On asthma : its pathology and treatment

Front matter

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Preface

TO

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 therapeutical effects of Chloroform, &c. I have also added some interesting 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.

14, Harley Street,

Cavendish Square,

Chapter I. Tkeliminaey Inquiry Into The Tenability 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 " Hsemic 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 h, rales vibrants" of M. Beau. — 4. The "Humoral" theory. — o. 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 dise^e . pp. 1 — 23

Chapter II. The Pathology Of Asthma. — Its Absolute Nature

Asthma essentially a nervous disease. — The phenomena of asthma immediately dependent upon spastic contraction of the organic muscle of the bronchial tubes. — Evidence derived from the dyspnoea and sovinds of asthma. — The four ways in which the bronchise 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 degrees of remoteness of irritant. — Irritant sometimes humoral ; a contaminate pulmonary blood. — Physiological argument : Spasm-theory confirmed by the purposes of the bronchial muscle in health pp. 24 — 60

X

CONTENTS.

Chapter III. 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 morning ; why ? — Description of access of paroxysm. — Appearance of the asthmatic in the height of the paroxysm. — Pulse. — Itching under the chin. — Muscular phenomena. — 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. 61—89

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 sestival 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. 90—117

Chapter V. Varieties Of Asthma

Idiopathic or uncomplicated asthma ("spasmodic"), and symptomatic or complicated asthma ("organic"). — Intrinsic asthma; ipecacuan, hay, toxLaemic asthma, &c. — Excito-motory ; peptic, organic nervous, cerebrospinal nervous, — Central asthma. — Asthma depending on bronchitis and heart-disease pp. 118—131

CHAPTER VI. THE JiTIOLOGY 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 disease; a. Organic and acquired ; /3. 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. 132—153

CONTENTS. xi CHAPTER VII.

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 ; permanent bronchial contraction. — 2. Eesults of obstructed pulmonary circulation : a. In the lungs (congestion, oedema, &c.) ; /3. In the heart (hypertrophy, dilatation) ; y. In the systemic venous system (venous stasis, oedema, &c.) — 3. Emphysema : is pure asthma capable of generating it? — 4. Acquisition of the asthmatic physique; its distinctiveness; its characteristic gait, physiognomy, and configuration ; rationale of the asthmatic spinal curvature ; pigeon-chest of young asthmatics . pp. 154 — 180

CHAPTER YIII.

TREATMENT OF THE ASTHMATIC PAROXYSM. — TREATMENT BY DEPRESSANTS.

Preliminary measures. — Ipecacuanha. Tobacco. Tartar-emetic. — Their modus operandi. — 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. 181 — 196

CHAPTER IX.

TREATMENT OF THE ASTHMATIC PAROXYSM {continued.) — TREATMENT BY STIMULANTS.

Theory of the modus operandi of stimulants. — Illustrated by coffee. — Alcohol. — Curative influence of violent emotion. — Its action analogous to that of stimulants.— Its acts also as a ''nervous derivative." — Cases . pp. 197 — 213

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 pp. 214—243

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. 244 — 254 xii

CONTENTS.

CHAPTEK XII.

DIETETIC AND REGIMINAL TREATMENT OF ASTHMA.

Facts showing the connexion 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. 255 — 267

CHAPTER XIII.

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 develope asthma. — Change of air per se prejudicial pp. 268—301

CHAPTER Xiy.

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 vapours ; of oxygen gas ; of compressed air. — Galvanism . . pp. 302 — 317

CHAPTER XY.

PROGNOSIS OF ASTHMA.

1. Indications derived from the actual condition. — The influence of age in determining 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. /. Indications derived from exciting causes — General conclusions ....... pp. 318 — 326

Appendix

(A.) Narrative Cases pp. 327—397

(B.) Tabulated Cases pp. 398—457

ON ASTHMA.

Chapter I. Preliminary Inquiry Into The Tenability Of The Theories Of Asthma

Tlieory 1. Tliat bronchial spasm is not necessarily present in asthma; Laennec's "Asthma, with puerile breathing;" Copland's "ISTervous asthma;" "Walshe's " Hjemic 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 disease.

Spasmodic asthma — paroxysmal dyspnoea of a peculiar cliaracter_, generally 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, however, 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

ANALYSIS OF THEORIES.

remain healthy and uninjured,, we may be sure either that the attacks are very mild^ so as to produce 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 because 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 suflPering ; 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 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 suffering 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 per-centage 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,

GENERAL REMARKS.

his life is marred ; and^ if lie 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 asthmatic 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 palliative. 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.

But, besides this, asthma is a disease about whose pathology more various 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 sub judice.

I think, then, I shall not be undertaking a useless task if I attempt to throw some light upon the pathology, and lay dovm some rules for the treatment, of a disease so comparatively common, so distressing, so intractable, 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 adduced 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 exclu-

B 2

ANALYSIS OF THEORIES.

sive claims of the new theory^ or if, on the other hancl_, 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 prima facie reasonableness 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 unconspicuous character of the post-mortem appearances in such cases^, or the total absence of any appreciable 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^ analyse in order^ and see if they bear investigation^ the many theories respecting it which are current^ and which have either been inherited 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 modification of the nervous

LAENNEC'S AND WALSHe's VIEWS.

influence ; tlie other^ spasmodic asthma, from a spasmodic contraction of tlie 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 distinctly 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 difficult breathing to depend upon morbid conditions of the blood which probably interfere with its ready oxygenation directly or indirectly, the breathing 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 breathlessness following over-exertion in health, is not frequent in the ratio of its apparent labour, 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 respiratory 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 • absence of the distress, of the characteristic wheeze, of the intolerance of the recumbent posture, of the evidence of deficient oxygenation, of the

ANALYSIS OF THEORIES.

repetition 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 nomenclature involves the confounding of things utterly dissimilar, and the surrender of the essential pathology of the disease. Besides, it is not in the interest of correct nosology, or rational treatment, that such errors in nomenclature should be allowed to stand.

I am perfectly familiar with this variety of dyspnoea, and have been 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 respiratory changes as would legitimately account for such deep and accelerated breathing — but that it arose from some perversion of the perceptive endowments of the resj)ii'atory 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 diabetes terminating in supj)ression 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 dyspnoea,^^ instead of " subjective dyspnoea indeed, I think it a better name, because I think it very likely that there is an objective cause

H^MIC DYSPNCEA.

for it — an imperfection, namely, in tlie respiratory changes going on in the lungs ; 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 anaemia would suspend the due oxygenation of the blood, inasmuch as it would directly diminish the agents concerned in that process ; if there were half the blood globules, for example, half the oxygenation would go on ; and we can easily understand how such arrears in the respiratory changes would give rise to instinctive respiratory efforts, with the object of reestablishing the balance. The dyspnoea 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 lungexpansion that characterises 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 Inquiry into Disordered Respiration, distinguishing the Species of Convulsive Asthma.'' He endeavours to show that the asthmatic paroxysm, and all the excessive muscular action tliat attends it^ is merely an extraordinary 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 — fa3ces of a particularly irritating character^ or a stone; that this irritating matter exists in the lungs antecedently to the attack ; and that the asthmatic paroxysm is the means and mechanism of its discharge. And this \iew 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 majority of cases of spasmodic asthma there is a copious secretion of pituita towards the end of the paroxysm^ with the discharge of which the attack passes off. Dr. Bree maintains his argument with a great deal of ingenuity^ and presses many facts into the service of his theory : but the most superficial reflection would suffice nowadays to show that it is utterly untenable ; 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 knowledge,^ of reflex nervous action would, in connexion with anatomy, have displayed the true nature of the disease, and made all its discrepant and scattered phenomena conspire to the production of its true and simple theory.

A word or two will suffice to show the fallacy of Dr. Breeds views, and where his error lay.

DR. bree's theory. 9

Was this peccant matter^ tliat Dr. Bree supposed to be tlie exciting cause of an astlimatic 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 coiu-se 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 violent muscular efforts and its great distension, is very slight. If a person suffering from asthma tries to blow his nose he finds he cannot make a sufiiciently full inspiration, or get enough air into his chest, to perform 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 forbear 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

ANALYSIS OE THEORIES.

embarrassment of his breathings — in fact^ as well as with it open. The fact was^ the amonnt of air respired was so small that the narrow chinks between the polypi and the walls of the nares were snfficient for its transmission.

Supposing^ on the other hand, coughing to be necessary to the expulsion of this irritating material, as some of Dr. Breeds observations indicate, a similar extraordinary respiratory power would be necessary, for an extraordinary 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 paroxysm is free from cough, — it is dry ; the wheezing dyspnoea is the only thing that troubles the patient. How, then, can the coughing and spitting explain the antecedent dyspnoea ? or how, if the coughing is necessary for the expulsion of the offending pituita, can the preceding laboured breathing 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 result of the congestion into which the capillaries have been thrown by the long-continued imperfect respn-ation, and the secretion, by unloading these congested capillaries, relieves one of the most pressing causes of the dyspnoea ; 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 bronchial tubes ; when the bronchial spasm ceases this is the only source of dyspnoea that is left, and its expectoration is therefore attended with immediate 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

THE BRONCHITIS THEORY.

chest to be freely filled with air^ efficient cough^, adequate to the free discharge of this accumulated mucus^ cannot be effected. Expectoration cannot take place till the intensity of the dyspnoea is already subsiding. The order of events,, then^ is this : — Air shut oflP 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 air into the lungs to cough efiiciently ; abatement of spasm ; consequent recovery of 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, recognising 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. Breeds in so far as it attributes 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 irritating humour, nor consider the muscular pheno-