on in the morning and last a day, a night and a day, then two nights and two days, then three nights and two days, and so on; and as the attacks be- came longer, they became more and more intense, and the intervals shorter. 204 APPENDIX. The points most worthy of remark in this case are : First—The sudden and apparently causeless access of the disease at the age of eighteen, a most unusual thing. There were none of the ordi- nary causes of young asthma—infantUe bronchitis, measles, whooping- cough ; nor of old asthma—chronic bronchitis, or heart-disease ; nor any evidence of asthmatic tendency or nervous temperament. Second.—The haemoptysis, not by any means a common event in asthma, and which, it wiU be observed, never occurred except as an accompani- ment of the asthmatic paroxysms, and in a quantity proportionate to the intensity of the dyspnoea. Third.—The invariable occurrence of the paroxysm at twelve o'clock at night, during the first sleep, with one single exception, when it oc- curred at twelve o'clock in the day. Fourth.—The influence which thunder and hot, sultry weather seemed to have in exalting the asthmatic tendency, a circumstance, however, not singular, but which I have seen in other cases. Fifth.—It also weU Ulustrates the gradual progress that asthma makes, in unfavorable cases, from bad to worse. At first the recovery from the attacks is perfect, no trace is left behind ; then appears an incapacity for brisk exercise or violent exertion, with otherwise perfect breathing; then slight night and morning dyspnoea in the intervals of the attacks; then the severe and long attack, after which the dyspnoea never leaves him; then regular severe morning exacerbations ; then the attacks cease to leave him at the usual time in the early morning, but last tiU noon, then till night, then tiU the next day, and so on, till they last three days and nights; then his deformity appears and increases ; till now he is bent double, creeping and helpless, a permanent wheezer, his attacks frequent, severe, and long.1 CASE vm. History of gradual establishment of disease.—Provocatives.—Well-marked influence of London air, absolute and relative.—Efficacy of nitre-paper. E. P., aged thirty. Had always had exceUent health, and was in perfect health at the time, when, having overwalked herself, and reclined for an hour or so on a couch near an open window, she apparently caught cold, and was seized in the course of three hours (about nine o'clock, before going to bed) with difficulty of breathing, a sense of constriction at the chest, and headache. The idea entertained was that she had caught cold, and that the attack was incipieut bronchitis. The only remedies applied were putting her feet in warm water, a little mustard to her chest, some warm gruel, and being put to bed. Gradually, toward morning the breathing began to get easier, profuse frothy expectoration gave increased relief, and she was able to lie down as the day came on. In the forenoon she got some sleep, and as the day advanced felt much as usual, except a little wheezy and fatigued. The following day she was as weU as ever. 1 This case terminated fatally, in the country, about two years after these notes were taken, and nine months after my seeing the patient. I may mention that there was considerable organic change in the lung (emphysema, and thickened and con- tracted bronchial tubes), and that nothing afforded any relief except the inhalation of the fumes of burning nitre-paper. APPENDIX. 205 This attack was in September. For three months she continued perfectly weU. About the first week in January she experienced a second attack, brought on apparently by taking beer after soup. The attack came on soon after dinner; it was much milder than the first, but it was the occurrence of this second attack that first suggested the idea that the first attack was asthma. The breathing was relieved by bedtime, and she had a good night, but bolstered up. Some time in February, being out at a party, she caught cold, and suffered an attack of asthma, followed by bronchitis, which con- fined her to the house for ten days ; she was then very careful of herself all the spring. Then from an error in diet—mUk and beer producing flatu- lence—she suffered another attack; and throughout the summer simUar errors in diet brought on occasional attacks, which gradually increased both in frequency and severity as the winter months drew on. She had a very bad winter. Every antispasmodic remedy that could be thought of was tried, but with little benefit; she was looked upon as a confirmed asthmatic. In the great majority of cases the attacks were brought on by errors in diet—anything that fermented in the stomach. She knew be- forehand that if she took any of these things she would have a paroxysm : any effervescing or fermenting substance, particularly beer, always pro- duced one. Exposure to fogs, damp, or smoke would make her a little wheezy, but as long as her diet was carefully regulated this speedhy went off. In this spring she had a very long and severe attack, and consulted Dr. O, who recommended lobelia and Indian hemp, from which she derived benefit for the time ; they checked the attack, but left her in so uncomfortable a state that it was only as a last resource she would take them. As the summer came on she began to try change of air, and soon discovered that the sea air was prejudicial, greatly increasing the severity of the paroxysms. Soon afterward she came to London, expecting to derive benefit from residence there, in consequence of a case having come under her knowl- edge in which a gentleman, suffering from most severe asthma, had been completely cured by residence in London. On arriving in town she took up her abode in Lombard Street, that she might be in the densest part of the city, for that, from the history of the case she was acquainted with, was the part in which she expected to receive the greatest benefit. Her ex- pectations were fuUy realized—she regained her health and strength ; and from being so weak as to be quite debarred from walking, she was soon able to walk, with perfect ease, an hour at a time. She then made a tour in the west of England—Leamington, Reading, Bath, Clifton, and the Channel Islands—but throughout this tour she was attacked with asthma, and got no permanent freedom from her complaint till she came back to London, where she immediately became quite well, as on the former occa- sion. She waited till her health was recruited by her residence in the city, and then returned to Scotland. She immediately became worse than ever, and passed a winter of most severe suffering. It was then deter- mined that she should come and live permanently in London as the only thing that afforded a chance of the restoration of her health, and she again returned to the city, with the same result as before—perfect cure, restora- tion to health, and comfort in aU respects. Soon after this she moved three miles further west to the neighborhood of Cavendish Square, and there, although she enjoyed an almost perfect immunity from attacks, she was not so perfectly weU as in the city; and she used frequently to go into the city for short visits, for what she caUed a "dose of health." After being a twelvemonth here in a state of very much improved health, she removed 206 APPENDIX. to the neighborhood of Bayswater, and there her asthma began to reap- pear, and she had occasional attacks of the old spasmodic type. She was stUl, however, much better than anywhere out of London. Sometimes she would visit the sea-side or the country in expectation that the change would be useful, but she was always the worse for it. Thus we may say there were four degrees in which she was affected by local influences—she was better in any part of London than in the country, but in its westerly suburbs she was decidedly asthmatic ; in the city she was perfectly well, and in the intermediate situation between these last two her condition was intermediate ; the fact being that the more completely urban the air was the better it agreed with her. In this case every remedy was tried that could be thought of, but, with a single exception, with no beneficial result. That single exception was nitre-paper. She had been advised, by way of experiment, though little expecting benefit, to give it a trial, and to her surprise, on the first occasion of her using it, experienced great relief; in her after-trials the relief was still more complete, because she managed it better than she had at first, and was more familiar with its manipulation. From that time she found it an unfailing remedy. Its effects were rapid and complete, and never varied. There was, however, one exception to its efficacy, and that was whenever the asthmatic attack was brought on and accompanied by bronchitis; in that case the relief it gave was triflng—it was, indeed, hardly any good ; the fact was that it only relieved the bronchial spasm, only put a stop to the asthmatic portion of the dyspnoea, while the bron- chitic portion persisted ; and, moreover, there was, in the inflamed condi- tion of the bronchial mucous membrane, a permanent exciting cause that probably restored the bronchial spasm as soon as relieved. At first the paper was used only every month or so, as the attacks were rarer ; but as the disease became more severe, the attacks occurred more frequently, and at last the paper had to be resorted to every day. Always at night, before going to bed, she burnt it in her room ; indeed, without it she could not have got any sleep, or even gone to bed. It invariably had a marked se- dative effect—sent her off to sleep in a few minutes, and gave rise to such an overpowering drowsiness that she was obliged to be watched, lest she might fall forward or drop the burning paper on her dress. She would give warning when she felt her drowsiness coming over her, in order that the burning paper might be taken from her, and that she might put her- self in a position from which she could not faU, as she had not power to save herself. Even by day, and when not previously sleepy, it would put her to sleep, as weU as cure her asthma, in ten minutes; but if at all sleepy, as in the evening, she would be quietly asleep in a third of that time. Now, we know that many remedies that relieve asthma are imme- diately foUowed by sleep, in consequence of their removing that laborious dyspnoea which is the cause at once of the wakefulness and the weariness. But that this was clearly not the way in which the nitre-fumes acted, but that they acted as a positive sedative, was shown by the fact that if her asth- ma awoke her at night from sleep, and prevented her sleeping, the burning of the paper had the same speedy sedative effect. As soon as her asthma awoke her she would strike a light and burn her paper (which she always kept by her bedside), and get immediate relief; and so quickly and sud- denly would the sleeping come on, that, though quite independent of her husband in the commencement of her operations, she was always obliged to wake him that he might take the paper of her when the drowsiness overcame her. In three minutes after hghting the paper she would be APPENDIX. 2C7 sound asleep ; sometimes her husband could hardly take the paper quick enough, so sudden were its sedative effects. Now, here she was awoke from sleep to relapse again into sleep in two or three minutes ; there had been no accumulated want of sleep, no weariness from protracted labori- ous dyspnoea. So uncertain was the time at which an attack might occur, and so certain was the effect of the nitre-paper, that this patient never went anywhere without taking some of it with her in her pocket. If an attack came on at any time, she would fly to it. Sometimes, when making a morning call, she would find her asthma approaching ; she would bear the increas- ing dyspnoea as long as she could, and then, when she could bear it no longer, she would ask to be allowed to retire to some room to use her remedy, and in ten minutes return to her friends as weU as ever. CASE IX. History of case.—Inoperativeness of all remedies.—Perfect cure by stramonium.— Method of administration. When a boy, I was subject to wdieezing and shortness of breath upon any slight cold, which wore off as I grew up, and for many years I forgot it; but when in China, in the year 1799, I was seized with a severe paroxysm of spasmodic asthma, accompanied with hepatitis, since which time I have been frequently, and of late years I may say constantly, afflicted with asthma. The paroxysm commences with the usual symptoms of cold, to- gether with purging and much evacuation of urine, succeeded by intoler- able flatus in the stomach and bowels, frequent convulsive cough, constant wheezing, with painful dyspnoea, being unable to fill the chest with air; any sudden exertion, speaking above a word or two together, or attempt- ing to walk up a hiU or up-stairs, bring on, at these times, suffocation; much frothy tenacious saliva is discharged from the throat, with some con- gealed phlegm from the bronchise, and in the mornings what is expectorated is often streaked with blood, and sometimes a little pure blood is coughed up. The paroxysm runs its course in from three to five days, when the flatus subsides and expectoration becomes free and easy, being, instead of frothy tenacious saliva, and the jelly or white of egg-like substance, com- mon phlegm, with a little good-looking pus. Health, appetite, and spirits quickly return. For the last three years 1 have never had an interval of above ten or twelve days, free from this distressing complaint. I cannot assign any cause for its commencement, and it goes off as unaccountably. With respect to the cure of this disease, I have been unwearied in my ap- plications to effect it; all my medical friends, both in India and England, have, at one time or another, prescribed for me, and I have not neglected to resort to all the books that came within my reach which treated on this subject—but all in vain. A few grains of calomel (submurias hydrarg) I have found, by experience, is the only medicine that is of service to me, taken on the accession of the fit; it purges and accelerates the evacuation of urine. Diuresis and catharsis being the first symptoms of an attack, I was led to encourage this natural propensity by taking the calomel, and I soon found it of benefit, by shortening the duration of the paroxysm. Dr. Bree's valuable publication encouraged me to persevere with his plan of cure for upward of two years, to which I as strictly adhered as my situation would allow ; but, I am sorry to say, without any other benefit 208 APPENDIX. than that arising from taking the infusion of coffee during the paroxysm, which expelled the flatus and prevented sleep. Always experiencing most misery after a few hours' sleep, I was glad to keep awake, especially as I did not find any difference in the duration of the paroxysm whether I slept or not—on this account the coffee was invaluable to me ; but stiU the dis- ease remained uncured, and, in despair, I resorted to the smoke of the stramonium, more with a view toward experiment than from any hopes of good to be derived from it. The effect, however, was wonderful— even to me almost incredible ; the very first time I smoked, the irritation and constant cough ceased, and the flatus was expeUed, and I expectorated from the bronchia pieces of clear congealed phlegm, from half an inch to about an inch in length, and the thickness of a crow's quill, which enabled me to fill the chest with air. The sensation I experienced the first two or three mornings was no less singular. On the first morning I was caUed up about two hours before my usual time of rising to go to Camberwell. 1 got ready quickly, not thinking of my complaint, but the moment I stepped into the street, I found I had not power to walk, though perfectly free from pain or any other sensible indisposition. I merely felt exhausted, and so feeble as to want support. Coffee was got ready, and I ate my ac- customed breakfast, which restored me at once, and I walked to Camber- well in an hour, the distance being about four miles. I must remark that when I commenced smoking the stramonium, the paroxysm was declining. It had been the most severe I ever remember to have experienced, and it is the last I have had, though I have frequently taken cold since, but with no other inconvenience than a httle shortness of breath and wheezing, which went off on taking my pipe in the evening. I have now been four months free from my complaint, and I have every reason to believe that I shaU feel no more from it, though I shaU continue smoking the stramonium at in- tervals, for a length of time to come. The way in which I employ this remedy is thus : I fiU a common tobacco-pipe with the stramonium cut in smaU pieces, and inhale the smoke as much as possible into the lungs, which causes heat and pain about the fauces and throat, and I am obhged to breathe once or twice before I can inhale it again, when I draw in the smoke ; and so on, alternately, until the herb is consumed, which occupies about half an hour once a day. The saliva I swallow. I think it right to observe that I find considerable difficulty in procur- ing the stramonium unmixed with other herbs. Mr. Harris, wholesale druggist, of St. Paul's Churchyard, was good enough to supply me with a little, and on this being consumed, I sent my young gentleman for a fresh supply, but, by mistake, he went to a Mr. Harris, patent and quack medicine vendor, and bookseller, also in St. Paul's Churchyard, and brought me a packet with a printed paper attached, specifying it to be " Stramonium, or asthmatic herb tobacco, prepared from the recipe of Surgeon Fisher," etc., etc., and, notwithstanding this was as different as possible from what I had before been using with so much benefit, I was induced to try it; but after smoking it as directed for three days, I was sensible the complaint was returning ; and I verily believe in another day or two I should have been laid up with a severe spasmodic paroxysm of asthma had I not got supplied with the genuine stramonium, and from that day to this I have enjoyed perfect health. I am happy to add that since I have experienced so much benefit from the smoke of the stramonium myself, I have recommended it in two cases of spasmodic asthma, with the best effect. APPENDIX. 209 CASE X. Disease apparently congenital—1. Ordinary asthma. Exciting causes. Symptoms. Remedies.—2. Hay asthma. History of the case. Description of a paroxysm.— 3. Cat asthma. Asthmatic symptoms. General and local symptoms. Nature of the affection. I have every reason to believe that I have been subject to an asthmatic affection from the time of my birth, and that my asthma is constitutional or congenital; the recollection of my earliest years is associated with much Buffering from it. As well as my memory serves me, at the youngest period of life it was at the worst, and has gradually diminished up to the present time. In childhood I do not know that I was ever entirely free from it, that is to say, I could never take a deep breath without a wheez- ing sound, but now, except when suffering from attacks, I am free from the least trace of it; notwithstanding it was then, as it is now, almost en- tirely under the influence of exciting causes. Exciting causes.—These are numerous, dissimilar, and some subtle and unaccountable ; they are chiefly these : cold, change of air, a recumbent posture, laughing, coughing, sneezing, bodily exercise, hay fever, and, what is decidedly remarkable, the proximity of a common domestic cat. Several of these causes are secondary to others, and cannot be easUy dis- tinguished ; for instance, I do not know that a recumbent posture or moderate exercise would ever produce a paroxysm without an existing tendency from the effect of cold, an unfavorable air, etc. The two last in the above catalogue of causes I shall consider separately—hay fever and the cat asthma: the first of these is entitled to this distinction because it is invariably accompanied by other symptoms, asthma being only one among many pecuharities equaUy conspicuous ; and the last on account of its singularity. I shall now describe my common asthma, that is, my asthma exclusive of that produced by hay fever, or the proximity of a cat. I was an exceedingly delicate chdd—pale, thin, weak, sickly looking, and cadaverous. Besides asthma, a foe ever present or near, I was subject to sore throat, bronchitis, swollen glands in the neck, enlarged tonsds, Eustachian tube deafness, headaches, and habitual wakefulness at night, a variable appetite, and an inability to stoop my head low, from a feehng of sickness which it invariably produced ; I was debarred from the natural and healthful sports of childhood, for I could neither run nor laugh heart- ily without danger of a suffocating paroxysm of temporary asthma. At the age of twelve or thereabouts I went to reside at a school at Salisbury, where the inland air, and probably the regular mode of living, produced a total disappearance of aU these symptoms of delicate health, and I became stout and strong, and my appearance remarkably healthy and robust. During this time I do not remember to have had one paroxysm of asthma, or that my sleep was at any time disturbed by it, nor on my return home for the vacations, or on finaUy leaving school, do I remember any re- currence of it. But two or three years after I had left Salisbury, my general health stiU remaining excellent, I remember I was perpetually distressed and burdened with tightness of breathing (to use an expression that seems to imply the sensation), to a degree and with a frequency suffi- ciency to destroy my comfort. Thus, in my early life my health was bad and my asthma severe ; at Salisbury my health was exceUent and my 14 210 APPENDIX. asthma was gone ; subsequently, my health remaining good, my asthma returned. So stands the case as bearing upon the question whether a good or bad state of general health has an influence on the asthmatic ten- dency, and the inference to be drawn from the facts, considering the pos- sible influence of other exciting causes, is involved in much uncertainty. In my case the most prominent and frequent of aU the exciting causes is what is commonly called taking cold, and this acts either directly, when the asthma becomes the immediate consequence, or remotely through the intervention of inflammation or congestion of the lungs, when the asthma comes on later. As it regards the first, if I walk in the garden when the air is damp and chiUy, in ten minutes my breathing becomes sensibly affected. At night if my dress is not securely closed in front, or the bed- clothes well adjusted about my neck and shoulders, a certain degree of asthma presently ensues. It has sometimes happened that I have faUen asleep without having made these necessary arrangements, and the conse- quence has been that I have awoke with a fit of suffocation, which, after the removal of the cause, has subsided in the ordinary way. The^ asthma consequent on cold on the chest (bronchitis) is of a most painful and distressing kind; unlike that produced by cold directly, it often lasts for days. In my childhood I suffered grievously from it; I can remember, when I was very little, spending hours at a time on a footstool, -with my head on a chair, as the best means of obtaining rest, together with ability to breathe. But it has frequently happened, at all events of late years, that I have had very severe colds, attended with soreness of chest and ex- pectoration, without any concurrent asthma. Another of the primary causes of asthma with me is change of air. That this produces my asthma I know from the fact that attacks have often occurred for the first few days or weeks after arriving at a place where, during a former residence—and, subsequently, when the effect of the change has passed off—I was as free from aU traces of the complaint as I have ever been. The remaining exciting causes—a recumbent posture, laughing, cough- ing, sneezing, bodily exercise—I caU secondary causes, as I cannot be sure I have ever suffered from any one of them without being at the time in- a condition of tendency to asthma from some primary cause. So great is the tendency of laughing to induce asthma that I have always been obliged, especially in chUdhood, to avoid it as much as possible on ac- count of its distressing consequences. Coughing, though a symptom of the complaint, is also a source of aggravation, and when there is no ap- pearance of asthma, is sufficient to call it into existence. A violent fit of sneezing in the summer wUl produce asthma, otherwise not. I have always suffered from the effects of bodily exercise, especiaUy in childhood; but even at my present age I cannot run a considerable distance, or jump a chUd, or skip with a skipping-rope, without the occurrence of some asthma. Symptoms.—Not the least interesting part of this subject is the form of my asthma—its conditions and symptoms—which I shaU endeavor to describe. The difficulty of breathing that characterizes it may exist either as a paroxysm of suffocation, or a continuous feeling of tightness and im- pediment : this last may continue for days or weeks, with some variation in degree, and prevails during damp seasons and the influence of hay fever. The paroxysm is attended with a wheezing sound, more or less audible, but this only occurs when the paroxysm is about to diminish ; at the commencement and throughout the worst there is no sound which can APPENDIX. 211 be perceptible to any one but myself, as, on listening, I can only hear a faint, long sigh, such as I should imagine would be produced by blowing through a sieve. At this time the visible signs are a distressed expression of face, open mouth, elevated shoulders, and somewhat of heaving or gasping—all these in proportion to the degree of spasm. Presently a change ensues, the wheezing sound commences, the attack then becomes more distressing to observers, but less so to the patient. Apparently a looseness of the mucus foUows the commencement of sound, which mucus continues to present itself at the top of the trachea, and to be disposed of in the ordinary way, even after the sound, which graduaUy becomes fainter, has ceased altogether. The lungs then resume their former normal con- dition ; but an occasional deposit of mucus, and a necessity of clearing the throat, wUl occur at intervals for some time after, but not long, if the spasm is produced by some sudden and violent exciting cause, and does not indicate an asthmatic condition. The continuous form of asthma which I have noticed is but a mUd and continuous phase of the other, but is always indicative of a liabUity to spasm from any secondary cause. It is unattended with sound, except on making a deep expiration, which, if performed, is immediately foUowed by a cough, or inclination to cough ; but during the whole of the period the mucus continues to be abundant, impeding the voice, and requiring to be perpetually removed. This de- position of mucus is one of the most characteristic features of the com- plaint. I beheve no asthma, however slight, exists without this concomi- tant (of course I am understood, here and throughout, to be recording only my own experience), for which reason I am always careful to avoid laughing before singing ; for though the asthma thereby produced may not be perceptible, the subsequent impediment by the production of mucus indicates some previous asthmatic affection. There are two peculiarities to which I have not yet referred—the asth- matic headache and an itching sensation about the chin, the middle part of the chest, and at the back between the shoulders. This headache is never present except in a violent paroxysm, with which it subsides, com- mencing after the difficulty of breathing has existed for some little time. Such headaches do not accompany all violent paroxysms of asthma, but are of rare occurrence ; stiU they are so peculiar and characteristic as to be entitled to rank among the symptoms of asthma. They are unlike any other headaches, unaccompanied by nausea, and consist of an acute pain over the brows and in the front part of the head, and a feeling of fulness ; they are greatly aggravated by coughing, during which the pain becomes intense. The other peculiarity is as characteristic, but more remarkable ; this belongs chiefly to the asthmatic paroxysms, but to which, unlike the headache, it is not entirely confined. I refer to the itching sensation about the chin, the middle part of the chest, and at the back between the shoulders. This itching does not resemble ordinary itching, being of a peculiar, irritating character; when very bad it might almost be called stinging, and it is impossible to allay it by rubbing or scratching, or to de- termine the exact part which itches. If the chest be rubbed all over the itching seems to fly to the back about the region of the backbone between the shoulders, or the chin : the same occurs with the chin and the back ; whenever an attempt is made to remove the itching by rubbing or scratch- ing, if it moves at all, it appears in one or other of the three localities men- tioned, and so till the end of the spasm, or till that symptom subsides. The most ordinary is the itching under the chin, and though so little benefit is derived from scratching, it is impossible to avoid it; the nails go up in- 212 APPENDIX. stinctively, and persevere in a vain application of the usual means of aUe- viation. I shall have occasion to refer to this symptom in reference to the hay fever and cat asthma. Remedies.—Of remedies I have not much to say, as I have seldom used any ; to speak paradoxically, the best of remedies is the avoiding the causes. As taking cold is so frequent a cause of asthma, I have found it of the greatest importance that that should be prevented, and when a cold is the occasion of asthma the obvious means of aUeviation are those which tend to cure the cold. It is essential to me to keep the feet dry, and it is of great advantage to keep the extremities warm, especially during the pres- ence of asthma. As a recumbent position is not the most convenient for breathing, besides being sometimes a direct cause of asthma, I sit upright during the paroxysm, or, in case of fatigue, lean forward, resting my head on a table, or on something placed upon it of a convenient height. I have never been obliged to have recourse to emetics for asthma ; I have taken antimony with very great advantage as regards the diffiulty of breathing. As weU as I can remember, all the symptoms of asthma disappeared, but the effect of the medicine was so distressing and so depressing that the remedy was never repeated. I tried smoking tobacco for some httle time, and discarded it for the same reason ; the aUeviation that it afforded was only in proportion to a sensation of faintness and nausea, and a horrible feeling; consequently, smoking was speedUy abandoned as a source of comfort. If I had persevered till habit had overcome the painful effects of the poison, I believe smoking the tobacco would have had no effect at aU, and would have ceased to be a remedy. I have occasionaUy had recourse to mild doses of ipecacuanha, and have found it a most comfortable and useful medicine. There is an instinct in suffering which suggests the immediate require- ments of the sufferer and the natural means of palhation. For instance, in asthma the next desire after a favorable position of the body is fresh air, cool air, and plenty of it. Frequently when I have been walking in the country, and have been conscious of the presence of some asthma, and have been visiting some of the cottagers in their warm close rooms, I have been obliged to escape, from a feeling of actual suffocation, to the open air. For the same reason we see asthmatics with their mouths open, with the aspect of fish ejected from their natural element. I have now described my case as respects the common asthma, includ- ing exciting causes, symptoms, and remedies. It only remains to relate the peculiarities of my asthma as it presents itself during hay fever, and in consequence of the proximity of a cat; which two subjects, for the sake of convenience, I shall detail separately, and as distinct from the common asthma, though in reality it is but one asthma, and every attack, from whatever cause, and with whatever accompaniments, is consequent on an asthmatic constitution. HAY ASTHMA. My hay asthma differs from the common asthma only in its origin and its accompaniments ; it is necessary, therefore, I should describe the mal- ady as a whole, detailing all the symptoms and peculiarities of what is commonly called hay fever. It seems reasonable to suppose that I must have been liable to hay fever, at the ordinary season, during the whole course of my life, but till within the last few years I was never aware of its presence, or of the exist- APPENDIX. 213 ence of such a malady. From the frequency of my asthma, and common colds in early life, it is probable that the recurrence of asthma at a par- ticular season, and the other symptoms of hay fever, were overlooked, and that when I became less generally subject to asthma, the tendency to hay fever remaining, that complaint more distinctly declared itself; or it may be that of late years I have become constitutionaUy hable to hay fever— either more susceptible of the influence, whatever it may be, or have ac- quired a constitution capable of evolving the symptoms. The period of the commencement of the hay fever, and the length of its continuance, are very variable, being never exactly the same two years foUowing; for one or two seasons, not long since, it did not make its ap- pearance at all or was so slight as to be scarcely perceptible. Speaking generaUy, I begin to perceive it about the middle of May, and it ceases about the middle of July; but I have observed that this depends some- what upon the forwardness of the season and the progress of vegetation. That which distinguishes my case (as I suppose) from the ordinary cases of hay fever is that the asthma is the most conspicuous feature. During the period of hay fever there is always a liabUity to spasm from an exposure to the influence, or there may be, for a part or the whole of the period, a shght but continuous asthma, and a liability to paroxysms from any secondary cause. I have suffered most from paroxysms whUe taking country walks, walking through grass meadows, and especiaUy in one par- ticular garden surrounded by fields. The prevalence of the influence in this locality is very remarkable, as there is nothing peculiar in the neigh- boring sod or its products. I know one other locahty where the influence is still more powerful; here there is abundance of flowering grass and rushes, the region is flat, the sod marshy, and in the neighborhood there is a great variety of indigenous vegetation. If the influence arises from the grass, it is not necessary it should be cut and dried; that is to say, the proximity of hay is not essential. The paroxysm generaUy commences with sneezing, which continues as long as the operation of the influence which produces the spasm. The sneezing appears to be the most readUy produced of any of the symptoms, and results directly from the exciting cause ; it is of a peculiarly irritating character, and greatly aggravates the asthma; it is followed and accom- panied by a stinging, itching feehng in the nose, an irritabihty all over the skin of the face, a watery condition of the eyes, and consequently of the nose. I have frequently returned from a walk with my handkerchief as if it had been dipped in clear water; the eyes become injected, the carunculce lachrymales more or less swollen, and the face wears somewhat the same appearance as during a severe cold. When the paroxysm has continued for about an hour there ensues a feeling of disarrangement about the upper part of the throat and palate and back of the nose, as though the whole of that region were mashed up together, so to speak, and had become swoUen and undefined. This condition is frequently accompanied by an itching sensation in the Eustachian tubes, which induces a desire to move the back of the tongue, or to thrust the fingers into the ears, so as to aUay the itching, but as the part affected cannot be reached, the itching can scarcely ever be alleviated. If this condition of the throat and palate continue for some time, perhaps about an hour, there ensues a feeling of soreness in the throat and chest, as in the case of a common cold. There is durin^ the whole of this period a feehng of general irritabUity; on such occasions the tickling of a hair, the blowing of the wind, any inconvenience or disarrangement of dress, the hitching of brambles, all interference, 214 APPENDIX. weight, or incumbrance, become quite intolerable. But the most con- spicuous symptom is the asthma, which must always continue longer than the sneezing, since sneezing on such occasions always produces it, and when it has reached the worst it takes some time to subside. The asthma during these paroxysms is violent, with a feeling of tightness and suffoca- cation ; it is accompanied with a wheezing sound, and is followed by much mucus. These paroxysms of hay asthma always exhibit the peculiar phenomenon of the itching of the chin; this itching, unlike the other symptoms of the hay fever, is attended only on the asthma, and belongs exclusively to it.' After all the symptoms have mostly subsided, which, if the paroxysm occur in the evening, seldom happens entirely before sleep, the throat remains sore, at least in appearance being red and vas- cular ; the edge of the palate is very red ; the parts contiguous somewhat swollen and undefined, and there is considerable mucous exudation. Always after these attacks there remains for some httle time a liability to asthma from every slight cause, and an inclination to the short asthmatic cough. The asthma may recur on lying down in bed and disturb the early sleep, but this with me is not of common occurrence. During a good night's rest aU is set to rights, and every symptom disappears, except those appearances which, were I not aware of the circumstances, would lead me to suppose I was recovering from one of those severe but short colds to which I am subject in the summer time; the face is somewhat pale, the eyes stiff and injected, with considerable enlargement of the carunculce, which are somewhat encumbered with that kind of inspissated mucus which nurses call " sleeping-dust." The throat is sore, and there is a degree of stiffness and swelling about the palate and tonsUs ; and the lymphatic glands beneath the jaw frequently appear swoUen and distinct, and feel about the size of acorns. If the paroxysm on the previous even- ing has been long and severe there is a feeling of languor and debUity, but this and all other indications disappear as the day advances. I have had attacks of hay fever more frequently in the evening than at any other part of the day,2 but I beheve that this results solely from the circumstance that evening is the time for walking in the summer. The remedies for these paroxysms which I have tiled, if remedies they may be caUed, are very simple. The best treatment is to use the means which inclination dictates, and then to wait with patience tUl the symp- toms subside. If an attack occurred in the evening, having provided my- self with a perfectly dry handkerchief, and being comfortably and warmly dressed, I should sit quite stiU, half reclining in a chair, in a room with the doors and windows closed, and so remain in stUlness and rest, avoid- ing, if possible, coughing and scratching the chin, tiU I felt able to attend to some quiet employment, and then wait for sleep to complete the cure. If the attack occurred in the daytime, I should, in addition, be careful to exclude light and noise. Light is particularly disagreeable and hurtful during attacks, but apart from this it is always comfortable, on such occa- sions, to shut the eyes. 1 This differs from the experience of a lady, an acquaintance of mine, who is a vic- tim of hay fever, and who, although her hay fever symptoms are quite free from any admixture of asthma, suffers grievou-ly from this itching of the chin and between the shoulders, so that, to use her own expression, " she could tear the inside of her chin out." 2 This is not always the case with hay fever; the morning is often the worst time. In the case of the lady referred to in the previous note, an attack invariably comes on from five to seven a.m. The source of these early attacks appears to be the first bright light of the summer sun. APPENDIX. 215 This includes ah I have to say respecting acute hay asthma. The other phase of hay fever is that slight continuous asthma which prevaUs fre- quently during the first half of summer, together with a frequent itching of the chin. This chin-itching is so conspicuous a feature in hay asthma that it may be considered a characteristic symptom, although it is by no means confined to that form of asthma which is produced by hay effluvium. / CAT ASTHMA. "*"> This singular phenomenon is, I imagine, almost peculiar to myself ; I never heard of a similar instance, except in the case of one individual, a near relative of mine, who is subject to the same affection, only in a less degree. The cause of this asthma is the proximity of a common domestic cat; the symptoms are very similar to those of hay fever, and, as in the case of hay fever, are Occasioned by some sudden influence inappreciable by the senses. I cannot recoUect at what time I first became subject to the cat asthma, but I believe the liability has existed from the earliest period of life. I believe some asthma would present itself if I were sitting by the fire and the cat sleeping on the hearth-rug ; but the effect is much greater when the cat is at the distance of one or two feet, or stiU closer ; it is stUl further increased by the raising of the fur and moving and rub- bing about, as is the habit of cats when they are pleased, also by stroking their fur ; but most of aU when they are in the lap, just under the face. The influence seems to be stronger in kittens from two months old and upward than in full-grown cats. Having been almost always accustomed to cats, I have had abundant opportunity of testing the peculiarities of this singular phenomenon. With respect to the symptoms, I have only to say they closely resem- ble those of hay fever, with only such difference as might be expected from the near proximity of the cause, from its defined and local nature, and also for the facility for its entire and immediate removal. The paroxysm is consequently generaUy more violent than that of hay fever, and the symptoms are not aUowed to go through their regular course. The asthmatic spasm is immediate and violent, accompanied with sneez- ing and a burning and watery condition of the eyes and nose, and exces- sive itching of the chin, which may also extend to the chest and between the shoulders ; the eyes are injected and instinctively avoid the light, and the caruncles are more or less enlarged. I believe if the cause were suffered to continue, all or most of the other symptoms of hay fever would ensue, only with a more excessive and conspicuous asthma. After the removal of the cause the symptoms I have described begin immediately to subside, and if the paroxysm is not very severe the cure is effected in five or ten minutes, leaving, as in aU other cases of asthmatic spasm, a ten- dency to mucus at the top of the windpipe, which being repeatedly re- moved in the ordinary way, the last symptom disappears, and the lungs and throat resume their normal condition. This includes all I have to say respecting the cat asthma ; but I shaU here notice the evidence of the more general influence of cats on my system— of the existence of what I am disposed to call cat-poison. I mention this partly because of its singularity, and partly because the symptoms arising from this general influence are often coexistent with those of cat asthma, and are only occasioned by a different application of the same cause as pro- duces, by its application to the respiratory surface, the asthmatic spasm. 216 APPENDIX. The symptoms of this poisoning are consequent on touch or puncture. The eyes, hps, and cheeks are susceptible of the effect of touch, but a puncture of the claw effects equally any part of the surface of the body. The eyes are more readily affected than the lips, and the lips than the cheeks. I have often known the eyes and lips most painfuUy affected by being touched by the fingers after handling a cat. That such a result may be produced by such a means proves very strikingly the power and subtlety of the influence. The eyes would at all times be affected by this means, but I do not think the lips would, unless there were some little crack or flaw in the skin, from cold or any other cause. The effect on the eye of rubbing it just after touching a cat is to produce a hot, stinging irritation of it, a profuse flow of tears and injection of the whole eye, a tender, painful swelling of the carunculee (the sensation is that of pain- fulness and itching combined), and intolerance of hght. If one eye only is touched the other merely exhibits the ordinary effect of sympathy. The result on the lips is an enlargement of the whole lip, and sometimes a sort of lump or protuberance at the part principally affected, together with a feeling of heat and irritation. The cheek is not influenced by this second- ary touch, but is affected by the slightest touch of the fur of the animal. If the cat rubs against the face the cheek immediately becomes hot, a httle swollen, and of a suffused red ; sometimes there appears a defined httle protuberance, something like nettle-rash, which I imagine is produced by the puncture of a hair. The wound from a claw, whatever be its form, is always surrounded by a white, hard elevation or wheal, very much resembling the appearance consequent on the sting of a nettle. The pain, which is very much greater than attends ordinary scratches, is accompanied by a feeling of irritation and itching, hke the pain of the scratch and a nettle-sting combined. I must not omit to observe that I have never discovered any trace of such influence in any other animal, with one shght exception; a deep scratch on my arms with the claw of a rabbit has, in two or three instances, produced the same sensation and appearance as those above described, only less clearly developed. The saliva of a cat is perfectly innocent, and a bite with the tooth in no way differs from ordinary wounds of the same character ; in a word, I beheve the influence is, in its source, exclusively cutaneous. CASE XI. Asthma from bronchitis in adult life.—Capricious and curious effects of locality.— Physical signs. —Inoperativeness of all remedies. ----H, Esq., hving near Kidderminster, applied to me in July, 1859, on account of spasmodic asthma. He was quite weU up to last October, when he caught a severe cold on his chest, with soreness beneath the sternum, cough, and expectoration, but he did not lay up, nor did he seek medical advice. Finding in the foUowing January that he was get- ting worse, he applied to his medical attendant, who told him that he had been, and was then, suffering from bronchitis. He experienced, I think, but little benefit from treatment. It was not tiU February that the asthma showed itself. It came on first in nightly paroxysms, waking him APPENDIX. 217 from one to two o'clock in the morning. Finding this new symptom in- creasing upon him, he consulted Dr.----, of Birmingham, who told him it was spasmodic asthma. Dr. ----did him little, if any, good. He then went to St. Leonards, and put himself under Dr. ----; for some time he got no better, and had his attacks every night; but one day, he says, something snapped in his left side, and he almost immediately began to mend. Dr.----told him it was a pleuritic adhesion that had given way, and ordered the infliction of mercurial and iodine ointment. For the rest of the time that he was at St. Leonards he was almost entirely well, and fancied himself quite cured. He then went to Malvern, and had not been there ten minutes before his asthma seized him, and he had a very bad attack; as long as he was there his asthma continued, and he therefore very promptly left. After this he came to London to consult Dr.----, and put up at Wood's Hotel, Furnival's Inn, Holborn, and there was per- fectly well. On returning home he was as bad as ever; and coming to Reading was advised, by a medical friend there, to come to town to con- sult me. Mr. H. is a fine, strongly built and muscular man, remark- ably well " fleshed-up." Chest movements good ; percussion everywhere clear without any emphysematous hyper resonance ; no emphysematous configuration of the chest or back. On auscultating the chest, I find: 1, respiration accelerated, about twenty-five a minute, I should think ; 2, expiration a little prolonged, post-expiratory rest almost lost; 3, respira- tory murmur not loud anywhere but at the apices, and below and behind decidedly deficient; 4, on forced respiration these parts are found to be the seat of a little rhonchus and sibUus; forced respiration everywhere else gives the normal puerile sound. The patient goes to bed well every night; at one or two o'clock he wakes up with, or rather is awoke by, severe dyspnoea, and obliged to assume the erect position. After an hour or two the difficulty of breathing gradu- ally subsides, and before it is time to rise he is able to fall back and get a little sleep; but he finds that even these little snatches make him worse, and that he wakes from them with his breathing not so free as when he lay back. He gets up to breakfast, but it is not tUl ten or eleven o'clock that his breath becomes perfectly free. When I saw him, ten o'clock, that time had not quite arrived. The attack generaUy goes off with a lit- tle expectoration. For some time, for some weeks, I think, he had, be- sides these nocturnal attacks, a little attack every evening at eight o'clock. He has taken the following remedies without any benefit: Indian hemp, lobeha, extract of stramonium, camphor, ether, squiU, ipecac, and chlorodyne ; also the fumes of nitre-paper. The thing that he says has done him the most good is a draught containing antimony (not in nau- seating doses), ammonia, and ether. He has not tried tobacco, antimony, or ipecacuanha ad nauseam, stramonium-smoking, or chloroform. I ordered him to smoke tobacco to collapse, the moment his asthma came on him, the more likely to be easily induced as he has never habitu- ated himself to smoking. Also to try smoking stramonium. Also to get some of Corbyn's ipecacuanha lozenges, and nauseate himself with them when the attack comes on. Also to hold chloroform in reserve. This is a case, as it has not been of long standing, and has inflicted no notable organic mischief on the lungs, of the cure of which I should be sanguine. It is one of the cases having an organic origin, being clearly due to the bronchitis. There is no history of asthma or lung disease in the patient's family. He never had any symptoms of it before. The situation of his house is evidently high and dry. The air, there- 218 APPENDIX. fore, from which I should expect the greatest good to him, would be low and moist. Either a mUd, relaxing marine air, such as Torquay, Ventnor, Hastings, or London near the river, such as Bridge Street, Blackfriars. Such advice I accordingly gave him. August 20th.—This patient has come to me to-day much worse than when I saw him last, and. with a very bad account of himself in the inter- val. He has been to Ventnor, Southampton, and various other places on the south coast, and has not, I think, had one good night. On the con- trary, his nights have been awfuUy bad, and his attacks have generally come on from six to eight in the evening. The dyspnoea also only imper- fectly leaves him by day, so that he is constantly troubled with it, and now, as he is talking, I can clearly recognize it. He spits a great deal more—an evidence and a measure of the increased embarrassment of breathing, and the consequent pulmonary congestion. He has lost flesh, too, and looks paler and " seedy;" in fact, he is suffering greatly from want of sleep. As he infers that his recent experience is against a mild and relaxing place agreeing with him, he is anxious to try a bracing one. Accordingly, with my approbation, he is going to North Wales. As he has tried three of Corbyn's ipecacuanha lozenges without any success, I have recommended him to take four or six. I have also advised him to try smoking strong shag tobacco, with the view of producing some nausea. A week or two after writing the above I heard from this patient that on his way to Wales he had stopped at Leamington, and there had found himself so perfectly well that he had prolonged his stay. He had not had the slightest return of his symptoms. The hotel at which he was staying, " the Castle," was one at which he had on a previous occasion enjoyed exceUent nights, when he could not sleep in other parts of Leamington; and, what is stiU more curious, it was at this very hotel, and in the same part of it, that another asthmatic patient, who was invariably Ul when he left London, had passed, to his surprise, three exceUent nights; in fact, been as well as in town. How long Mr. H. stayed at Leamington, or what has been the subsequent history of his case, I have not been in- formed. CASES XH., XIH., XIV., and XV. UTERINE ASTHMA Varieties of uterine asthma.—Case XII. Catamenial and dysmenorrhoeal asthma.— Case XIII. Asthma ceasing on marriage and re-appearing at parturition.—Case XIV. Asthma of parturition.—Case XV. Asthma of gestation, ceasing at par- turition. There is nothing that throws more light upon the pathology of diseases than their loedentia, and this because the nature of the perturbation is so clearly involved in the nature of that which perturbs. In nothing is this more clearly shown than in asthma ; and if all other evidence of the ner- vous nature of the disease were wanting, I conceive that its loedentia alone would sufficiently establish it. Of all the provocatives of asthma, those that perhaps point the most clearly to its nervous nature are those distant sources of irritation, occur- ring in some organ far removed from the lungs, which can only exert their influence and produce bronchial spasm by a reflex path. The more APPENDIX. 219 distant such a source of irritation the more striking the result, and the more clear does it become that only by a nervous circuit can the lungs be accessible to its influence. Among such loedentia various forms of uterine irritation hold a prominent and striking place, and I conceive that such cases as I am about to relate are, in relation to the pathology of asthma, fuU of instructiveness, as they undoubtedly are of clinical interest. In speaking of the varieties of asthma I have mentioned the fact that uterine irritation is not an unfrequent exciting cause; but I had then seen only one class of cases—that in which the periodicity of asthma was marked by a monthly interval, the attack being particularly disposed to come on at the menstrual period. Since that time I have not only seen many more of these cases, but I have also seen others in which the effect of uterine irritation in producing asthma has been shown in very different and very various ways. All the cases that I have seen may, I think, be classed under one of the four following heads, which I wiU place in the order of their frequency: a. Asthma obeying a monthly periodicity, and worse at the menstrual period. b. Asthma produced by parturition, and occurring at no other time. c. Asthma ceasing at the commencement of child-bearing. d. Asthma commencing at and coextensive with pregnancy, and ceas- ing on delivery. In some instances, as the foUowing examples wUl show, more than one of these forms of uterine asthma may coexist. For the foUowing case, which well iUustrates the connection between menstruation and asthma, I am indebted to my friend Dr. Paget Blake, of Torquay, and I give it in his own words: Case XII.—"A married lady, who had never had children, came under my care a few winters since for the treatment of severe spasmodic asthma, from which she had been a sufferer many years. She was well formed, rather tall, somewhat inclined to embonpoint, of a fresh complexion and healthy appearance, and declared herself quite weU except when these ter- rible attacks visited her, which generaUy lasted two or three days. " On inquiry into her case, I found that the paroxysms came on at va- rious times, sometimes at intervals of three weeks, then five, then four, then again six weeks, this being the longest time she was ever free. On further investigation, I ascertained that the catamenial period was very irregular, and varied from three to six weeks in its recurrence; that the discharge was pale and scanty, and always caused much dragging pain, sense of fulness, and great general discomfort. I clearly saw that there was a decided connection between the two occurrences ; but the idea of thus putting cause and effect together seemed quite new to the patient's mind, though she said she certainly had noticed that these fearful par- oxysms always occurred when she was " unwell;" but she looked upon it as a mere coincidence, and thought that the one was in no way dependent on the other. " Considering in my own mind that the case clearly arose from some peculiar sympathetic irritation, and must be treated as a disturbance of the uterine economy quite as much as an attack of spasmodic asthma, I prescribed mild emmenagogues, to be taken at the immediate onset of the catamenia ; and I soon noticed that the more freely menstruation took plaoe, the less, in almost exact proportion, was the violence of the spasm. "As the periodicity of the catamenial discharge became more regular, 220 APPENDIX. I was soon able to administer the emmenagogue (compound decoction of aloes, tincture of myrrh, and spirit of nitric ether ; aloes with myrrh pul and compound iron pill at bedtime) a day or two before the expected ap- pearance of the catamenia; and also ordered a hot mustard hip-bath as well. I always observed that if the bowels were thoroughly relieved, and the menstrual flow came on freely, the paroxysms were greatly modified and were much shorter in duration ; the emmenagogue thus proving, secondarily, an exceUent antispasmodic. " During the attacks I found she derived great benefit from dry-cupping. Generally, four small-sized glasses were put as close together over the bifur- cation of the bronchi as they could be placed to draw weU. In the worst attacks immediate rehef always foUowed their apphcation. I also exhibited the ethereal tincture of lobelia, chloric ether, and tincture of hyoscyamus combined; but I do not think this materiaUy assisted the subsidence of the spasm. Possibly it helped a little, but the dry-cupping in her case was unquestionably the remedy. " By perseverance in the line of treatment I have mentioned the gen- eral benefit derived was very marked : the monthly epochs became regular and of proper healthy character, and at each successive period the spas- modic asthma was less, untU the attacks were of so slight and endurable a nature that I discontinued my attendance, feehng sure they would event- ually cease altogether. She determined to continue the aloetic mixture, phis, and mustard-bath, regularly, a day or two before her expected time; and she learned to become quite expert in the apphcation of the india- rubber exhauster, in case dry-cupping should again be necessary. She expressed great gratitude at my having been the means of her thus getting almost rid of her violent attacks of asthma, by also rendering her monthly periods so regular and comfortable." Case XHI.—C. B., aged forty-two, married, with several chUdren, has been troubled, ever since the age of sixteen, with asthma, and also with sneezing to such a degree as to amount to a positive disease. The sneezing would last the whole day, and was not confined to any particular season of the year. Her husband would frequently say, " There is C. at her sneezing again." Her attacks of asthma were only occasional. These symptoms came on apparently from want of development of the menstrual function ; when, however, that appeared she got no better. But when she married her asthma at once left her. The only times at which the asthma has reappeared are during labor—at each "of her confinements. She is now forty-two, and expects the reappearance of her disease in its old form when she ceases to bear chUdren. In the foregoing case it wiU be seen that the disappearance of asthma on marriage coexisted with its appearance at each act of parturition. Case XIV.—Mary H., a lady aged forty, has had asthma regularly for the last three years, but for years previous to that she had it occasion- aUy under the foUowing curious circumstances: She has four chUdren, the eldest being fifteen years of age. At each confinement she has had an attack of asthma. Up to the last three years she has only had asthma under these circumstances. Her youngest child is ten years old. The difficulty of breathing in these puerperal attacks was very severe, accom- panied with wheezing, and there can be no doubt about their true asth- matic character. APPENDIX. 221 For the following highly interesting case I am indebted again to my friend Dr. Paget Blake, of Torquay. It is related so well and so graphic- aUy that I shaU, as in the case of Dr. Blake's that I have already related, transcribe it verbatim from the account with which he has furnished me : Case XV.—" A lady, aged twenty-one, came under my care some three months after her marriage, with weU-marked symptoms of spasmodic asthma, which had existed, before my being sent for, about three hours. She had never suffered from the complaint tiU just a month before I saw her, when the attack was so slight and of such short duration that it caused her scarcely any uneasiness. She attributed it to having taken cold by sitting on damp grass. " I prescribed lobelia for her, with immediate and decided benefit, and the paroxysm soon subsided. The following week the attack recurred, and now appeared to be uninfluenced by the lobelia, which was immedi- ately resumed ; but it gave way to morphia and chloric ether. The next week the symptoms reappeared, and abated only with increased doses of morphia ; this time the bimeconate with Hoffmann's anodyne. " The attacks, from having been weekly, now came on twice a week, and each time appeared more obstinate and less disposed to yield to treat- ment. Their duration also extended from five or six hours to ten or twelve, and at length they held on tenaciously with greater or less vigor for eighteen and twenty-four hours. Each attack, too, obliged me to adopt a fresh remedy, so that I had to ring the changes upon lobelia, mor- phia, ether, nepenthe, ipecacuan, chlorodyne, belladonna, and so on. I think the stramonium cigarettes were more lasting in their benefit than anything else. " This continued till I had been in attendance off and on for fully three months, when I began to suspect she was in the family-way, though she did not at all imagine that she was so, inasmuch as she had had regu- lar returns of the catamenia, was not at aU increased in size, and had not experienced the slightest morning sickness! I was, however, soon con- vinced that, notwithstanding the absence of these leading signs, she was unquestionably pregnant, from the tumefaction and tenderness of the breasts, the well-developed areolae, and the abundant appearance of kies- tine in the urine. She did not believe my conclusions were correct, argu- ing chiefly from her unaltered size, which was certainly conspicuous in its absence ; and, I may add, she continued remarkably smaU throughout her pregnancy. She resolutely opposed my inductions till quickening had indubitably occurred, which, as I afterward reckoned, must have taken place toward the end of the fifth month; and from, this time the cata- menia ceased. "Just before she unmistakably felt the child she had a most alarming paroxysm, and for twenty-four hours her life was in great perU, for it seemed scarcely possible she could carry on respiration sufficiently to oxygenate the blood, so terrible was the violence of the spasm. It was also a question whether she would not sink from exhaustion, inasmuch as her whole attention was engrossed by the tremendous struggle for breath, and she had neither time nor ability to swallow any food. She was wholly occupied for more than twenty-four hours battling desperately for life— one huge, unceasing, weary effort to breathe. " Feelin^ that she was in imminent danger unless a remission soon occurred, and having waited in vain for a luU, notwithstanding the satura- tion of the air with nitre, stramonium, etc., I hesitatingly determined to 222 APPENDIX. administer chloroform very cautiously. I diluted it largely with air, for it really seemed that if any circumstance happened to aggravate the symp- toms one iota, the result must speedily be fatal. I waved a sprinkled handkerchief before her a long way off, and then, gradually lessening the distance, was rejoiced to find that the effect was not—as so often happens at first—to produce any excitement, but that it slowly broke the violence of the fearful spasm. I did not bring her thoroughly under its influence, but as the attack subsided she gently went off to sleep from sheer fatigue and exhaustion following such long-continued hard work. " She had a recurrence, not nearly so severe, at the end of the sixth month, and another very bad one at the end of the seventh month, which, after another hard fight for life and breath, succumbed to chloroform. I administered it earher this time, though, looking at the congested state of the vessels of the head, face, and neck, all weU-nigh bursting, I, as before, gave it with fear and with extreme caution—not till aU other means had utterly faded. She had to take it now almost to insensibUity ere its calmative, soothing effects were visible. " She again experienced an attack at the end of the eighth month, and a rather smart one just before signs of labor set in. " This latter event proved her most potent and persistent remedy; for no sooner had delivery occurred, than all her distressing symptoms van- ished, and her breathing from that time became calm and tranquU as of old. The child was small, but perfect, fuUy formed, and healthy. " The chief peculiarities of this case were : "1. The suddenness of the onset; though, as the sequel proved, it must have been coincident with conception. " 2. The doubt as to its cause, and the almost entire absence of any symptom at first to lead to the supposition of pregnancy. " 3. The pneumal branches of thenar vagum being so entirely affected, to the exclusion, in toto, of the gastric branches; for there was no sickness throughout; it seemed as if the pneumal branches were affected instead of the gastric—as if the asthma took the place of the ordinary sickness. "4. The speedy wearing out of each remedy, every successive attack necessitating a change of medicine, and being apparently quite uninfluenced by what had previously been of signal service. " 5. The periodicity observed. The first appearance of the asthma oc- curred clearly about the time of conception; the next attack just a month after; the intermediate attacks were numerous, but culminated in that fearful one just before quickening took place, which was unusually late ; then, after this crisis, the recurrence happened regularly every month again until parturition, when, at once, the whole affair was at an end." APPENDIX B. TABULATED CASES. ANALYSIS OF TABLES. In the following tables is contained an analysis of two hundred and twenty- six cases of asthma. The notes of these cases I have tabularly arranged, in order to show their points of coincidence and contrast, and facilitate the estimate of their coUective results. Nearly all of these cases have come under my personal observation ; for the notes of the rest I am indebted to my medical friends in London and the country.1 I may mention that aU those who have so kindly helped me are men on whose opinions and ob- servations I can entirely rely, and that I have been very particular to embody the notes of no cases except those of the true spasmodic form of the disease. The events in the history of asthma that my tabulated notes record are— 1. Name, age, sex. 2. Appearance, especiaUy in relation to asthmatic physique. 3. Occupation. 4. Residence, past and present. 5. Age at first appearance of the disease. 6. Cause. Under this head I have stated—a, the original cause of the disease ; 6, the provocatives of the attacks. 7. Frequency of attacks. 8. Time of day (or night) at which the attack occurs. 9. Premonitory symptoms. 10. Whether the disease is unmixed or complicated with other chest disease. 11. Of what standing the case has been. 12. Whether inherited or not, and famtiy history. 1 The way in which I have collected these notes is this : I have issued to my medi- cal friends,• with the request that they would fill them up for me with any cases under their observation, slips of paper ruled so as to have, one under the other, compart- ments for the different events of asthma mentioned in my tables. These they have filled up and returned to me, and have thus furnished me with complete abstracts of cases in the very shape in which I required them, and fit, without any change, for in- corporation with my own cases similarly recorded. I would recommend such a plan to any who may be studying any particular disease, and who wish to enlarge their data beyond the sphere of their own observation. I have found, as the result of the plan I have adopted, that I have not only acquired a wider basis for facts with which I was previously acquainted, but have learnt many points in the clinical history of the disease which were essentially new to me. 224 APPENDIX. 13. Associated diseases (such, for example, as nervous affections, dys- pepsia, etc., frequently coexisting with asthma). 14. Effects of remedies. The first point iUustrated by my cases, to which I would call attention, is the question of age. On this point my tables furnish information in three aspects: a. The actual ages of the individuals at the time the notes of their cases were taken. 6. The age at which the disease made its first appearance. c. The length of time the asthma had existed. I will examine my tables on these three points in order. a. The actual ages at the time of taking the cases.—I have records of age in two hundred and twenty-six cases. The relative numbers in the suc- cessive decades of life are as foUows: Under 10.................... 12 From 60 to 70................19 From 10 to 20............... 22 " 70 " 80................ 7 20 " 30............... 38 " 80 " 90................ 1 " 30 " 40............... 46 ___ " 40 " 50............... 51 226 " 50 " 60............... 30 Average age of living asthmatics, nearly thirty-nine. Thus we see that twelve were under ten years of age ; that the largest number in any one decade was in that from forty to fifty—fifty-one out of two hundred and twenty-six, almost one-fourth of the whole number ; and that in each succeeding ten years the numbers became fewer and fewer. The youngest case was four and a half years old, the oldest eighty. Now, these numbers prove two facts : first, that very young people may be asth- matic ; and secondly, that asthmatics reach a great age, and, therefore, that the disease has but a slight tendency to shorten life. These two facts are, however, much more strikingly iUustrated by the testimony of my tables with regard to the other two aspects of age in asthma, viz., the time of life of its first access and the length of time that the disease has existed. 6. The time of life of first access I have considered in the chapter on the Clinical History of Asthma (p. 47, et seq.), to which I refer the reader. c. The third point with regard to age that my tables teach is the stand- ing of the disease—the length of time it has existed. In eight cases in which it had declared itself in the first year of life—in which, therefore, the asthma was as old as the individuals—the ages at the time of taking the cases were twenty-one, twenty-two, twenty-six, twenty-seven, thirty- five, thirty-seven, forty-five, forty-seven. Another patient, aged seventy years, has been asthmatic sixty-four years; another, aged sixty-nine, from " childhood;" another, aged sixty-five, for fifty years ; another, aged seventy-three, for forty-eight years; and another, aged seventy-one, for forty-four years. One patient, aged fifty-nine, had suffered from child- hood ; another, aged sixty-five, for fifty years ; and one patient, aged forty- five, had been an asthmatic from two years old. These are but a few out of many examples in which the disease had been almost life-long. The long- est duration of the disease I have met with is in two of the cases just no- ticed—the old gentleman of seventy, who had been asthmatic for sixty-four years; and the gentleman, aged sixty-nine, who had suffered from chUd- APPENDIX. 225 hood. Nothing can show, to my mind, more clearly than this, the little tendency that asthma has to shorten life. And this is a fact that is gener- aUy known, and so popularly believed, that the possession of asthma is vulgarly spoken of (hke the possession of an annuity) as a pledge of longevity. It is, however, of the pure nervous asthma—in which the respiratory organs are sound, and the breathing healthy in the intervals of the at- tacks—that this protracted duration of the disease and feeble tendency to shorten life can alone be predicated. Organic asthma is a very different thing. I do not think that a hfe affected with bronchitic or cardiac asthma would average worth two years' purchase. It would be weU for insurance offices if they recognized this distinction. But they make no difference— asthma is asthma to them. I know one office in which aU cases of asthma are refused ; and in others in which they are admitted, there is but one asthma-scale of increased premium. The result is that some cases pay far too httle and some far too much, and that many offices lose what would prove to them valuable lives. The average duration of asthma, as furnished by my notes, is 15f years. But this must necessarily be below the mark, for it merely represents the average time the disease had lasted, from its commencement to the time the notes of the cases were taken. In only one of those cases that came under my observation was there any threatening of an ap- proaching fatal termination : all the others, except some of the oldest, were as hkely to live twenty years as not. The only way, manifestly, of forming a correct estimate of the average duration of asthma would be to> calculate from its first commencement to the time of death. Sex.—For the influence of sex on liability to asthma I must refer the< reader to Chapter IV., p. 59, the data there given being furnished by my tabulated cases. Appearance.—In almost all my cases there is something scored against; the asthmatic under the head of appearance. Some of the descriptions are as foUows: "High-shouldered, thin;" "very thin, cartUages of ribsi drawn in ;" "very thin, and short for his age ;" " saUow, emaciated, coun- tenance anxious ;" "tall, slight, not unhealthy-looking ;" "tall, emaciated, hoUow-cheeked, cadaverous-looking;" " emaciated, high-shouldered, round- backed ;" " tall, leucophlegmatic ;" " stunted and ill-grown ;" " thin, coun- tenance indicative of suffering ;" " asthmatic physique strongly marked;" " thin, with distressed look;" " thin, high-shouldered, anxious;" " pale, thin, narrow-chested ;" " pale, thin, and stoops ;" " thin, pale, rather dusky ;" " emaciated, and very high-shouldered ;" " thin, dusky, eyes watering ;'" "face slightly dusky and bloated;" " marked asthmatic deformity ;" " skin' and bones;" "figure asthmatic;" "diminutive, emaciated, cyanosed;" "eyes; varicose and prominent." In truth, the asthmatic is generaUy a miserable- looking wretch—round backed, cyanosed, veiny, and thin, with a face marked with the lines of suffering, and a premature senility. If the asthmai has come on young, he is generally below the average height. Some asth- matics, however, as my tables show, have nothing whatever the matten withi their appearance, and would be taken for perfectly healthy people. Occupation.—On analyzing the two hundred and twenty-five cases ins which " occupation " is specified, I find one hundred and fifty-four were males, and seventy-one females. I find that of the one hundred and fifty- four males, one hundred and eighteen were gentlemen—men of private fortune, clergymen, professional men, military men, or merchants, includ- ing a good many wine merchants ; and thirty-six were tradesmen, artisans, 15 226 APPENDIX. or laborers. Thus about seven-ninths of the male asthmatics were gentle- men. Of the seventy-one women, fifty-seven, or more than three-fourths, were ladies. The upper-middle and upper classes would seem, then, to con- tribute more than three times as many cases of spasmodic asthma as the lower (one hundred and seventy-five to fifty); and this conclusion seems the more certain and striking when we remember the numerical inferiority of the upper classes, and that they ought therefore to furnish fewer cases of asthma, even supposing they were equaUy liable to it. But would this conclusion be correct ? Is it reaUy as it seems ? It appears to me to be just one of those cases where the numerical method may fail, where it may give the fact but not the interpretation thereof, and where the imme- diate and apparent conclusion may be the wrong one. The reason why the upper classes furnish so large a portion of the cases may be that asthma, in the rich, is sure to come under medical cognizance, in the poor not. I have known some poor asthmatics, who, from the chronicity and apparent incurableness of their disease, and the tolerableness of their health in the intervals, never think of consulting a doctor about it. The rich do not sit down so patiently under their maladies, but seek relief wherever they can hope to get it; so aU their cases come under our observation, whUe of the poor many, I believe, pass unrecorded. It may well be, however, that the upper classes really are more liable to asthma than the lower, and that this depends on the tendency of the state of hyper-civUization in which we hve (and to the effects of which the upper classes are most exposed) to generate a morbidly sensitive neiwous organ- ization. It may be, too, that those diseases which, when severe, so fre- quently lay the foundation of asthma—measles, whooping-cough, infantUe bronchitis—when faUing on the chUdren of the poor, cut them off at once ; while those of the rich, from the medical and sanitary advantages they possess, and the tenderness and care with which they are nursed and guarded, pull through them and survive as asthmatics. The rearing of an asthmatic child is a difficult task, and I have no doubt many of the poor perish in the process. . As far as my tables go, it would seem that particular occupation has no influence in affecting liability to the pure nervous form of the disease ; and in this respect we see a strong contrast between uncomplicated and com- plicated asthma, the liabUity to the latter being greatly influenced by oc- cupation and the external circumstances of hfe that it involves. Asthma, which is a mere appendage to bronchitis, for instance, is of course induced by the cause of bronchitis, such as exposure to wet and cold, and out-door employment in inclement seasons ; and cardiac asthma by occupations that involve excessive and sustained effort, and exposure to those depressing influences that generate fatty and ossific change. To organic asthma, therefore, depending on lung or heart-disease, we find the lower classes much more liable than the upper; and if I had recorded cases of this kind, the proportionate numbers of the rich and poor in my tables would have been very different. If I were asked what occupations, in my ex- perience, tended most to induce bronchitic asthma, I should say those of costermongers, cabmen, and Covent Garden porters. Residence.—The column under the head " Residence " shows that every conceivable variety of locahty may be the residence of asthmatics—every part of the United Kingdom, the Continent, America, Egypt, and Spain, the Cape, India, Australia ; the crowded city, the open country; high, dry situa- tions, and low, damp ones ; inland and the sea-coast; in a relaxing, and a bracing air ; on chalk, gravel, and clay soUs. I have instances of asthmatics APPENDIX. 227 in aU of them. It also shows that the disease may continue during pro- longed residence in one locahty and under perpetual change of place. But the influence of residence is far better illustrated by the teachings of another column, that of the " Effects of Remedies," where in a great number of cases it wiU be found stated that residence in certain specified localities has effected a cure. For the results of my cases in illustration of the therapeutical influence of locality, I must refer the reader to Chapter XH1, which is devoted to the examination and discussion of this subject, One case (Case 5) furnishes one interesting point. It is the case of a native Hindostanee lady, aged forty, who came under my care about a year and a half ago, and who gave me, in relating her symptoms, a very clear history of a weU-marked case of pure spasmodic asthma from which she had suffered (in her native country) for twenty years. It shows that the phenomena of the disease are not modified by chmate, and that they are identical in the Hindoo and European constitutions. One new feature in her asthma she did notice, however, the tendency of hay and flowering grass to induce it; she had some very severe attacks brought on in this way, in fact, regular hay asthma. From this she had never suffered in her native country, and had been at a loss to explain the phenomenon until I offered her its solution. I have known similar instances. A late Governor of the Bombay Presidency had suffered from hay asthma all his life, till he went to India. During the whole of his residence there, twenty years, he was perfectly free from it. But no sooner did he return to England than his old symptoms reappeared. A lady of my acquaintance who suf- fered greatly from hay asthma went to the Cape. During the seasons there in which she had been accustomed to expect the visitations of her complaint, she had not a trace of it; but on coming back to England it re- appeared in the old way. I think she has twice spent some years at the Cape, and both times with the same result. It would seem, then, that the particular species of grass, the emanations from which give rise to the symp- toms, must be indigenous to this country, or at least to Europe ; for hay asthma seems to be as abundant on the Continent as in this country. Causes of asthma. —Under the head of causes of asthma, I have adopted a division, which I think a perfectly natural one, into the original cause of the asthmatic tendency (i.e., the essential cause of the disease) and the provocatives of the attacks. Under the first division—the essential cause of the disease—I find, in the two hundred and twenty-two cases in which it is recorded, that in one hundred and twenty-five it is assigned to some bronchial affection. Of these one hundred and twenty-five, seven are specified as whooping-cough bronchitis, and one hundred and eighteen as catarrhal bronchitis; this last, in a large number of cases, has been in- fantile bronchitis, or that of early childhood, in many was very slight, and seemed to be nothing more than a common cold on the chest, and in al- most aU was so completely recovered from that the cases afterward pre- sented the characters of pure spasmodic asthma, and not that of bron- chitic asthma. In some cases the original chest affection was so slight that it was not recognized, and the cause of the asthma was called " cold," or "cold and damp ;" but we cannot conceive how these agents shoukl affect, and permanently affect, the physiology of the bronchial tubes, except by affecting their mucous membrane, and the one and only way in which cold and damp affect the bronchial mucous membrane we know to be by more or less inflaming it. All cases, therefore, assigned to cold I have set down as bronchitic, although the bronchitis may originaUy have been so slight as not to be recognized. 228 APPENDIX. In sixty out of the two hundred and twenty-two cases the cause of the asthma appears to consist in a constitutional proclivity to the disease, re- quiring for its development no appreciable cause. Some of these cases are set down in my notes as " cause unknown," or " constitutional ten- dency," or " congenital," but I believe they are all one and the same, and depend on a peculiar morbid irritability of the nervous system of the lungs, which is a part of the individual. Many of these cases appeared very early in life, quite in infancy, and in the majority of them distinct inheritance could be traced. Nothing could prove more than this last cir- cumstance their constitutional character. Indeed, in most cases where asthma appears to be hereditary, it will be found to be of this apparently spontaneous kind. And that we can easily understand ; the more intense the tendency to the disease, the slighter wUl be the circumstance (if any) that is necessary to elicit it. In three cases the disease is assigned to suddenly suspended eruption ■—in one case small-pox, in the two others eczema. Now this, remember- ing the intimate association of the skin and bronchial mucous membrane, as shown by the materials they eliminate, the bronchitis of severe burns, etc., I think possible. In two cases it appeared during croup, in two during measles, and in one after it (no mention being made of cold or bronchitis). In one case at the time of a tooth rash. In five cases hardship, violent exercise, and exposure were assigned as the cause. One appeared after rheumatic fever with cold. One after " a supper of meat, onions, and hard beer ;" and another from a " weak stomach." One from " hay asthma ;" one from "miasma of China ;" one from "Indian climate ;" one from the "air of Rothsay," and another from the "air of Ramsgate;" one from "an op- pressive night at Torquay ;" one from waking quickly ; one from sudden cessation of menstruation ; one after an attack of dysentery, another during bihous fever, one during inflammation of lungs, and one " caused by gout." In four cases the disease was supposed to be induced by grief and trouble. This, remembering its nervous nature, I ako think possible. In one case it appeared immediately after typhus fever ; in one was supposed to be caused by liver complaint; in one by sudden hard work and sobriety after habitual drinking ; and in one came on suddenly on going to Ashby, as if that air had caused it. In these cases I consider the causation apocryphal. Now, what do these cases teach ? Disregarding the isolated cases, I think they teach two things: a. That in one hundred and twenty-five cases out of two hundred and twenty-two, that is considerably over half, the asthma was due to some- thing organically and vascularly affecting (though perhaps slightly and temporarily) the bronchial mucous membrane. b. That in sixty cases out of two hundred and twenty-two, that is in more than a fourth, it appeared to depend on a constitutional idiosyncrasy, in some cases congenital, in some cases inherited—that the cause was in- trinsic not extrinsic. The implied pathological teaching of these facts I have fuUy discussed in Chapter VI. In the second class of causes—the immediate excitants of the atatcks— my tables show that asthma exhibits the most extraordinary variety. If I were to mention aU, the provocatives of the asthmatic paroxysm, I should mention almost as many as there are cases in my tables. But I think they may be divided, with few exceptions, into three classes : respired irri- APPENDIX. 229 tants ; alimentary irritants, or circumstances affecting the digestion ; and circumstances affecting the nervous system. Among respired irritants, materials affecting the air breathed, I find : " Dust, hay effluvium ;" " any air but Richmond ;" " aU airs but London ;" "ahot, ill-ventilated room ;" "smeU or presence of mustard in any form, smell of a poulterer's shop, fresh skins;" "cold, damp, dust, mustiness;" "hghting a lucifer match, cat influence ; " " east wind ; " " ipecacuanha effluvium ;" " grass poUen, dust generally ;" "particular smeUs, dust, and smoke ;" " change of air ;" " fog ;" " effluvia of animals ;" " smoke of London ;" " tobacco smoke ;" " a particular house in Matlock ;" " smeU of linseed ;" " Brighton air; " "nitre papers;" "smeU of rabbits;" "pitch;" "any strong scent;" "stable, hay, new air;" "trees;" "house near the sea;" "a cat in the room." In many cases east winds ; change of temperature often a cause. Among the provocatives of the attacks acting through the digestive organs, I find mentioned in my tables : "A late full meal;" " deranged stomach ;" "a late dinner or supper;" "pie-crust, eggs, any sweets, heavy malt liq- uor ;" "pastry or indigestible food ; " "a glass of hock ;" "a glass of port wine, immediately ;" " any food of a fermenting or gaseous kind ;" " eat- ing beans, old peas, or cheese ;" '.'sleeping after food;" "dining out;" "flatulent distention of the stomach;" "pork;" "veal;" "confined bowels;" " emptiness ;"" taking food after five o'clock;" "taking food after eight o'clock." Cheese and malt liquor are frequent causes. " Made- up dishes;" " fruits, especially nuts." In two cases milk would always bring on an attack, in two coffee is mentioned, in three " malt liquor." Among the nervous excitants of asthma I find " anything that troubles the mind;" "nervous excitement;" "severe exertion;" "mental depres- sion ;" " any sudden fear or alarm." There are some provocatives of asthma enumerated under the immedi- ate excitants of the attacks that might raise some doubt as to where they should be placed: "Hot weather," "laughing," "over-exertion," etc. Many people are much worse in hot weather, some only troubled with their complaint then, and many asthmatics I know who dare not laugh for fear of bringing on an attack, especiaUy after a meal or in the hay season. For an explanation of the modus operandi of these excitants, see page 71. Frequency of attacks.—Of two hundred and fifteen cases, eighty-seven are specified as irregular, having no periodicity, the remaining one hun- dred and twenty-eight were periodic; the proportion, therefore, of periodic to non-periodic asthma is about three to two. The intervals at which asthma may occur may be divided into natural and arbitrary. In one hun- dred of the cases at which the period is mentioned the interval is arbitrary, in one hundred and thirteen it is natural; natural periodicity, therefore, predominates over arbitrary. What I call natural periods are the diurnal, the weekly, the monthly, and the annual. Of the one hundred and thir- teen naturaUy periodic cases, in sixty-nine the period was diurnal, in eighteen weekly, in five monthly, and in twenty-one annual. In fully one- half of the diurnal cases the attack occurred early in the morning ; in six night and morning ; in seven twice to seven times in the day ; and in three cases more or less continuously. Of the eighteen weekly cases six, curi- ously, occurred on a Monday morning, and four on Sunday. Of the twenty-one annual cases eleven were summer or autumn asthma—nine summer, and two autumn ; one summer and autumn ; six in winter ; one from September till May ; the other two not stated. One of them was true hay asthma. In asthma annuaUy periodic, a summer instead of a winter periodicity distinguishes the purely spasmodic from the bronchitic 230 APPENDIX. form of the disease—a very important diagnostic point. Of the one hun- dred cases in which the periodicity was arbitrary, in one case the asthma occurred every night or two, in two every two days, in one every six days, in nine every fortnight, in one thrice a month, in two every two or three weeks, in three every three weeks, in two every month, in one eight or ten times a year, in five every two months, in one six in the year, in one every two or three months, in* two every three months, in one three or four in the winter six months, in one two or three in winter. In some cases the periodicity may be said to be double—a period within a period : thus, in the annually recurring cases the summer or autumnal batch of asthma has commonly a diurnal periodicity throughout the time of its continuance. In some the periodicity may be said to be complex, to be regularly irregu- lar ; thus in Case 4 " a severe attack occurred once a month all the year round, and in the summer a slight attack every night in addition ;" in Case 21 " nightly in July and August, once a month the rest of the year;" in Case 34 " every night slightly, and once a month severely." In some of the cases the periodicity may be said to be an advancing one—the intervals getting shorter ; in some a receding one—the periods lengthening. Time of attack.—The evidence of my cases as to the time that asthma chooses for its accession is as follows : In the two hundred and fourteen cases in which it is stated (in twelve there being no record), the time of the attack was constant in one hundred and eighty-one and variable in thirty-three, i.e., constant in five and a half cases out of six. Of the one hundred and eighty-one cases in which the time of attack was constant it occurred in the early morning in one hundred and thirty-five, and in the evening in twenty-seven, i.e., in the morning in four oases out of five. In addition to these are four which occurred in the afternoon, and fifteen which occurred in the morning and evening. In other words, morning asthma is four times as common as evening asthma, and a stated time for the appearance of the attack five and a half times as common as a variable one. These results may perhaps be more clear if tabularly expressed, thus: (Variable... 33............... 33 stated.........2U j constant... 181 j ^Zl;;;;;] ^ Not stated..........................,............ 12 My tables show that of the one hundred and thirty-five morning cases, in ninety-eight the attack commenced from midnight to four o'clock ; twenty-four occurred later than four o'clock, of these, thirteen wTere from four to five, one occurred from one to five, one from two to five, three from three to five, one from two to six, and one from four to six ; two from five to six, one from three to seven, four from six to seven, two from seven to eight, one from eight to nine, and one from eleven to twelve. From two to three o'clock a.m. is the commonest time for asthma to appear. I may remark that, as a rule, the cases of asthma in which the time of attack is irregular are cases in which the disease is irregular, and not typicaUy marked in other respects. Premonitory symptoms.—My tables show that premonitory symptoms were wanting in one hundred and eleven cases out of two hundred and • twenty-six; they were present in the rest, that is, in more than one-half of the cases. But from these I think thirty-one must in fairness be taken, as the premonitoiy symptoms in these appeared to be nothing more than the first traces of the invasion of the attack. In sixty-three cases the pre- APPENDIX. 231 monitory symptoms were nervous ; of these sixty-three, the symptoms in thirteen consisted of " unusual drowsiness overnight," or at other times, in eleven of " headache," in thirty-nine something affecting the spirits and mental condition, such as "a sense of unusual security," " a sense of un- usual health," " a conviction of the approach of the attack," "boisterous spirits," "irritabuity of manner," "fidgetiness," "feeling dull, low, and miserable, without a cause," "hilarious, almost hysterical," in one "neu- ralgic aching of bones," in two "depression of spirits," in three "feeling unusually well," " pain from armpit to armpit," " very tired and sleepy," " distinct, but indescribable, flushing of one cheek in particular ;" in eight there was "profuse diuresis," in another "giddiness." In fourteen the premonitory symptoms were referable to the stomach, such as flatulent distention, a sense of fulness, tightness of dress, dyspepsia, gastralgia, nausea, "eructation of sulphuretted hydrogen," "ravenous appetite," "dis- agreeable taste in the mouth as of blood," " evacuation of a yeUow matter like yolk of eggs " at stool, " feehng of indigestion." For the teaching of the column relating to " Family History," I must refer the reader to Chapter IV., especiaUy the paragraphs treating of the hereditariness of asthma. An analysis of the last column is simply impossible ; it would be httle less than rewriting the chapters on Treatment. Number. Name. Sex. Age. Appearance. Occupation. Residence, 2§ Cause. a Original cause Frequency Time Premoni- Unmixed or complicated with other lung •a | Associated past and pre- 4J 1- of disease. of of tory C3 C diseases and family Effects of Remedies. sent. © P. cm o, /5 Provocatives of attacks. attacks. attack. symptoms. is history. W a > « in w to OS Number. Name. Sex. Age. Appearance. Occupation. Residence, +■> . £ 8 Cause. § a Original cause Frequency Time past and pre-sent. a boo. <; cs of disease. 0 Provocatives of attacks. of attacks. of attack. 9. Edward P., m., set. 39. North-Wales; 6 o Exposure to At first every Various. Tall, leuco-phleg- Sudbury, In years. wet. two months. matic. Suffolk. 0 Digestive de- Now three Clergyman. rangement, certain airs— e.#.,cannotlive in London. times in two years. 10. Annie J., f., set. 37. South coast, Infan- a Supposed bron- Quite irregu- No rule. Appearance nothing low, mild sit- cy. chial catarrh. lar, accord- special. uation ; Lon- 0 Nervous excite- ing to excit- Gentlewoman. don. ment, coffee, laughing,light-ing a lucifer, cat influence. ing causes. 11. John P., m,, set. 61. Downton, val-ley surround- 31 years. a Bron ch i tis E verv fort- Thin, countenance in- from unusual night. dicates suffering. ed by chalk exposure to Incapable of work. hills. cold in an in-undation. 8 Change of wea-ther; any oth-er excitants not stated. 12. Penelope K. W., f., Downton, low, 4 a A n ordinary Once in three GeneraUy set. 21. gravel, sur- years. child's cold. weeks; lat- evening. Tall, stout, and pale. rounded by 3 Certain locali- terly much Gentlewoman. chalk. ties will imme-diately induce; also any dis-turbance of the digestion. rarer. Unmixed 0 Premoni-tory or complicated with other ^ ti B a Associated diseases and family Effects of Remedies. symptoms. lung diseases. O history. Coryza some- Seems often 23 No associated dis- Remedies directed to the relief times. mixed with years. eases. of the chest useless. Calomel congestion of Inherited from fa- has sometimes done good. the liver. ther and grand-father. Father's sister died of it. Boating and gymnastic exer-cises afforded much relief. Certain airs very beneficial, as Oxford and Sudbury. In the ordinary As sociated Life- Bronchial suscepti- Sitting up or stnnding relieves asthma none. with bron- long. bility. Very ner- the spasm. The nausea of In hay-asth- chitis in vous tempera- tobacco-smoking and ipeca- ma sneezing. childhood. ment. cuanha immediately cure; At present Not inherited. Two mucus rises to the top of the no complaint brothers with both ordinary and hay-asthma. trachea, is expectorated, and so the spasm passes off. Feeling of hav- Considerable 30 Health in other Orthodox remedies worthless. ing taken a bronchitis. years. respects perfect. Seven years ago tried Lo- Afresh cold," Several indirect cock's wafers, and soon great- increased ex- branches of the ly improved. During the sec- pectoration family have been ond year had but one attack, and cough. asthmatic, but neither parent. and that in a thunder-storm, since then, five years, entirely free. Sleei s low, walks well; can do anything. Fulness and No lung com- 17 Paroxysms of ex- Ordinary remedies useless, ex- tig h tness, plication ap- years. traordinary gen- cept inhalation of the fnmes rendering it parently. eration of flatus. of nitre-puper, which have necessary to giving rise to always relieved the attacks; loosen her "flatulent hic- except when complicated with clothing. cup." Mother slightly rsthmaiic; ma-te i- n n 1 i;roa t-gramlinnthc r a L.artyr to it. broni hitis. In certain locali-ties she is quite well. Charles B., in., ret. 23. Bclgrave Gate, Tall, well-formed, thin. Grocers Assistant. 14. T. Z., m., sat. 49. Short, slight, fair. Surgeon. 15. William H., m., set. 45, Appearance perfectly healthy. Private Gentleman. 16. A. B., m., set. 71. Broad-chested, well- made man. Military. Annie M., f., set. 67. Widow. Stokesby, Mid- dlesbro', and within ten miles. Near Kidder- minster,high. dry situation. on red sand stone. India 19 years; since at Guernsey, Near Peter bo r o' and Cambridge. 20 o U n k n o w n. Every 2 or 3 Irregular. Generally shi- years. Went to Ashby months: but vering and for 9 months. slight dysp-j " aching of and was at- n ee a more the bones." tacked there. frequently. 8 Severe exer- tion, malt li quor, pastry. or indigestible food. 48>T a Original cause Every 6 davs; Uncertain. A mere in- years. unknown. | but ureal h- crease of the 0 Atmospherical ing never usual dysp- influence. free. noea in walk-ing, etc. 44 a Bronchitis. Every night From 1 to 2 None. years. 0 Certain airs, as Malvern, f i .r weeks. A.M. Kidderminsteri Ventnor, etc. 37 o Liver com- In the autumn Generally Tickling in the years. plaint. almost daily, after first throat, and 0 Disordered sto- sleep. then cough- mach, damp ing. situations with much vegeta- tion, a glass of hock. 52 a Followed ty- Every 2 or 3 Toward s Pain between years. phus fever. I weeks, be- night. the sli oul- 0Excitantsof comingmore ders and fe- attacks not, frequent. verishness. mentioned. Unconip' cated. Unmixed. Slight bron- chitis; trace of emphyse- ma. Uncompli- cated. Unmixed. 3 years. 4 mos. 31 years. 15 years. No associated dis- eases. No hereditary ten- dency, par ruts living, family healthy. Indigestion. N o Inheritance. No associated dis- eases. No history of any lung disease in his family. Liver and stomach disease. No inheritance. No associated dis- eases. One sister died of consumption, fa- ther of renal dis- ease, mother in childbirth. Have seen him twice or thrice ; the attacks last from 21 to ."(i hours, but not severely ; an emetic has been useful, and a combination of T. opii, ether chlor., and M. camph., seemed beneficial. Nitre-paper fumi- gation apparently useless. •'After all remedies had failed, I exi>ericnced immediate relief on driving three miles into the country toward Stokesbj; I therefore went to reside at Stokesby, and three weeks cured me. If again attacked, I shall do the same." Indian hemp, lobelia extr. strain., camphor, ether, squill, ipecacuanha, chlon_dyne, ni- tre-paper, all useless. Perfect- ly well at Wood's Hotel. Hol- born, and the "Castle." Leam- ington ; not tried tobac., ant., or ipecac, (id navncum, stra- monium smoking, or chlorof. Always well in London and Bath. Nitre-paper gives im- mediate relief; strong coffee and a cigar the same, but less. Has cut short an attack by go- ing a mile to the sea-side. Ap- parently permanently cured himself by walking 520 miles a day. Emetics were formerly used with great relief. Has found now that small nauseating doses of ant. pot. tart. £i\e morercliefthr.n any thing else. oo Number. Name. Sex. Age. Appearance. Occupation. Residence, past and pre- « a Cause. a Original cause of disease. Frequency of Time of Premoni-tory Unmixed or complicated with other lung diseases. a £ . Associated diseases and family Effects of Remedies. sent. a, bo a ■ no good. Coffee, Blisters, Mustard poultices, Emetics and ether relieve for a time. London air cures. Feeling of de-bility mid ill-ness forsome days before contin u o u s attacks. Extensive em-physema. 12 years. Father was wheezy as a boy, but grew out of it entirely, Everything that could be thought of has been tried without any benefit. Physical signs perfectly healthy. 2 years, Timid and ner-vous. Not inher-ited. Nitre-paper gives relief. Emetics and chloroform give hardly any relief. The other asthmatic remedies have not been tried. None. 5 years. Excitable and ner-vous. No dys-pepsia. Father died of bron-chitis. Nitre-paper always relieves. Coffee sometimes. Free open air, as on the deck of a steamer, relieves. The ma-jority of asthmatic remedies not tried. Heaviness about the head, and drowsiness. 6 years. Cured by coming into Charing-cross Hospital, and subse-quently living in a street in the neighborhood. t-3 bj d tr< H u a ► EM to Number. Name. Sex. Age. Appearance. Occupation. Residence, past and pre- n d != Cause. a Original cause of disease. Frequency of Timo of Premoni-tory Unmixed or complicated with other lung diseases. *3 a 4a si « a Associated diseases and family Effects of Remedies. sent. M p, •<) d 0 Provocatives of attacks. attacks. attack. symptoms. o history. 62. Eleanor B.. f., out. 11. Crown court and Hart 10 years. aUnknown; appeared one About every 3 months, but 3 honrs after going to None. m 1 year. Not nervous. Pill containing ext. stramon. Stunted and ill-grown. gr. % hyosc. gr. 1%, and co- A little asthmatic street, Co- Saturday night a 1 w a y s bed. nium gr. 1%, completely put build. vent Garden. without any wheeze s a stop to the night paroxysms School Child. apparent pro-vocation. 0 Cold and over- loudly every night. and cured the case. 63. exertion. Samuel B., m., set. 35. Canonbury till 26 a Miasma going Annual perio- 2 or 3 a.m. Always feels 8 Dyspepsia. Father Strong coffee on empty stomach High-shouldered, 25, then 6 years. up the Chinese dicity, worse particularly years. died of asthma does good, chlorodyne especial- dusky. years inj rivers in boats. from May to light - heart- at 50. 7 brothers ly en empty stomach. Lobe- Merchant. China, where it came on; then in Rus-sell square and Doughty 0 Errors in diet, hay effluvium, smell of horses, cattle, horse and dog shows. September. ed and well before an at-tack. and sisters healthy. lia for a time, also strong to-bacco from a colored pipe. Stramonium smoke and nitre-papers are no good. 61. street. Elias B., m., set. 54. Native of Tan- 53 a Cold falling on At first rarely. Mostly in the Pain from Resp. m o v e - 1 Anxiou s, nervous Smoking stramonium does good, Very dark. gier, residing years. the chest. lately every evening. armpit to ment imper- year. tempera ment, \ also nitre-paper. The major- Merchant. at F ay a 1 when itcame on. England 3 months, well; St. Mi-chael's Well. 0 Slight exertion, having a letter to write, catch-ing cold, men-tal perturba-tio n, food; mostly without other day. armpit. fect, occa-sional moist sounds. nervous head-ache every week. Mother died at 98. ity of asthmatic remedies not tried. Pot. iod. was subse-quently tried with great ben-efit. 65. Wm. B., m., set. 53. Tall, thinnish, other- any cause. Thorley ever since he has 48 a Cold. Formerly once About two Evident bron- G Two sisters and an Nitre-naiier srives exeat relief : years. 0 Taking cold, or twice in a hours after chitis ; spits years. uncle died of] tobacco some; squills, chlorio wise not unhealthy- had the at- animal food winter, now going to a great deal; consumption. ether, belladonna and chlo- looking. tacks; the taken Into at often every bed. no adventi- rodyne were useless; other Farmer. situation is rather low. night; going into a barn also night. tious breath so u n d s; remedies not tried. damp, and brings on hay- resp. mur- mild. I fi;vcr symp- mur clear; a toms. little patchy. to a 66. A. B., m., set. 48. Rather spare and high-shouldered. Country employments. 67. Grace B., f., set. 65. Very stout, dusky. Gentlewoman. George B., m., set. 49 Asthmatic figure, eyes varicose and watery, face dusky. Gentleman. 69. J. S. B., m., set. 69. Tall, thin, not much asthmatic physique. Sedentary. 22 years. 15 years. Principally in Bishop's Tanton, i n Devonshire ; has visited about; worse at Coast of S.D. Resided in all parts of the world. Sud- den changes give relief. Free at Ber- muda. Had it in London. Came on at S t a n m ore. At Brighton much better. At Cuckfield always was worse within an hour. West Riding, 57 Yorkshire, years, up to 12 years ago, since then at Torquay. 36 years, a Inherited pro- bably ; ovit- excrtion and cold. 0 Cold, dust, lu- cifer-matches, pitch smoke. confined state of bowels, supper, over- anxiety. a Cold on the chest neglected 0 Smoke, dust, shaking up of feathers, danc- ingon a carpet, hay, sharp cold, taking cold, eating late. a Cannot tell, unless catch- ing cold. 0 Winds, damp, being near the sea, eating hearty, drink ing port. hay. confined bowels, thun- der. oNot known, came on grad- ually, the in- tervals at first long. 0 Fatigue, indi- gestible food, a late meal, a railway jour- ney if long. Irregular, ac- cording to exciting cause. No regular period. 1, 2, 3 a.m. D i uresi s of .Considerable Often after dinner, Soon after midnight. limpid water, drowsiness. Profuse diure- sis. emphysema. No regular 4 a.m., 3 or Som etimes Great deal of interval; worse in the summer, better in the winter. No periodicity except the diurnal eve- ry morning from 2 to 4. 4 P.M. 2 to 4 A.M. headaches,! emphysema, fidgetiness,I heart weak, profnse diu-i and rather resis. dilated. Clearly no bronchitis; when he has had a little bronchial irritation he has had no asthma. 26 years. 50 years. 13 years, 12 years. Father hnd asth-ICannot stand starvation. Nitre- ma, mother and brother died of consumption. Dyspepsia, ner- vous, anxious temperament. paper better than anything. Smokes tobacco regularly, and thinks he derives advan- tage. Emetics give immedi- ate relief. Sudden emotion will give relief. Grandfather a Emetics did good when young. martyr to asth- Nitre-paper, coffee, and spirit ma,also an uncle, give relief. Ether for a time. Irritable, nervous, excitable, dys- peptic: hadrheu- matic fever. Father and sister had asthma. Smoking Btramonium the best; emetics do good ; nitre-paper does good. Nervous, anxious;,Great relief derived from smok- paternal uncle and paternal grandmother were both asth- matic. ing stramonium and tobacco mixed, from iodide of potas- sium, and tincture of stra- monium. Nitre-paper and strong coffee give slight relief. to Number. Name. Sex. Age. Appearance. Occupation. Residence, *3 . ■a g Cause. a Original cause Frequency Time past and pre- dl of disease. of of sent. CJ o a 6e a 0 Provocatives of attacks. attacks. attack. 70. Henry C, m., set. 46. At Bou 1 ton 20 a First attack at No regular pe- 3 A.M. Stout, eyes injected outskirts till years. Southport, sup- nod; as bad and watery. four years posed owing to summer as Cotton-spinner. ago. since which near Bolton; if anything, rather worse since. sea air. 0 Exposure, fa-tigue, indiges-tion, eating late, excite-ment, stoop-ing, exertion, sulphur fumes. winter. 71. J. E. C, m., set. 19. Caught at 7 o Rheumatic fe-No regularity; 2 or 3 a.m. Tolerably healthy. Brighton! years. ver, with cold. lately every Gentleman. after rheu-matic fever. At Lausanne much better; always has it travelling; always has it in London. 0 Eating a sup-per, a late din-ner sometimes, certain articles of diet, cold taking, going ton stable, trees. fortnight. 72. A. C, m., set. 17. Rotting dean. 9 a Not in the least No regular pe- 2 or 3 a.m. Healthy appearance. where it years. known. riod. Military Student. commenced; Streat h a m, not well; Wimbledon . very often bad : Sand-hurst, better; South Ken-s i n g t o n. much the same. 0 Indigestion, a late dinner, certain articles of die t, cold taking, worms. Unmixed T3 a Premoni-tory symptoms. or complicated with other lung & .u 60 d a is O Associated diseases and family history. Effects of Remedies. diseases. D r o w s i ness over night. 26 years. Indigestion; slight rheumatism. Mother asthmatic before she was married. co, and emetics, some good; chloroform temporary; eme-tics, good. Strong brandy and water, great good. Chlor-odyne and lobelia, great good. Nitre-paper, some; coffee, none. Unusual viva-city of spirits Resp. m ur-innr feeble on left side, with a little hyper-resonance. Heart sound, no dry or moist sounds. 12 years. Slight indigestion. Brother distinct asthma. Great relief from nitre-papers; some from smoking stramo-nium, Paris's cigars, cigars d'Espic, and from coffee, and the air of Rottingdean. Other remedies not tried. None, 8 years. Not nervous; a lit-tle indigestion; worms. Aunt a doubtful asthmatic. Nitre-paper does good, stramo-nium-smoking none. Other remedies not tried. to 00 73. J. C, m.. set. 80. A remarkably healthy-looking old man. Country Gentleman, 74. Walter C, m., set. 30. Thin, otherwise not looking ill. Farmer 75. Jane C, f., 33t. 30. Thin, round-shoul- dered. Shirtmaker. 76. Helen C, f., set. 30. Round-shouldered, stooping, dusky, thin. Married. Cromore,in the north of Ire- land ; an ex- posed but not cold situ- ation. Asth- ma much mitigated on coming to London, and Boon lost. Hartlcbury in Worces t e r shire till r when itcame on. Then at school near H agley, where he never had an attack. In Soho ever since she had the com plaint. When in the hospi- tal perfectly well for 10 days and nights. 78 a Bronchitis. Every night years. 0 Cold, worry, now for five sleep. weeks. every day. Mon 5 a Unknown, had Formerly years, eczema very; regular, now badly foryears. 0 Cold catching; worse in win- ter, free in summer. Food if asthma is threatening. 27 la Cold in chest. Asevereattack years. 0 Any violent ex- ertion, especi- ally of the arms. Always bad in hot wea- ther. Very sound sleep. Formerly at monthly peri- ods. London, when the bronchi- tis came on: the Isle of Wight when the asthma appeared. Torquay two years ; Yelmpton 2 years. 23 years, a Acute bronchi- tis. 0Food after 8; anything un- wholesome: cold catching; smell of paint: closeness, as in a railway car- riage. every fort- night. A slight one every third morning. No period. About 1 A.M. Sometimes by day. 4 A.M. 1 A.M. after sleep. Looks sallow in the face and dark and puffed under the eyes,very nervous. Slight bronchi- tis. No em- physema. No expectora- tion. No ab- normal sounds. Heart beats J inch too low. A feeling of No bronchitis. swelling in Very little em- t h e throat physema. for two days| before. Not had that since she smoked. Feeling of re- laxed throat. Bronchial sounds; a little emphy- sema. For- merly yellow expe c t o r a- tion; lately none. 2 years. 25 years. 3 years, 7 years. Family history re-Xobelia did good; ammonia, markably good, ether, and camphor did good. Every organ in Whiskey did good. Straino- his body sound. nium-smoking gave great re- lief. Dyspeptic ; n e r - Hot tea gives relief, and cer- vous; hay fever ;i tain airs completely cure. Father had hay fe Ipecacuanha, as an emetic, ver, but not true coffee, and nitre-papers do no asthma. good. Other remedies not tried. Very nervous. Fal.her'B family asthmatic. Dreadfully ner- vous, and neu- ralgic. Father gouty. Stramonium-smoking always cures. Hot gin-and-water gives temporary relief, ns also emetics. Other remedies not tried. Ammonia inhaled will cure di- rectly. Sulphuric ether; in- haling lobelia, stramonium, and hyoscyamus, and smok- ing datura tiitula, do gre;it good. Smoking stramonium, emetics, coffee, lobelia, iodide of potassium, and nitre-pa- pers, worthless. to CO ^ . Cause. a Original cause of disease. Unmixed 73 Number. Name. Sex. Age. Appearance. Occupation. Residence, past and pre- d 5 Frequency of Time of Premoni-tory or complicated with other lung diseases. d d a Si O Associated diseases and family Effects of Remedies. sent. ., in., set. 67. Thin. Merchant. Came on at 12 M o s e 1 e y ;! years. well at Lea-! m i n gton,| some places can't sleep a night. supper, dust, smoke, foggy mornings, east wind. Worse cvery'No special autumn. In time. November daily. a Anxiety o f Double period- mind 0 Errors in diet, damp, cold. lcity; every night for 2 or 3 months, then a re- spite. 85. John C. E.. m., set. 54. High-shouldered, bron chitic face. Gentleman, River Plate when the asthma com- menced. Since that at Liverpool. In travelling never sub- j ect to at- tacks. a Apparently No regular pe- living in a: riodicity. damp situation e n d i n g in a constant cold. 0 Laughing, dust, smoke, p articular kinds of air. 3 a.m. regu- larly. 4 a.m. 25 years. 44 years, ing to cause, a Catching cold No regular pe- from sleeping: riod; accord- in a damp bed. 0 Indigesti on, eating supper, sleeping in a small room, feather bed, fog, smoke, damp, confined bowels. a Repeated at-Every mornin; tacksof inthun-! after risin; mation of the from bed. lungs. 0 Catching cold, iver-cxertion. From 1 to 4 A little tight- ness over night. 8 a.m. Mere sense of suffocation. Bronchitis and cmph\ sem a both largely developed; heart's beat in scrobicu- lus. Slight hyper- trophy of the heart; heart action irreg- ular, not in- termittent. No other dis- ease what- ever, Nothing stated A good deal of bronchitis; profqse pu- rulent morn- ing expecto- ration. 17 years. 1 year. 42 years. 10 years, Of nervous tem- Stramonium-smoking and nitro- peramcnt,suffers a good deal from indigestion ; fa- ther had asthma. papers very beneficial. A mixture containing lobelia, henbane, chloric ether, ami squills no good. London air no good. Irritable ; family Coffee and hot stimulants give long-lived. relief. Smoking stramonium hardly any. Other remedies not tried. Slightly nervous. Family healthy, Dyspepsia. Not nervous. Mother and brother asth- matic. Lobelia gives relief. Hot strong coffee and emetics, worthless. Other remedies not tried. Chamica (a South American plant) always cures at once. Nitre paper, and hot strong coffee slightly relieve. Stra- monium no good. Other remedies not tried. Smoking tobacco and stramo- niums gives relief. The air of Reading cures. Other re- medies not tried. LO Number. Name. Sex. Age. Appearance. Occupation. 86. Anne E., f., act. 50 Congested, dusky, eyes watery. Gentlewoman, 87. W. H. E., m., set. 41. Wine Merchant. James G. F., m., set. 47. Thin to emaciation, asthmatic physique to a remarkable ex- tent. Clergyman. Residence, past and pre- sent. q> a 6o a The neigh- 18 borhood of years, Barnsbury; has been laid up at most places; no place agrees so well as London. Five miles 34 from Ply-' years. mouth for, the last five years, pre- vious to that in Plymouth Pyrenees in I860; worse and worse. At Nice nearly died; in Wales bad, at Hod- desdon not an hour well. London agrees. 35 years. Cause. a Original cause of disease. 0 Provocatives of attacks. a Severe cold falling on the chest. 0 Dust.efipecially woolly dust, taking cold, damp, change of air, certain articles of dieD, nuts and al- monds ; exer- tion. a Liable to croup, bronchitis, and throat affec tion from childhood. 0 C o 1 d, east wind, indiges- tion, dry celd weather. Frequency of attacks. a Oppressive night at Tor- quay. 0 Cold, damp, exertion, ex- citement, any error in diet, particular airs, gas escape. camphor, con- stipation,heat, thunder. No regular pe- riod. On going to Depression of No periodicity. Rare in sum- in e r, fre- quent in winter. Time of attack. Premoni- tory symptoms. bed; some- times 5 A.M. 2-3 A.M. spirits, some- times hyste- rical hilarity complicated with other lung 32 years, Bronchitis, but 7 injury to lung! years, very slight; patches of emphysema; heart remark- ably weak. No periodicity, 4)£-5 a.m. at Feeling of in-E vidently a except diur- nal, first, al- ways 10 minutes after 2 digestion after dinner, 12 great deal years of emphyse- maand bron chitis. Associated diseases and family history. Nervous tempera- ment. Grandfa- ther and brother gouty. Highly nervous, hysterical, flatu- lent, dyspeptic. Weak heart and dyspepsia inher- ited. Gout at 16 and 17 nervous, highly sensitive. Several aunts on both sides, nephew, and cousin asthma- tic. Effects of Remedies. Tobacco-smoking, chloric ether, inhaling chloroform, blue pill and hot spirits, do good ; stramonium, coffee, cigars d'Espic, cigars de Joy, nitre- paper and starvation none. Datura tatula gives immense relief, as also hot strong coffee. Tobacco inoperative. Other remedies not tried. Datura tatula the best remedy; strong coffee always relieves. Stramonium, cigars d'Espic and nitre-papers do some good. Chloroform aggravates. to Of to 89. Elizabeth F„ f., set. 42. Emaciated, tall, pale. Formerly a t 40 a Chronic cough Formerly once Usually Sense -of pros- Partial emphy- 2 Facial and cranial Inhaling chloroform, and stra- Mill Hill, years. of six months' a month, lat- early in tration ; gen- sema of both years. neuralgia, and monium-smoking give relief. Gentlewoman. Hendon; lat standing, fol- terly once in the morn- eral feeling lungs. occasional neu-: Valerianate of zinc and oui- terly in Up- lowed by bron- two months. ing. of malaise. ralgic pain in the nine benefit. per Seymour chitis. knees. street, where 3 Catarrh and she has im dyspepsia. 90. proved. E. F., 1, at. 26. Near Epsom 10 a Unknown, but No distinct pe- From 1 to 3 None. A little passive 16 Nervous. Father's Datura tatula does great good. Rather fat, no asth- till 17: no years. before 10 riod. A.M. conges t i v e' years. family very asth- Nitre-paper, lobelia, and star- matic physique, a lit- asthma there. breath was bronchit i s; matic. vation seem useless. Tobacco- tle dusky. always if short, had chronic ex- smoking inoperative from Occupation anxious. away. Free in London two years; since whooping cough badly at 4. pectorati o n by day for 2 years. habitual use. 91. reappeared. 0 Special airs. W. F. G.. m., set. 40. Came on at 16 a Not known. Three or four After 12 p.m. Dryness about Perfect chest. 24 Suffers from indi- Nitre-papers, certain airs, and Perfectly healthy. Saffron Wal- years. 0 Taking cold; attacks from the eyes, years. gestion; the asth- stramonium-smoking always Granite Merchant. den; return-ed to London when it left him; none till went to Leeds 20 change of loca-lity the chief; supper, late dinner, wine, nuts, macaro-ni, and cheese. October t o March. drowsi n e s s and yawn-ing. ma increases it. relieve; smoking tobacco, oc-casionally, coffee and ipecacu-anha, slightly. Other reme-dies not tried. 92. years ago. Frances F., f., set. 57. Plymouth al- 48 a Cold falling on Worse in the N o special Violent sneez- Dry bronchial 9 Highly nervous. Nitre internally, ipecacuanha, Thin, dusky, high- ways; often years. the che6t. winter half time. ing. sounds below years. Had waterbrash. and inhaling decoction of shouldered, stooping. benefited by 0 Change of tem- of the year. and behind; in Augu st for poppy-heads give relief. Other Gentlewoman. Teignmouth and Ilfra-combe. perature, go-ing from one room to anoth-er, an east wind, fog, smoke, dust; worse after patch of em-physema at right scapula many years. remedies not tried. 93. food. F. M. F., f., aet. 34. Hampstead, 33 aBronchitis Every morn- 7 A.M. None. A little bron- 1 Very nervous. Strong coffee, and the smoke of Face dusky, eyes Downshire years. caught from ing. chitis of the year. Suffers from in- her husband's cigar relieve. watery. Hill. cold. large tubes. digestion. Nitre-papersaggravate. Other Gentlewoman. 0 Laughing, run- Father died of remedies not tried. ning, eating a asthma. supper, crowd- e d room, change of wind, fatigue. ► t-i > o a > CO to Ol 03 Number. Name. Sex. Age. Appearance. Occupation. Residence, past and pre- 43 , !§ Cause. a. Original cause of disease. Frequency of Time of Premoni-tory sent. o a 6p a <| d 0 Provocatives of attacks. attacks. attack. symptoms. 94. F. Fitz C, m., set. 34. India from 20 27 a Cold, stomach Perfectly un- Generally Depression. Appearance healthy. to 27; a good years. out of order. certain; has worse a t Gentleman. deal on the 0 Cold, cough. been free for night. 95. Fredk. F., m., set. 48. Continent. 15 months. Aintree, near 40 o Over-exertion. One attack 8 3 a.m. Pain and swell- Thin, otherwise Liverpool ; years. 0 Sudden emo- years ago. ing in the healthy-looking. stands high: tion ; after eat- Since May, eyes; profuse Solicitor. goes to Wales ing; east wind once in three diuresis o f every Satur- makes it worse weeks. limpid wa- day ; never if on. ter. 96. Jane G., f., set. 42. had it there. Lambeth near- 39 o Came home At first every 2 or 3 a.m. Headache, no- Thin, pale. ly all her life, years. hot, undressed. 3 months; thing more. Needlework. up to the pre-sent time. threw herself on the bed, and awoke with asthma. 0 Excitement, damp, cold, smoke, over- now every 2 or 3 weeks. 97. exertion. P. Gallegher, m., set. At Texas when 50 a Hardships, vi- Every morn- 2-3 A.M. None, 52. Appearance it first came years. cissitudes, and ing. healthy. on. Less dif- probably pre- Merchant. ficulty at the coast than high land of Mexico. disposition. 0 Eating supper, excitement.ex-ertion, and fa- • 98. tigue. J. G., in., tct. 39. Fkst came on 17 a Unknown. No period. 3 to 4 A.M. Drowsiness Appearance but little at Chelten- years. 0 Going to bed over night. affected ham. Lon- early, sitting Public Singer. don since, and travel-ling on en-gagements. all day in a room. Unmixed or complicated with other lung diseases. 7 years. years, 3 years. 2 years, 22 years. Associated diseases and family history. Highly nervous and dyspeptic; acne rosacea. Uncles asthma- tic. Otherwise healthy, Slight dyspepsia. Effects of Remedies. Ether, ammonia, and squills give great relief; stramonium uncertain. Other remedies not tried. Datura tatula. always cures immediately. Nitre-papers, emetics, hot strong coffee give great relief. Chloroform use- less. Other remedies not tried. No remedies have been tried in this case. Lobelia, nitre-papers, and to- bacco no use. Other reme- dies not tried. Neat rum instantly relieves; other spirits no good. Nitre- paper entirely cures. London air better than any other. to 90. M. A. G., f., aet. 47. Devonshire till 35 o Apparently Severe attacks 4 to 6 a.m. Thin, pale, worn. 20, Essex till years. Bpont a n c o u 8 from three to Gentlewoman. 27, Russia and sudden. six months. till 37: since 3 Ordinary pro- Slight at- vagrant. vocatives, as damp, sweets, Fpiced and pre-served things. tacks more frequently. 100. Capt. G., m., set. 47. Formerly 33 a Bronch itis Fir.it year one 3 or 4 a.m. Hale, florid, in good everywhere. years. from cold. a month. flesh. County Clare 8 Late full mixed then one a Military Appointment. since 1846. meal, wines, ex-citement, over-exertion, cold in the chest, fog week; es-pecially Fri-day. 101. William G., m.. set. 33. A n d o v e r . 24 a Severe bron- Formerly in 2 o'clock to a Cyanosed, quite blue, Change of years. chitis. spring and minute. eyes watery, high- place makes 0 Indigestion, summer Bhouldered. no difference peas, nuts, al- months; Architect. monds and rai-sins, fruit gen-erally, beer, taking cold. lately irreg-ular. 102. A. A. G., f., set. 33. Merton; since 21 a Unknown. Once' every 3 2-3 A.M. A little asthmatic at Bourne- years. 0 Fog, a high weeks; since figure. mouth, wind, damp, the birth of Gentlewoman. Brighton.St. Leonard's. dyspepsia. child, 16 months, no bad attack. 103. , Charles G., m., set. 34. Primrose hill. 29 a But little evi- At present 6 No constant Thin. Sou t h of years. dent, appa- a 11 a c k s in time. Cook. France. rently bron- the year, for- Fin d s no chitis. merly more. particular 0 Sometimes difference. change of place, taking cold. 104. A. H., m., set. 52. Witney till 22; 22 o Bronchitis. No regular pe- 4 p.m. 3 or Thin, round-shoul- London till years. 0 Cold, windy riod. 4 A.M. dered, asthmatic phys- 25; Witney weather, eat- iognomy. ever since. ing when the Medical. tendency is on. None. A good deal of emphysema and bron c h i a 1 con gestion. Unmixed. Certainly some bronchitis. Lungs and heart per- fectly free from disease 12 years. 14 years. 9 years, 12 years. 5 years. 80 Rheumatic: when- e v e r rheumatic no asthma. Grandmother asth- matic. Weak digestion, nervous since the attacks. Mother died at 62 of con sumption. General health good. Not in- herited. Hot strong gin-and-water an infallible remedy. Nitre-pa- per formerly gave relief, and chloroform temporarily. Nitre-papers always relieve, and if used at once prevent an at- tack. The air of England al- ways does good, especially London. Other remedies not tried. Nitre-papers relieve; hot coffee sometimes; raw gin did for- merly. Smoking stramonium, tobacco, and cigars, and in- haling chloroform worthless. Nitre-papers, Paris's cigars, emetics, and tea acting as an emetic do great good. Other remedies worthless. No indigestion. Nitre-papers slightly relieve. Not inherited. Coffee, smoking stramonium, belladonna, and tobacco no good. Other remedies not tried. Marked dyspepsia. Chloric ether and squills, a fluid H « t-i H u a drachm of each, give great relief. Stramonium and nitre- papers not tried. Other re- medies useless. to Of Number. Name. Sex. Age. Appearance. Occupation. 105. S. L. H., m., set. 45. Thin, round-Bhouldered Kept a store in Aus- tralia. 106. Elijah H.,m„ set. 68. Stout, healthy-looking. Missionary. Residence, past and pre- sent. 107. B. H., f., set. 30. Thin, pale, fair, stoop- ing and round. Gentlewoman. 108. W. P. H., m., set. 58. Tall, stout, healthy. Clergyman. Cam p b e 11 Town. 34 miles from Sy d ney. Much in China and India. Asthma came on at Isling- ton. Better in London than any- where. Asth- ma at Hast- ings, Bath, and Brigh- ton. Tunbr id ge, Clifton, Stroud, St. Leonard's, and Brigh- ton ; asthma at all, especi- ally at sea- side. Near South- a m p t o n , close to Net- ley Abbey, ever since (he attacks. ag 41 years, 36 years. 13 years. 55 years. Cause. i Original cause of disease. 0 Provocatives of attacks. a Bronchitis and cold. 0 Cold,east wind, eating late in the day, drink- i n g anything cold, any stim- ulant,einotion. a Seems to have graduallycome on as dysen- tery ; gradu- ally went off. 0 Going to a fresh air, espe- ciallyacountry air. Any indi- gestible food, east wind. a Neglected cold. 0Cold, cast wind,exertion, excitement. a Bronchitis. 0 Exposure, fa- tigue, food, the attackscoming on after dinner Frequency of attacks. Every night. No regularity. Time of attack. 3 hours after going to bed. Either even- ing or 4-5 A.M. At first every About 3 p.m. three yeais, since mar- riage once a year. No regular pe- riodicity. 2 or 3 A.M. Premoni- tory symptoms, Unmixed or complicated with other lung diseases. Emphysema 4 about the; years. lower part of! lung; bron- chitis un- doubtedly, Knows for 2 or 3 weeks before, feels weak and ill, and head- ache. A little emphy- sema. Dry sibilant rales Loss of respi- ration of left lung, except a patch about tho scapula; right side air enters freely 32 years. 17 years. 2 years and a half. Associated diseases and family history. Subject to croup when young. Grandmother and aunt asthmatic. Brother and two sisters consump- tive. Effects of Remedies. Tobacco-smoking and chloric ether relieve. Stramonium, emetics, nitre-paper, lobelia, coffee, and spirits no good. Other remedies not tried. A mixture containing sulphuric ether, Indian hemp, conium, and ipecacuanha gives great relief. Strong green tea does some good. Other remedies inoperative. Highly nervous. Lobelia and nitre-papers relieve. Habitual const! pation. Father and brother asth matic. Highly nervous and neuralgic, Datura tatula and coffee did formerly. Other remedies not tried. London air gives complete im- munity. Nitre-paper and in- haling hot steam great relief. Other remedies not tried. to 05 103. G. H. H., m., ret. 49. 1 Anywhere and 39 a Cold falling on No regular pe- 2-3 A.M. Drowsiness; Healthy-looking man. | everywhere, years. the chest. riodicity till cannot keep awake. Commercial Traveller. Sunderland, 8 Cold, damp, lately, when N e w c astle, exposure, east every night. east coast, wind; worse 3 etc. or 4 hours af-ter food. M 110. 60 d a Associated diseases and family Effects of Remedies. sent. 6o a <; d 0 Provocatives of attacks. attacks. attack. symptoms. ,a'rt o history. 114. E. H., f., set. 30. Shropshire, 23 a Apparently Slightly every 3 A.M. None. Chest perfectly 7 Not nervous but Inhaling chloroform, stramo- Fair, moderately stout, open and years. spontaneous, night; badly free from all years. animated; liable nium, cigars d'Espic, and ipe- no asthmatic physique. dry. At Tor- gradual. at irregular abnormal to colic. Father cacuanha as an emetic, give - Gentlewoman. quay twice, asthma all the time. Change, as a rule, preju-dicial. 0 Taking cold, fatigue, dust, laughing, vio-lent exertion; diet exercises no influence. intervals. sounds. rheumatic relief at the time. 30 drops of chloric ether gives great relief. Iodide of potassium cures. Other remedies worth-less. 115. B. H.. m., set. 71. England, In- 27 a None appreci- Every evening About 7 None. Physical signs, 44 Formerly a liver " Care " does good. Other reme- A fine old man, no di a, East years. able. for a week or p.m., din- those of years. complaint in In- dies worthless. asthmatic physique. Kent, and for 0 Over-exertion, two. ing at 6. health. dia. Gout every Civil Service. 23 years at Blackheath. Asthma ap-peared in In-dia. indigestion, al-ways after din-ner. Not cold. spring for 15 years. 116. MaryH , f., set. 40. Hartlepool 37 aBronchitis Once a week, From 1-3 An uncontrol- No appreciable 3 Nervous tempera- No remedies have been tried. Eyes dusky, watery, ever since years. from cold. on the same A.M. lable drowsi- morbid sign. years. ment; dyspep- and full. asthma ; at 0 The least cold, day. n e s s; fre- Respiratory sia; grandmother Gentlewoman. Whitby much worse; at Hartle-pool and London al-most well. fog, east wind, u n w holesome food,as sweets, cheese, stuff-ing. quently dys-peptic symp-toms. m u r m u r every wh ere clear. and uncle asth-matic. 117. Thos. H., m., set. a3. Licensed Victualler. Chelsea. 33 2 Datura tatula cures in five min- years. mos. utes : coffee gives great relief. Much improved under the use of iodide of prtassium. to 00 118. Louisa H., f., set. 19. Appearance healthy. Gentlewoman. 119. Mrs. H., f., set. 60. Stout, healthy-looking, Gentlewoman. 120. Charles H., m., set. 31 Appearance healthy. Merchant. 121. — H.,f.,aet. 65. Appearance healthy. Gentlewoman. 122. Mary H., f., set. 26. Appearance healthy. Governess. Came on at 5 i Can't tell. He- Every night 4 o'clock. None. 14 Excitable and ner- Nitre-paper, emetics, mustard Raynham, years. reditary. almost. The years. vous; mother and plasters, emotion, and starva- continued at 3 Hay fever, tak- severe at- grandfather tion do good; coffee and lobe- Smarden. ing cold on tacks rare. asthmatic. lia none. Others not tried. Well by sea chest, indiges- at Herne tion, supper, Bay, an d wine, meat late London. in the day. Kent, between 36 a Catching cold, No periodicity. In the even- Feeling par- 24 Rather nervous; Nitre-paper, coffee, and pills Ashford and years. but inherited. ing. ticularly years. father asthma- containing conium, Dover's Staplehurst. 3 Cold, a late din- well. Sleepy. tic, daughter so. powder, and James's powder First came ner, particular Little sore do good. Lobelia, ether, on at Hast- airs, meat-pud- throat. stramonium, cigarettes and ings. Well ding, a hay- emetics worthless. travelling. stack heating. smell of hay. New Provi- 30 a Cold on the From 2 in a Evening or None. Cough and a ^ Not inherited; fam- Inhaling chloroform relieves dence, where years. chest. week to 1 in 2-3 A.M. good deal year. ily healthy. for a time. Coffee, nitre-pa- the asthma 0 Exertion, tak- two weeks. of expecto- per, stramonium and tobacco- first came on. ing cold,damp, fog, smoke. Food makes no difference, ex-cept eating late. ration. smoking, and dieting no good. Other remedies not tried. Leeds, asthma 40 a Hereditary. No periodicity. Nothing reg- None. The ordinary 25 Nervous and dys- Gin-and-water always cures. 11 years; In- years. 0 Fog, smoke, ular. chest sounds years. peptic. Mother, Lobelia, coffee, and chloro- d i a 1 year. east wind,close of c h r o n i c sister, and two form not tried. well; Birken- hot rooms, bronchitis. uncles asthma- head 5 years, dust, damp, tic. well; India 5 any strong years, asth- scent, tobacco ma re-ap- smoke. peared. Peckham til Infan- a Hereditary. No regularity, About break- None. Evidently 25 Grandfather, fa- Coffee and emetics always re- 16; Herts cy. 0 Taking cold, worse in the fast time bronchitis years. ther, brother, sis- lieve ; nitre-papers at first; over-worked, walking quick- winter. and 8-11 from the his- ter, and uncle hot spirits for a time. Change very bud. ly, laughing, P.M. tory, but no asthmatic. of air to France always cures. France, per- talking, fog, sign of any Mother's family fectly well. smoke, lucifer, east wind. disease whatever. consumptive. fc-i b en to Number. Name. Sex. Age. Appearance. Occupation. Residence, d| Cause. a Original cause Frequency Time Premoni- past and pre- of disease. of of tory sent. « a tea <] d 0 Provocatives of attacks. attacks. attack. symptoms. 123. Chas. R. H., m., set. 48. North Riding, 37 o Cold after ill- Formerly 3 2-5A.M. Drow s i n e s s A little round-shoul- where it years. ness. weeks, now profuse din dered. came on. 0 Over-fatigue, every night. resis. Clergymen, Past 9 years near Upping-ham — high, but not dry. derangement of stomach, veal, sweets, laugh-ing, high wind, damp, fog, frost. 124. H. H., m., set. 53. Greenwich, 49 a Thinks it must Annua lly. 2-3 A.M. None. Thin; high shouldered. moved from years. be cold. worse in Tailor. one house to another, and was better. 0 Catching cold, east wind, sup-per. summer and autumn. 125. John J., m., set. 68. Travelling in 58 a Not known. Every night. Immediately None. Very stout, cyanotic. various years. 8 East wind ; ex- on lying Merchant. places. Lo-cality makes no difference ertion ; night thechiefthing, and lying down always. down. 126. George J., m., set. 33. Liverpool, its Early a Not known. Onoe in two 6 or 7 a.m., None. Very thin, sallow. neighbor- child- 3 Taking cold; months, one goes to bed Student of Medicine. hood ; Lon-don ; coun-try, and by sea; better at sea side. hood. east wind; dust; breathing stuf-fy after a full dinner. month, fort-night ; for seven months every morn-ing. at 2. Unmixed •6 a or complicated with other lung diseases. Z 60 d a Si'" is O Associated diseases and family history. Effects of Remedies. A little Iobs of respiratory murmur at right apex and left base in front. 11 years. Highly nervous; very dyspeptic. Grandfather and child asthmatic. Brandy and water always cures, coffee occasionally; tobacco-smoking only temporarily. Nitre-papers, stramonium.anil datura tatula have lost their effect. Respiratory m u r m u r patchy, scat-tered em-p h y s-e m a; hardly an y adventitious sound. 4 years. Rather timid and nervous:dyspep-tic. Mother a martyr to gout. Coffee, tobacco, iodide of potas-sium, ipeoncuanha and bella-donna, chloric ether and am-monia and counter-irritants do great good. Stramonium-smoking none. Respiration good in front and above, bad behind and below; crepita t i o n in this last: heart sounds dull. 10 years. Health otherwise good. Not inherited. Cigars d'Espic, and chlorodyne give slight relief; stramoni-um, tobacco, and cigars give none. Respiratory murmur un-equal and defective. Life-long. Mother asthmatic; father died of bronchitis. Emetics always give relief, and smoking, if it produces vom-iting or nausea. Coffee, stra-monium, nitre-paper, spirits, and lobelia no good. to o 127. Gertrude K., f., set. 8. High-shouldered and dusky. No occupation. 128. Charlotte K.,f., set. 40 Thin. Gentlewoman, 129. JamesK., m., set. 62. Stout, plethoric, round- shouldered. Pipemaker. 130. Lady L., f., set. 40. Healthy-looking. Gentlewoman. Liverpool sincel n'< her birth:! years generally better at sea- side: Wales and Scotland no good. 131. William L., m., set. 42 Rather thin and pale. Engineer. 87 years, 62 yes-rs, In v a r i o u places in England and the conti nent. Local ity makes no difference. South Stock ton, in e badly venti later! house, for the last 15 years. India for nine 28 years. Wim- years bledon, Roe- fa a m p t o n, and K ew. Occasionally i n France. Italy, and Scotland, now L o n- don. Bilboa, had it there 3 yrs.;| years. since in Eng- land ; not so bad till late- ly- a Bronchitis. 0 Any excite- ment or exer- tion; taking cold; fog, smoke, hay. a Repeated at- tacks of bron- chitis. 0 Indigestion ; cold, through bronchitis; fog andsmoke. a Not known. 0 Nervousness. a Exposure to cold driving to Edinburgh from the coun try. 0 Exposure to cold. No regular pe riod; lately every night. a Ap parently indigestion. 0 Taking cold cold leet; for- merly indiges- tion ; a late meal : sneez- ing, always. Begins in Sep- tember and goes on till May. Nightly at- tacks ; night- ly for three weeks; since, only a very Blight at- tack. Since return to England 2 or 3 times a year. 11 p.m. or A.M. Half an hour aftergoing to bed; again at 4. About 2 A.M. In the even- ing, or dur- ing the night. Until lately* 3 or 4 attacks in the year; for the last month every night. 3 a.m. Catarrh; sneezing. Slight scat tered, iln nn'd moi> bronchia sounds; in appreciabt. emphysema The physioa signs of bron chitis. State of heart not mention- ed. Accompan i e d with more or less bronchi- tis. 2% years, Evidently bronchitis: has had an attack of acute bron- chitis for the last month. None, except the bronchitis. Uncle asthmatic. Family consump- tive. Asth- Highly nervous: ma 3 I suffers from dys vears% bron- chitis 13 years. 12 years. 4 years. psia and gra- 1. No family history of asthma. Strength reduced at different times by amenorrhcea and effects of cli- mate ; slight leu- corrhcea. Nitre-papers chloric ether, and ammonia, hot wine and water, and the inhalation of carbolic acid, relieve. Chloroform no good. Nitre-paper invaluable; cigars d'Espic do great good; datura tatula but little, and emetics only temporary. A mixture containing ext. strain, and iodide of potassium, has done great good. A mixture containing tincture of opium, sulphuric ether, and compound tincture of lav- ender, cures like magic. In the early stage, relieved by chloric ether; if the attack is established, nothing relieves but continued expectoration. For the last 10 or Nitre-papers, and chloroform on 12 years very ner- sugar (m. 20) do great good ; voub. spirit, stramonium, datura Father had gout. tatula, and French cigarettes, none. This patient was cured by dieting. to Number. Name. Sex. Age. 1 t % ] Cause. Residence, ! * § a. Original cause past and pre- "S b j of disease. Frequency of Time of Appearance. sent. „ g, I 0 Provocatives attacks. attack. Occupation. he a 1 of attacks. 132. London in 39 a Bronchitis. Every night. 4 P.M. and S. L., f.. set. 48. winter and! years. 0 G o i n g up on going to Stout, florid. coast in sum- stairs, close bed. Gentlewoman. mer ; Lon- room, smoke, don agrees! fog, cold, damp better than air. the country. 133. Stephen L., m., set. 36. St. Giles', 32 a An attack of Every Sunday, 2 p.m. High-shouldered, thin, Crown St., years. bilious fever; after dinner. round-backed. where he has came on grad- Printer. lived for many years. ually. 0 Cold, heavy supper, un-whole some food. 134. Israel H. L., m., set. 70. 'Hampstead to 36 a Unknown. Irregular; less After dinner Very thin, asthmatic 15; Norfolk, years. 0 Nothing but frequent for- and 2 to 3 figure. 17; America, food, sweets, merly. A.M. Gentleman. 28; Norfolk, 33; Kent, till now. late dinners, malt liquor, made dishes. 135. Thomas L., m., set. 40. Buckhurst 3] 'a Catarrh on the'No true perio- From 12 to 4. Thin, tolerably mus- Hill, bad; vears chest. y 0 Smell of lin- dicity. cular, sallow. Can^nbury, Tea Inspector. better; Micklesham, always bad, can't stop a day. seed; the le:ist exertion, ex-citement, fa-tigue, east wind, heavy food, hay. Unmixed 13 a Premoni-tory symptoms. or complicated with other lung * S Si o Associated diseases and family history. Effects of Remedies. diseases. None. Bronchitis. 9 years. Highly nervous. Dyspepsia; gout. Coffee and counter-irritants re-lieved ; other remedies not tried. None. A good deal of bronchitis. 4 years. Health in other respects good. No inheritance. Completely cured by leaving off meat at dinner. None. N o complica-tion, except bronchial congest ion. In Amer i c a all spitting ceased. 34 years. • Maternal grand-father and aunt asthmatic. Son shows a ten-dency. Nitre-paper, and a mixture con-taining iodide of potassium, antimonial wine, and tincture of henbane, give great relief. None, Very little em-physema with bronchial sounds at low-er part of right lung be-hind. 9 years, but ten-dency al-ways. Nervous; lately suffered a good deal from indi-gestion. Emetics, stramonium, nitre-pa-per, datura tatula, and a mix-ture of lobelia, ether, and cainphoralwaysrelieve. Other remedies not tried. to Oi LO Isabella M. M., f., set. Came on in1 S5 a. Bronchitis. No regularity. On getting 26. London. years. 3 Cold air. vio- u p gener- Healthy, not thin. Then in Ayr- lent exert io >, a 11 y, but Genilewonian. shire, then back to town; cold in park, came back. a hot room, taking cold, fog, food, laughing, mo-mentary appli-cation of cold. irregular. 137. Jane M., f., set. 50. Dumfries till 48 a Chronic bron- Every morn- 3 to 5. Usu- Very fair, yellow hair. 23. Liver- years. chitis suddenly ing for 18 ally 3 to 4. Gentlewoman, pool since. aggravated. 0 Cold the chief; excitement, ex-ertion, crying, laughing. months. 138. Rev. J. M., m., set. 39. Till 12, near 32 a Cold. Slight attacks 1 A.M. Aspect healthy. Liverpool. years. 0 Cold; nothing whenever he Clergyman. Since then a wanderer. A severe attack at South-port; anoth-er at Guil-ford. else. takes a se-vere cold. 139. William M., m., set. 5S. Near the 44 a Cold on the Formerly, sev- 2 to 3 A.M. Very stout, dusky, Thames, years. chest. eral months bloated, eyes very Westminster 0 Any great apart; worse prominent. when itcame emotion, east every winter Solicitor's Clerk. on. Always lived at Pim-lico. wind, damp, fog, catching cold. 140. George M., m.. 83t. 38. Gravesend, 37 a Cold on the Every night. 3 a.m.; used l'ale, emaciated, when the at- years. chest. to be 12. round-shouldered. tacks came 0 Catching cold, Groom. on; the last 3 months at Stockwell, better. fog, damp, sup-per, too large a meal. None. None. Uneasiness in epigastrium, and drowsi- ness. None. Bronchitis Breathing clear and dry. Slight bron chitis. C o m p 1 i cated with chronic bronchitis; crepitation about the lower part of both lungs behind. 1 year. Bron chitis 20 years Asth- ma 2 years, 7 years. 14 years. Very nervous. Mother, brother, aunts, and uncle asthmatic. Nervous tempera ment; brother asthmatic, died; sister, son, and two paternal aunts. Highly nervous. Asthma not inheri- ted. Indian hemp and linseed-poul- tices to the chest do good. Other remedies not tried. Chloroform gives perfect relief; stramonium, nitre-paper, to- bacco, and extract of stramo- nium for a time. Sulphuric ether, the only thing tried, has always succeeded. Nervous tempera- ment, gouty. Mother, aunt and grandmother asthmatic. Otherwise healthy. No inheritance. Chlorodyne and hot tea give great relief; chloric ether and tobacco-smoking, some. Stra- monium and nitre-paper no good. Pot. iod. very benefi- cial. Perfectly cured by London air (Charing Cross Hospital). Extract of stramonium at night quite successful. to 03 43 . Cause. a Original cause Unmixed •i a Number. Name. Sex. Age. Appearance. Occupation. Residence, 53 a d Frequency Time Premoni- or complicated with other lung diseases. | m Associated past and pre- d ™ of disease. of of tory ■S 5P diseases and family Effects of Remedies. sent. a) a 6o a t. 12. came on. 2. years. off flannel. but in winter bronc h i t i s, years. ment; no dyspep- emetics give a little relief; Thin, high-shouldered. Blackheath, 0 Catching cold. 2or3 months some emphy- sia,but imperfect nitre-paper, lobelia, coffee, Schoolboy. better. 3. Scotland, still better. 4. Hastings, any anxiety. over - exertion, damp air, worse in hot without at-tack. sema. teeth. and spirits none. Others not tried. 150. well. weather. Georgina O., f., set. 44. Formerly Jer- 20 a Damp. No regular pe- 3 or 4 a.m. Depression of SUght, scatter- 25 Father had asth- Datura tatula and coffee do Thin, pale. sey coast, years. 0 Cold,east wind, riod. spirits. ed dry sounds; years. ma, and a neph- good; nitre-paper, stramoni- Gentlewoman. very bad. Then 7 years in Jersey country, well. One year P i m - smoke, over-exertion. crep. below;! respiratory^ murmur un-equal. Cough great;expecto-ration profuse ew has it. um, cigars d'Espic, chloric ether,ipecacuanha.and squills none. Others not tried. 151. lico, bad. I C. 0., m., set. 48. Kennington. Child- a Not known. Very uncer- Uncertain. None marked; Compl t c a t e d Near- Not hereditary. Extract of stramonium and High-shouldered, hood. 0 Damp, cold, tain ; in sum- perhaps oc- with bronchi- ly the squills give most relief; chlo- dusky, eyes congested certain locali- mer frequent- casion al 1 y tis. whole rodyne did for a time. and watery. ties—Hampton ly from abdominal of life. Medical. Court, D e n -mark Hill. The smell of rabbits draughtsand vegetables. dist e n t i o n after food. to OS at Number. Name. Sex. Age. Appearance. Occupation. Residence, past and pie-Bent. « a si o

a 0 a to OS -1 Number. Name. Sex. Age. Appearance. Occupation. Residence. d Cause. a Original cause Frequency Time Premoni- Unmixed or complicated with other lung •a a d Associated • past and pre-sent. d d o a 6c a of disease. 0 Provocatives o£ attacks. of attacks. of attack. tory symptoms. -ia 6J0 d a Si'" diseases and family history. Effects of Remedies. < d diseases. O 163. W. H. R.. m.. set. 40. Birmingham About a Bronchitis No regular pe- 3 a.m. None, except The lower half; From Grandfather had Nitre-paper never fails to cure Round-shouldered, to 3, Hast- 6 when young. riod. From dyspeptic of right lung' child- chronic bronchi- in a quarter of an hour. Port rather thin, but healthy ings 15, Sit- years. 0 Cold, * eating 2 months to distention. emphysema- hcod. tis. wine (no other wine) will euro looking. tingbo u r n e green vegeta- 3 or 4 days. tous, and in ten minutes. Medical Country Life. 18, London 22, Yealmp- bles, mental excitement, an base of the left behind. 164. ton 40. apple or pear. F. R.',t. Born in West 14 o Unknown. Variable, Uncertain; Flushing of Freq u e n t at- Neuralgic pains in Smoking stramonium an infal- Thin, but not narrow- Indies. Den- years. 0 Special airs. worse at one cheek in tacks of tra- back of head and lible remedy. chested. mark in ear- Summer heat. night. particular. cheitis and incapacity to Studiou.s Sedentary lychildhood; bronchitis. draw a full Habits. lately Paris and London. breath, but no spasmodic action 165. of lungs. Robt. R., ni„ set. 36. Newcastle till 15 a BronchitiR. Ana3stival pe- From 2 till 5 Nothing but Physical signs 21 Nothing specially;London air cured 17 years ago. Thin, high-shouldered, 6, Wisbeach years. 0 Food, sleep af- riodicity A.M. Same drowsiness. not stated. years. wrong with the' Sudden'emotion stops it in a asthmatic stoop. till 17, then ter food, worry. every sum- P.M. general health. moment. Tobacco ad nau- Sedentary Occupation. he began to east wind. mer; from Not inherited. seam instantly cures; nitre- suffer. Lon- over-exertion. autumn to paper in a quarter of an hour. don since. spring well. 166. R. R., m., 33t. 62. Cambridge. 45 a A series of bad Commences in Night after Chilliness in Emphysema, 17 Father slightly Putting feet in hot water and Thin and worn. years. colds. spring and 3 or 4 hours back, low- and occa- years. asthmatic. mustard, plaster to back or Gentleman. 0 Error in diet, damp, night air, sud <1 en change of tem- lists through summer, subsiding in autumn. sleep. ness of spi-rits, slight headache. sional at-tacks of bronchitis aggravating chegt wards off an attack. Stramonium relieves slightly. 167. AmyR., f., ast. 22. perature. the attack. Rutland Gate 8 a Cold, and what In summer Generally at Seldom any A s 1 i g h t a- 14 Mother's familv Chloroform and belladonna give Tall, moderately stout, and Penn, years. was called in- o nee i n 3 night. other than mount of years. prone to bronchi- most relief; emetics and stra- fair, yellow hair. Bucks. Lon- flammation of weeks; in some tight- emphysema tis: one maternal inonium slight. Gentlewoman. don agrees, lungs. winter every ness of the and bron- uncle had asth- Penn very 8 Cold, indiges- 10 days. chest. chitis. ma up to 15 years much disa- tion, excite- of age. grees. ment, fatigue. to cs OC 168. W. H. R.. m., set. 47. Chief part of Short, stout, dusky, Congested. Manager "f a Railicay at Ba/ua. 169. Thomas R., in., set. 35. Pale, not otherwise peculiar. Journeyman Baker, 170. Albert S., m., set. 26. Thin, eyes injected and watery, a little dusky. Broker {Indian). 171. E. A. S.. m., set. 73. Thin, round - shoulder- ed, stooping, dusky. Army. 172. David S., m., set. 39. Pale, high-shouldered, Clergyman. life in Bra- zil, where asthma ap- p e a r e d . Worse since reaching Lisbon. London 17 years. Sleep ing at Ber wick street for the last five. 15 months asthma a t C alcutta. Voyage home better. Ham pstead suffers dreadfully. C « fl m opolite; came on in Canada while ex- posed in making a survey. England, bron chitis; India, 4 yrs. well; then asthma ever since 46 \a Catching a vio- years.| lent cold. 0 Anything dis- agreeing with stomach ; ex- c i t e m e n t; bowels con- fined ; wine and ale, 30 years, 25 years, a Repeated cold on chest. 0 Food, malt liquor, damp, smoke, sul- phur, bad smells. a Cold caught in India. 0 Over-exertion, wheezy after food, the later the worse smoke. 24 About two a month, but exciting cause at any time. Generally on Monday mornings. 2% to 8 or 4 A.M. Every night. with rare ex- ceptions. a Exposure and No regular pe- years. I hardship. 0 Taking cold, anxiety and mental excite- ment. 33 years, riodicity now every night and af ternoon. a Bronchitis. At first nightly 0 Mental worry, j for a month a hearty laugh, I then 2 or 3 food almost al-! months with ways, but di?i-\ out. ing out, never.] Hi p.m. and on getting up. hours after going to bed. 2 a.m. The signs of semi-chronic bronchitis. Physical signs not stated. Defective res- piratory mur- mur at right front, and left base behind. Distinct, but Nothing stat- indescribable. ed. Physical signs of bronchitis. It) mos. 5 years. 18 mos, 49 years. 5^ years, Excitable tempera- Stramonium always gives im- ment; indiges- tion, very bad Father has asth ma, and two bro thern also. mediate and complete relief: coffee, chlorodyne, and pur- gatives considerable. Mother asthmatic. Stramonium and nitre-paper give relief. Other remedies not tried. Has become ner- Hot spirits and stramonium cig- vous; has had great excitement in business. Sec- ondary syphilis at the present time. arettes do great good; tobac- co-smoking some; morphia, stramonium pills, and chloric ether none. Indigestion. High- Emetics give complete relief; ly nervous. Fa-j lobelia, coffee, datura tatula, ther lost asthma! and extract of stramonium at 70, and died at some good ; iodide of potas- 80. sium gi eat good. Not timidly ner-Violent emotion acts like a vous, but mobile charm; sudden shock of cold and excitable, water the same. An emetic Brother and mo- (ammonia) always gives re- ther's sister died lief ; chloroform, coffee, and of consumption. nitre-paper did formerly. > Hi H 0 > to Oi Number. Name. Sex. Age. Appearance. Occupation. Residence, past and pre- d d Cause. a Original cause of disease. Frequency . of Time of Premoni-tory Unmixed or complicated with other lung diseases. a 1 Z 60 d a Associated diseases and family Effects of Remedies. sent. p a 6o a tf Consumption on Emetics of great service. Com- A thin, high-shoul- stead to o : years. the head (?). ger, now a going to citement. and thick- years. mother's side. pressed air bath no good. dered, round-backed since chiefly 3 Emotion, cold, week. bed. sneezing.and ening of No inheritance boy. at Brighton. going in open redness of bronchial of asthma. "Lessons." This summer air, food late, eyelids. tubes. 178. G. S., m., set. 60. wandering. wet weather. Always in St. Giles'parish. 54 years. a Apparently-spontaneous. No periodicity. Evening. Never a- None. 6 years. A little excitable. Flatulent. Stramonium and tobacco re-lieve. Other remedies not No at-thmatic physique. Never had a 8 Exci t e m e n t, woke at Father had asth- tried. Medical. severe attack in the coun-try- over-exertion, easterly wind, fog, smoke. sleep after night. ma. 179. . food. E. S., f., set. 22. Asthma first 17 aWhooping According to No time. Irritation in No other lung 5 Five paternal aunts Effect of remedies not known. > el ► W u Well formed and not at Scarbro'. years. cough at 15, no weather. No Depending the throat, disease; good years. died of consump- thin. Locality no doubt. periodicity. on cause. and a ten- respirat ion. tion, 2 maternal Gentlewoman. difference. 0 Laughing, ex- dency to No dry or aunts and moth- ertion, smoke, cough. moist sounds er bronchitic. damp, a fit of 180. coughing. Alice S., f., set. 21. A valley near 16 a Protracted cold At first 2 mos., 4 or 5 a.m. Hea d ac he, Lungs per- 5 Not inherited. Hot spirit relieves in ten min- Nothing particular. Chepstow. years. on the chest. then 1—fort- languor, and fectly sound, years. Nothing particu- utes; turpentine externally; Gentlewoman. Always bad 0 Damp, cold, tak- night, week, depression. h ardly a lar. All her fam- ether, datura tatula, and o there. De- ing food late, 2 days. trace of moist ily with slight emetics relieve slightly ; nitre- > von, Corn- walking fast, sound. tendency to colds paper, coffee, and tobacco no CO wall, and close rooms. on the chest. good. « elsewhere * Cfi 181. free. * Julia S., f., m., rot. 30. Four years at 26 a Cold on the Every night, 4 A.M. None. Spits abun- 4 or 5 Apprehensive. No Chloroform, nitre-paper, and Slightly dusky. Brick lane, years, chest. 6 hours after dantly. Em- years. other disease. opium did good for a time; No Occupation. S p italfields, where the asthma has 0 Hurrying, over-exertion, a fog-gy day, smoke, being in bed. physema in both apices. No basal cre- Father died at 58 of bronchitis. chloric ether, chloroform, stramonium, nitre-paper, and iodide of potassium none. 182. William S., m., ret. 55. come on. cold air. pitation. London, south 40 aUnknown, No rule. No rule. None. Emphysema 15 Not nervous or dys- No remedies seem to have been Rather stout, healthy- side. Better years. thinks inheri- When ex- at front years. peptic. tried. looking. at Hastings. ted. e r t i n g bases. Bron- Mother bronchitic. Literary Agent of 0 Exertion, and himself. chial sounds Newspapers. exertion alone; never when still. everywhere. to Number. Name. Sex. Age. Appearance. Occupation. Residence, past and pre- £g « a ^ d "2 ** d d Cause. a Original cause of disease. Frequency of Time of Premoni-tory Unmixed or complicated with other lung diseases. * a d Z £ d a Associated diseases and family Effects of Remedies. sent. e « a 6e a <; d 0 Provocatives of attacks. attacks. attack. symptoms. J3"* o history. 183. Robert S., m., set. 5. Vauxhall, 4 a Unknown, pro- About once in Soon af ter N o n e but Physical signs 1 "Squamous." Emetics always give relief. Healthy-looking. where it years. bably cold. 3 weeks. he goes to sneezing. not stated. year. Grandfather and Other remedies not tried. No Occupation. came on. Chatham hotter: Ports-mouth two attacks. 0 Taking cold, cold weather. bed. great grandfather had asthma. , 184. M. B. S., m., set. 33. Came on at 12 a Cold. No regular pe- 4 or 5 A.M. None Emphysema 21 Rather nervous. A strong glass of hot whiskey A fine man, a little Harrow; yearB. 0 Cold taking, riod. at lower years. All his family are and water, Bmoking three or dusky. worse at the windy day, any margins; gouty. four pipes of strong tobacco, Barrister. Temple. Ventnor, Egypt, Spain better. violent exer-tion, hot close room, church, cold air after warm. no mo i s t sounds, hardly any dry. Strong black coffee, starva-tion, and emetics always do good. 185. Fred. S , m., set. 55. F a r e h a m , 49 a Exposure to 4 to 7 in 24 12 to 4 p.m. Fulness of Very little lung 6 " Frightfully ner- Hot spirit the only remedy. Pale, emaciated. Tichfield, and years. . wet. hours. 8 to 8a.M. chest; mischief. A years. vous." Undoubt- Every other remedy tried and Farmer. London — all alike. Dork-ing, could not live. 0 Nervous ex-citement; a full meal; certain food ; confined bowels. " weight of phlegm ; " cough. little crepi-tation at bases. ed evidences of gout. failed. 186. William S., m.. set. 49. Better in Edin- 28 aThc air of Formerly rare, 4 a.m. None. Patchy em- 21 Slight depression An ipecacuanha emetic relieves No asthmatic burgh than years. Rothsay. now almost physema at; years. | lately. in ten minutes; nitre-paper, physique. neighbor- 0 Particular lo- abiding. apices, right! Not inherited. coffee, and chloroform always Actuary. hood. Gen- calities; change base behind, do some good. Stram., pot. erally well in in weather; in- arid left in iod., lobelia, none. London ; al- digestion ; east front. ways in Glas- winds; damp; gow. fog. to to 187. ---S., m., set. 52. Thin, stooping. ABthmatic physique. Country Gentleman. 188. M S. C. S., t, set. 4.^. CO Fair ; dry epidermis. Occasionally dusky. Young Lady. 189. Robert S., m., set. 46. Asthmatic physique. No Occupation. 190. Phillis T., f., set. 44. Bhort, stout, florid. Charwoman. London and Cornwall. Game on re- cently in the latter. Wemys Bay, Renfrew- shire. Better at Bourne- mouth and Men tone. At Dundee. when it came on. Nauen- aer, Brun- fells, Aix, no difference. Southend. Croydon for 24 years. 191. James T,, m., set. 5. Thin, pale. No asthmatic physique No Occupation. 192. T. C. T., m., set. 29. No special asthmatic appearance. Lessee of Coal Mines. Milton Hall, Cumberland, near Carlisle, Rather high ground,coid. Milton Hall, Cumberland, always ill; well e 1 s e- where, espe- cially London 52 years. 2K years. 41 years 43 years. IK year. 24 years. a Cold on the 3 in 24 hours, chest. Evident- ly bronchitis. 0 Food and sleep. a Cold. 0Doubtf ul. Bowels, not clear. Cold, certainly. Diet, not clear. o Cold falling on the chest. 0 Food; wind speaking some- times. Sleep at any time. aSupper of meat, onions, and hard beer. 0 The attack has lasted from the commence ment. a Apparently spontaneous. 0 Residence at home. Meat supper; taking cold; indiges- tion; exposure; damp; east wind. a Cold on the chest. 0 Late dinner; dust from hay; cheese, nuts, etc. Cold tak- ing. Not missed a day About once in 3 months 4or 5 every day for five years, except three weeks after Nauenaer. The illnessmay be said to be one attack. Formerly once a month; frequently on Saturday and Sunday Every fort- night or*3 weeks. Gen- erally worse Sunday nights. 7p.m. 2 a.m. 7 A.JI. 3 or 4 a.m. 3 p.m. 9 p.m. and through the night. 4 A.M. the worst time. 3a.M. Gradual ap- proach and culmination of the asth ma. None, but the Blight com- mencem e n t of the asth ma. None. Twice has had| 10 pleurisy ; weeks weak heart, Base of right lung behind respira t o r y murmur de- fective. Nervous tempera- ment ; impaired digestion. Maternal grandfa- ther gouty. 2 Highly nervous. years. Grandfather asth- matic. Very little 5 emphysema; years, only at left base behind, No emphyse ma or bron- chitis. A little conges- tion. Yellow in face; Certainly a lit- drowsy and! tie bronchi- cross over tis; emphy- night. sema of the left lung be- low and in front. Nothing but a Nothing orga little tight- nically wrong ness across with the the chest. chest. 1 year. 3K years, Victim of rheuma- tic gout; suffers from dyspepsia as a result of tak- ing sedatives for asthma. Indigestion. The asth ma com- menced with 3 weeks' vomiting, Mother died of asthma at 53. 5 years. Father asthmatic. Great aunt asth matic. Nothing but dys- pepsia. Maternal aunt had asthma. Cured by iodide of potassium. Chloroform relieves, but pros^ trates. Nitre-paper the only other remedy. Ipecacuanha always does good. Other remedies not tried. Coffee gives great relief; chloro- form uncertain; stramonium- smoking, and whiskey, only temporary. All other reme- dies no good. Smoking tobacco ad nauseam, ipecacuanha, wine, and a pill of stramonium, camphor, and squill, all do good. Cured by London air; excite- ment the only thing that gives relief. Other remedies have little or no value. Newcastle air immediately cures ; hot coffee and tobacco- smoking relieve: nitre-paper of no value. IO Number. Name. Sex. Age. Appearance. Occupation. Residence, 43 . E g *a Cause. a Original cause Frequency Time past and pre- of disease. of of sent.

u d d o> a 6c a << d Cause. a Original cause of disease. 0 Provocatives of attacks. Frequency of attacks. Time of attack. Premoni-tory symptoms. Unmixed or complicated with other lung diseases. -a c d *j 60 d a Si'" O Associated diseases and family history. 215. Harry W., m., set. 4%. Thin. No Occupation. Stepney till 2. Limehouse the last two years; asth-m a only since then. 3 years. a Bronchitis. 0 Sometimes from cold, at others appa-rently desti-tute. Four in a year, no regular period. 5 A.M. Ravenous ap-petite. Physical signs not men-tioned. 1* year. Suffers from indi-gestion. Not in-herited. 216. Charles Y.. m., set. 6. Fair, red hair, healthy looking. No Occupation. Richmon d. At Bourne-mouth con-stantly bad; at Broad-stairs quite well. 3 years. a Cold on the chest. 0 Too much c.ike, fruit, over - exertion, easterly wind, taking cold. No regular pe-riod. 2 or 3 hours after going to bed. None. Nothing wrong in the physical signs of the ohest. 3 years. Inherited from his g r a n d m o ther. An uncle of hers had it. Trace of gout. 217. Y. Z.. m., ret. 49. Moderately thin, dark. Military. 218. Asthma came on in India at 33 ; since in London, B a g n o r , Scotland, Barnet. 47 years. a Unknown. 0 Cold, stomach d isturbance, imprudence in diet. Irregular ; in-tervals have become lon-ger. After first sleep, and after din-ner. Great drowsi-ness, frontal headache. A little emphy-sema. 2 years. Old liver mischief. Enlarged liver; great dyspepsia, pyloric tender-ness. A maternal aunt asthmatic. James B., m.. set. 10. Pale. fair, stooping, emaciated. No Occupation. Princes Park, L i v e r p ool. Benefited by Clifton. Any high place suits. 4 years. a After measles. 0 Colds on chest. over-fatigue, errors in diet, pastry, dust, smoke. No rule. From two a week to one a month. 10-12 p.m. None. R e s p i r a tory murmur de-fective here and there. Sibilant rhonchus 6 years. Nothing particu-lar. 219. everywhere. Gertrude M., f., ret. 9. Thin, high-shoul-dered. No Occupation. Bowrton, near Wincanton. Never away in winter. 4 years. a Bronchitis in infancy. 0 Taking cold, cold air, over-exertion,certain articles of diet. No regularity, worse in win-ter. 2-3 A.M. None. A little emphy-sema at left base behind. 5 years. Excitable. Uncle asthmatic : father's family consumptive. to GO Effects of Remedies. Ether mixture, and grayrowder and rhubarb have relieved much. Effect of other reme- dies not known. Emetics always do good ; nitre- papers slightly. Finally cured by iodide of potassium. Emetics and nitre-paper give great relief; chloric ether und stramonium, none. Nitre-paper, chloroform, stra- monium.daturatatuln. coffee, no good; London air, tobacco, abstinence, emetics, lobelia. potassium iodide, and cigar- ettes not tried. Rubbing and shampooing and striking the hands and feet give relief. Emetics, nitre- paper, coffee, starvation, chloroform, smoking, lobelia not tried. 220. Jane B., 1, set. 19. Thin. No Occupation. 221. Charles M., m„ set. 21 Thin. Undergraduate. 222. Thomas S., m., set. 25 Thin. Merchant. 223. James Y., m., set. 37. High- shouldered. Solicitor. Edinburgh. Always worse in re- laxing, and better in bracing places. St. Giles', Dorset. Al- ways bad at sea-side Better in London and Oxford. Glasgow. Lo- 7-8 4 years. 5 years. cality has no influence. Came on in E d inburgh, London al- ways agreed. Asthmatic everywhere in Scotland, years. Severe attack of bronchitis. 0 Cake, pudding with currants, veal, pork, cheese, nuts, Bupper, excite- ment. a Croup in in- fancy. 0 Cold taking, nuts, dust, smoke, over- exertion, damp muggy wea ther. a Bronchitis in childhood. 0 Cold and heavy dinner produce long attacks ; vio- lent exertion, short ones. years. o C o 1 d from damp sheets. 0 Close rooms ; anything dis- agreeing, espe- cially oatmeal, eating late, dust, fatigue. Once a fort- night. Formerly ev- ery Tuesday. No regular pe- riod. Formerly once a year, lat- terly every night. No set hour, 2-3 A.M. 3 A.M. 2-6 A.M. Cross eructa- tion of sul phuretted hydrogen. None. Sleepiness. Hilarious, al- most hysteri- cal. Emphysema at 15 bases in front, years, and apices be- hind. Cough, e x p ectorates enormously. A good deal of 16 patchy em- years. physema at apices be- hind ; occa- sional bron- chitis. Aortic systolic 17-18 bruit. Patchy years emphysema, Emphysema at left front and right back. 29 years. Nervous amenor-IEmetics, coffee, hot spirits, and rhcea; constipa-j pepsine do good ; nitre-paper, tion; heartburn.; lobelia, and cigars de Joy, Grand-aunt and none. Stramonium, datura Grandmother tatula, and tobacco not tried. asthmatic. Nervous and dys peptic. Nothing in family history. Nervous. Nothing in family history. Highly nervous. Great-uncle asth matic. Family long-liyed. Datura tatula, Paris cigars, and chloroform relieve; stra- monium, coffee, lobelia, and nitre-paper do not. Emetics, tobacco, and potassium iodide not tried. Coffee and hot spirits do some good ; stramonium, chloro- form, nitre-paper, and eme- tics, none. Datura tatula, ab- stinence, potassium iodide not tried. Coffee and nitre-paper do good ; stramonium, datura tatula, tobacco, opium, emetics, lobe- lia, chloroform, Indian hemp, none. Cigarettes, potassium iodde, abstinence not tried. h3 t> fcf <3 > H3 W O a > m w to INDEX. Abatement of spasm, time and mode 42,43 Access of paroxysm described, 36 iEstival asthma, 49, 50 ^Etiology of asthma, 70 Age at first access, 56 favors organic change, 169 its value in prognosis, 168 Airs, special, a cause of asthma, 155 Alimentary irritants, 78, 139 Alum powder, inhalation of, 166 Analysis of theories, 3 Animals, emanations of, a cause of asthma, 65, 74 Annual asthma, three varieties of, 49 periodicity, 49 Antimony, treatment by, 98, 103 Appearance during the paroxysm, 38 Asphyxia, 84 Atelectasis in asthmatics due to bronchitis, 95 its possible production by asthma, 94 its relation to pigeon-breast, 94 Atmospheric influences, their subtlety, 155 Auscultatory signs in asthma, 19, 41 Beau, M., views of, 6 Blood, its condition as a cause of asthma, 65, 78 Blood-stasis, pulmonary, 84 Bree, Dr., theory of, 4 Bronchial contraction an expiratory force (?), 11, 27 muscle, purposes of, 27 et seq. narrowing, four forms of, 19 spasm essential to asthma, 17 spasm, its relation to bronchitic irri- tation, 66, 67 Bronchitic asthma, 67 Bronchitis a frequent cause of asthma, 78, 79 commonness of bronchial spasm in, 66 diagnosis of, from asthma, 7, 17 theory of asthma, 6 Budd, Dr., views of, 10 Cannabis Indica, treatment by, 128 Capriciousness, 56, 153, 157 Cardiac asthma, 67 Cat asthma, 65 case of, 214 Cause, basis of classification, 63 Causes of asthma, 70 alimentary, 78 constitutional, 80 immediate, 70 nervous, 78 organic, 78 primary, 78 psychical, 78 respiratory, 73 I Central asthma, 23, 65 Change of air prejudicial, 157 Change of type, 55 cause of, 55 Chemical irritants, 74 Chest-distention during a paroxysm, 40 Chin, itching of, 38 Chloroform, caution respecting, 117 different results from, 115 treatment by, 115 City air, curative influence of, 144 Clinical history of asthma, 32, 47 Coffee, physiological action of, 107 theory of its efficacy, 105 treatment by, 107 Cold, modus operandi of, 71 Configuration of asthmatics, 89 Congenital asthmatic tendency, 80 Consequences of asthma, 82 on the lungs, 85 on the heart, 85 Contrariety of asthma. 153 Cough, a normal act, 27 assisted by bronchial contraction (?), 28 its prognostic value, 171 Coughing, an excitant of asthma, 72 its modus operandi, 73 Curvature of spine in asthma, 91 Datura (stramonium), treatment by, 12'3 Deformity, asthmatic, 91 De-obstruent function of bronchial muscle, 29 Depressants, indications for the choice of, 100, 103 282 INDEX. Depressants, their modus operandi, 99 treatment by, 99 Diagnosis of asthma from bronchitis, 7, 17 emphysema, 17 heart disease, 17 Dietary of asthmatics, 138 , Dietetic treatment of asthma, 135 ' Dilatation of right heart, 85, 169 Disorganization rarer in young asthmatics, 168 Distention of chest during paroxysm, 40 Diuresis, 15, 31 Diurnal periodicity, 47 its indication, 48 Drowsiness a premonitory sign, 15, 32 Dyspepsia, its relation to asthma, 135 Dyspnoea, asthmatic, 17, 37 characteristics of, 17, 40 Effluvia, animal, production of asthma by, 74 vegetable, 173 Emotion a stimulant, 112 curative influence of, 112 Emotional asthma, 65, 78 Emphysema, diagnosis of. from asthma, 17 its relation to asthma, 68, 87 Enlargement of capacity of chest, 40 Epilepsy, alternating with asthma, case of, 23 analogy of. to asthma, 32 Ether, treatment by, 12S Excitement, curative influence of, 212 Exciting cause, its prognostic value, 172 sometimes humoral, 24 Exciting causes of asthma, 70 Excito-motory asthma, 21, 65 varieties of, 65 phenomena, 105 Exercise, value of, 163 Expectoration, 43 microscopical characters, 44 prognostic value of, 171 Expiration, prolongation of, 41 Expiratory jerk peculiar to asthma, 40 Extrinsic provocatives of asthma, 73 First access, influence of age on, 56 Flatulence, 136 Floyer, Sir John, 32 Food, relation to asthma of, 137 rules with respect to, 138 Frequency of attacks, 47 prognostic value of, 170 Gairdner, Dr., views of, 7,12 Gait of asthmatics, 89 Habitude, tendency to, 52 Haemio asthma (Dr. Walshe), 4 Haemoptysis in asthma, 45 its causation, 45, 84 Hay asthma, 101 narrative case of, 173 treatment by tobacco, 101 Heart disease, diagnosis of, from asthma, 17 Heat, its modus operandi, 72 Heberden, case related by, 68 Hemp, Indian, treatment by, 128 Hereditariness, 60 Humoral asthma, 7, 24 Hygienic treatment, 163 Hysterical asthma, 49 Idiopathic asthma, 62 its essential difference from organic, 63 varieties of, 63 et seq. Immediate irritants, 73 Immunity left by attack, 51 Indian hemp, treatment by, 128 Infancy peculiarly prone to asthma, 58 Influence of sex, 59 Inhalation of compressed air, 167 of nitre-paper fumes, 11:9 of nitro-hydrochloric vapor, 166 of oxygen gas, 166 of powdered alum, 166 Inheritance of asthma, 60 Initiatory symptoms of attack, 36 Intrinsic asthma, meaning of the term, 63 varieties of, 64 et seq. provocatives of asthma, 73 Iodide of potassium, treatment by, 160 Ipecacuan asthma, 64 Ipecacuanha, treatment by, 99 Irritants, alimentary, 78 animal, 74 chemical, 73 immediate, 73 mechanical, 73 nervous, 78 psychical, 78 remote, 22 respiratory, 73 Itching of chin, 38 L/ENNEC, views of, 3, 28 Laughing, a cause of asthma, 72 its modus operandi, 72 Law of respiratory distress, 18 Length of attacks, 42 prognostic value of, 170 Lengthening of respiratory interval, 40 its indication, 40 Local influences, their potency, 141, 146 Locality, therapeutical influence of, 141 rules for the choice of, 154 Lobelia, treatment by, 126 London air peculiarly anti-asthmatic, 146 Macaulay, Mr. (Leicester), cases com- municated by, 145, 146, 149 Meals, rules for an asthmatic's, 138 et seq. INDEX. 283 Measles, a frequent cause of asthma, 56, 78 Mechanical irritants, 73 Mental emotion, curative influence of 14. 112 ' ' modus operandi oi, 112 Moist sounds, their indication, 43 Monthly periodicity, 49 Morning access, 35 Narrative cases, 173 et seq. Nervous irritability of the young, 169 nature of asthma, proof of, 13 system, extent of implication of, 22 Neuralgia, an initiatory symptom, 36 Nitre-paper, cases of cure by, 129 method of preparing, 134 treatment of asthma by, 129 Opium, objections to, 122 treatment by, 123 Organic asthma, 66 common to the old, 169 its varieties, 63, 67 Oxygen gas, inhalation of, 166 Paralysis theory of asthma, 11 Paroxysm, phenomena of, 32 Paroxysms, the causes of, 33, 48, 73 Pathology of asthma, 13-31 Peptic asthma, 24 rationale of, 24, 25 Periodicity, 15, 47 annual, 49 annual, three varieties of, 50 arbitrary, 50 diurnal, its indications, 48 monthly, often hysterical, 49 not essential to asthma, 51 varying as exciting cause, 50 weekly, its explanation, 49 Peripheral nervous irritation, 21 et seq. Phenomena of asthma, excito-motory, 21 intervals, 47 paroxysm, 32 Physiognomy, asthmatic, 90 Physiological asthma, 21 Physique of asthma, characteristic gait, 89 configuration, 91 its distinctiveness, 89 physiognomy, 90 Pigeon-chest in asthma, 93 its relation to atelectasis, 94 Pneumogastric innervation, perversion of, 21, 136 Post-expiratory rest, lost, 41 Predisposing causes of asthma, 80 Premonitory symptoms, 15, 32 Prognosis of asthma, 168 Prognosis influenced by age, 168 by cough, 171 by degree of reoovery, 170 Prognosis influenced by exciting cause, 171 by expectoration, 171 by frequency of attacks, 170 by length, 170 by organic complications, 170 by past history, 170 Prolonged expiration, 41 Provocatives of attacks, 70 Psychical irritation, 78 Reflex action favored by sleep, 105 excitability favors asthma, 106 phenomena, 105 Regiminal rules, 138 treatment, 135 Remoteness of irritant, degree of, 21 Repetitive tendency of asthma, 51 Respiratory distress, law of, 18 interval prolonged, 40 Respired irritants, 73 Rhonchus an expiratory sound, 27 Rhythm, respiratory, modified, 40 Sanguis cibi, a cause of asthma, 136 Sedatives, treatment by, 114 Sex as implying cause, 59 Sexes, relative liability to asthma, 59 Shower-bath, treatment by, 164 Sibilant rhonchus, 19, 42 Sleep favoring asthma, 105 Smells, peculiar sensitiveness of asthmatics to, 74 provocative of asthma, 74 Sneezing an excitant of asthma, 72 its modus operandi, 73 Sounds in asthma, 19, 41 their implication, 19, 42 Spasm theory, proofs of, 16 Spinal curvature in asthma, 91 its explanation, 92 Sputum of asthma, 44 Starvation during attacks, 43 Stimulants, treatment by, 105 theory of treatment by, 106 Stomach, its connection with asthma, 135 Stoop of the asthmatic, 91 Stramonium, treatment by, 123 varieties of, 125 Symptoms, initiatory, 36 premonitory, 15, 32 Tartar-emetic, treatment by, 99, 103 Temperature during attack, 37 Tendency, accumulation of, 51 to habitude, 51 Therapeutical influence of locality, 141 Thompson. Dr. Theophilus, cases by, 153 Thoracic distention during paroxysm, 40 Thunder, influence on asthma, 50 its modus operandi, 72 Time of attack, morning—why ? 33 life of first access, 56 and mode of departure of attack, 42 284 INDEX. Tobacco, treatment by, 99 as a sedative, 114 importance of its early administration, 103 modes of administration, 104 Tonics, value of, 165 Toxaemic asthma, 24, 65 Treatment, dietetic and regiminal, 135 hygienic, 163 preliminary, 97 by change of air, 141 by depressants, 98 by evacuants, 97 by galvanism, 167 by inhalation of alum powder, 166 by inhalation of oxygen gas, 166 by iodide of potassium, 160 by nitre-paper, 129 by respiration of compressed air, 167 by sedatives, 114 by shower-bath, 164 by stimulants, 105 by sustained exercise, 163 by tonics, 165 Urgency of asthmatic dyspnoea, 17, 39 its implication, 18 Urine of commencing paroxysm, 15, 36 Varieties of asthma according to age at access, 56 Varieties of asthma, 62 central, 66 excito-motory, 65 intrinsic, 63, 64 organic, 66 Vegetable effluvia, production of asthma by, 64 Vitanda, special alimentary, 139 Walshe, Dr., views of, 3, 11 Weekly periodicity, 49 Whooping-cough a frequent cause, 56, 78 Williams, Dr., views of, 28 Winter asthma, commonly bronchitic, 49 Youth a favorable element in prognosis, 168 RETURN TO NATIONAL LIBRARY OF MEDICINE BEFORE LAST DATE SHOWN NOV 27 198^5 5*^ * I I