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Under the head of Hygiene, we introduce to our readers a work by Dr. Armstrong, the well-known medical officer of the Investigator, the first vessel that achieved the North-west passage.
The title is, Observations on Naval Hygiene and Scurvy.' Mr. John Roberton, of Manchester, again favonrs us with valuable
Suggestions with a view to the Improvement of our Hospitals. We are glad to find that he has not laboured in vain, and that a new hospital is about to be erected at Blackburn, in which the old principle of construction--by which per ventilation was impossible, and the generation of a hospital atmosphere unavoidableis cast to the winds. This building will be erected upon a plan already adopted in the great Hospital of Bordeaux, in the Hôpital St. Jean of Brussels, the magnificent Lariborisière of Paris, and, last not least, the admirable but now historical hospital of Renkioj*—viz., of having detached wards, with windows on each side, connected only by a common corridor. “Suggestions and Instructions, in reference to Sites, Construction, and Arrangement of Buildings, and Plans of Lunatic Asylums,' come to us as the first achievement of the new Lunacy Board of Scotland. A lecture on the Sanitary Condition of the British Army,” by Dr. Guy, places certain points of the recent Sanitary Report on the Army, especially the evil results of overcrowding, in a very strong light. On the other hand, Dr. Barker gives us experimental proof of the noxious influence of sewer emanations, and of the individual gases which prevail in the cloacæ, and make their way to the lungs and noses of her Majesty's lieges through the untrapped gully-holes of the streets and open mouths of conduits discharging into the Thames. It is interesting to observe the close resemblance of the symptoms produced in the animals experimented upon to the typhoid fever of man, especially when subjected to the influence of sulphide of ammonium. We trust that if the new Public Health Act, of which a copy is before us, be carried in the present session, the good sense of our corporations will prevail to cause its universal adoption, and the consequent abatement of all removable causes of disease. In connexion with sanitary matters, we have to mention the Second Report of the Commissioners of Her Majesty's Customs, including the Medical Report on the Health of the Water-guard and Waterside Officers,' by Dr. McWilliam.
The Surgical works that claim our attention are Mr. Zachariah Lawrence's work On Surgical Cancer,' which has attained the honours of a second edition; the second number of the Ophthalmic Hospital Reports,' edited by Mr. Streatfield, containing communications from Messrs. France, White, Cooper, Dixon, Bader, and the editor, besides a polemical article of Dr. Von Gräfe; and Mr. Marion Sims' address, in which he dwells with great unction on the importance of silver sutures in surgery: As a branch of surgery, we next advert to Odontology, which now has its separate representative in the republic of literature under the title of Transactions of the Odontological Society,' to the first number of which Mr. Rogers, Mr. Bate, Mr. Tomes, Mr. Shelly, and other wellknown dentists, have contributed.
Materia Medica and Therapeutics are represented by a large work by Dr. Tally (United States), of which the two first parts of the first volume have already appeared, extending already to 1534 octavo pages. Under this head we would also mention a new work by Dr. Lawrance, On Localised Galvanism,' a subject which, with daily improving knowledge, attracts daily greater attention. We intend shortly to lay before our readers a summary of this department of therapeutics, when we shall revert to Dr. Lawrance's volume. Dr. Tyler Smith's Manual of Obstetrics, a similar German work by Dr. Spiegelberg, and the reprint of a paper by Dr. Boseman, of North America, On UrethroVaginal, and Vesico-Vaginal Fistules,' comprise the productions of Midwifery that the past quarter has brought.
In Medical Jurisprudence, we have received the sixth edition of Dr. Taylor's well-known, and evidently well-appreciated, manual—one of those works upon
* See British and Foreign Medico-Chirurgical Review, Oct. 1856, and Oct. 1867.
which the deserved applause of a discerning public has already conferred the highest distinction to which an author aspires. The proposed scheme of Mr. Pearson* to afford certain facilities to medical students in taking their degree at Oxford, is discussed by Dr. Child and Mr. Hussey; both speak as if they were treading on dangerous ground. It becomes daily more apparent that if Oxford is really to do her duty as the alma mater of all the learned professions, a more searching reform is necessary than that implied in Mr. Pearson's wellmeant proposition. Let those who do not clearly apprehend the intimacy of the relation between the physical and moral and mental training of man, read Mr. Buckle's introduction to the ‘History of Civilization as an indication of the advantages to be derived from a symmetrical development of the intellect. We wish to see Oxford the representative of the whole mind of the nation; and for this reason, more than for the benefit that will accrue to the medical profession, we hope yet to see medicine occupying its legitimate position there. We are glad to perceive by the daily papers that Cambridge is also agitating reforms in a similar direction; the Council of the Senate having submitted to the Senate for adoption, certain regulations which will much facilitate the graduation of medical students at that University.
It remains for us to notice a well-written and interesting book, by a Fellow of the Royal College of Surgeons, entitled the Unity of Medicine, to which we shall again recur; the essays of Mr. Herbert Spencer, collected from the Quarterly Reviews, and a second edition of the Handbook of Chemistry of Messrs. Abel and Bloxam, which on a cursory glance makes the impression of being valuable as a practical guide to the student; if to this we add Mr. Chalmers' work. On Electro-Chemistry,' and Dr. Harvey's letters. On Administrative Reform,” which have reached us at the last moment, we have exhausted the list of the more important productions to which in this summary we wished to advert.
On the Pathology of Asthma. By HYDE SALTER, M.D., F.R.S.
THERE are three motives that have induced me to put together the following thoughts on the pathology of asthma. One is the extreme interest of the subject
. in a pathological point of view, the beautiful illustration which the clinical history of the disease affords of the phenomena and laws of that particular form of perverted nervous action in which I believe it essentially consists. Another is the importance of correct pathological views in relation to the therapeutics of the disease. A third is a desire to refute the various erroneous theories that have been, and still are, advanced with regard to the pathology of asthma, and to sup
• See British and Foreign Medico-Chirurgical Review, April, 1888.
plant by something precise and definite those muddy and loose notions about it that I find, both from conversation and from their writings, to be so common among medical men. Some, I find, even now-a-days, do not believe in stricture of the bronchial tubes at all; others do not believe that such a condition would explain the phenomena of the disease; and others again, while admitting that spastic contraction of the bronchial tubes does exist in asthma, believe it to be only a part of a complex condition, that it does not constitute the disease, but that some special derangement of the pulmonary circulation shares, equally with it, in the production of the symptoms. I may even add a fourth class—those who deny the existence of asthma as a substantive disease altogether; who affirm that you never have it without organic disease of the heart or lungs, and that it is merely a particular form of dyspnea induced by that organic disease. No doubt there are many circumstances peculiar to asthma that go far to explain why such vague and 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, or the total absence of anything special and peculiar in the post-mortem appearances in such cases, and the remoteness of the actual morbid condition from the manifest phenomena of the disease. But, at any rate, such is the fact; and if any doubt of it existed, a reference to the literature of the subject, or ten minutes' conversation with any half-dozen members of our profession, would soon dissipate it.
What I shall endeavour to show will be this: 1. 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.
2. That the phenomena of asthma—the distressing sensation and the demand for extraordinary respiratory efforts—immediately depend upon a spastic contrac
a tion of the fibre-cells of organic or unstripped muscle, which minute anatomy has demonstrated to exist in the bronchial tubes.
3. That these phenomena are those of excito-motory or reflex action.
4. 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 airpassages themselves.
5. That in a large number of cases the pneumogastric nerve, both in its gastric and pulmonary portions, is the seat of the disease.
6. 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.
7. 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.
8. 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 the propositions in the order in which I have stated them, and see what proofs can be brought in their support.
1. The reasons that force upon one's mind the conviction that asthma is essentially a nervous disease are very numerous, and not less forcible and convincing ; but I shall here be able only briefly to indicate them, as their fuller consideration would involve too great space. They are principally derived from the following considerations :a, The causes of asthma; B, its remedies ; %, its associated and precursory symptoms ; 9, its periodicity; 6, the absence of organic change ; &, 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 affect the nervous system, and such as give rise to other diseases acknowledged on all hands to be nervous. Thus, fatigue and physical exhaustion, and sudden or violent mental emotion, will bring on an attack. I was informed, some short time since, by my friend, Dr. Theophilus Thompson, of a case in which, on two occasions,
severe asthma was brought on in a gentleman by sudden fear, from his having, as he imagined, administered accidentally something deleterious 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 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, papa,” 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 recognised 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 physiologically or anatomically
B. Again, the remedies of asthma are such as appeal to the nervous system, as antispasmodics, sedatives, direct nervous depressants, &c.; tobacco, for example, stramonium, antimony, chloroform. Perhaps the effect 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 whiff's, and the asthma is gone; a dyspnea that a few seconds before seemed to threaten life is replaced by a breathing calm and tranquil-it acts like a charm. 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 ordinary remedies, there are other circumstances that will put a stop to the paroxysm, that eminently prove its nervous nature; one of these is niental 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 we are not without analogies—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 nervons impressibility-and thus facilitating the induction of excito-motory action. Nothing, indeed, in the whole range of pathological phenomena is to my mind more remarkable 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, except the mental perturbation at being within the precincts of the physician, the difficulty of breathing has vanished. We see just the same thing in tooth-ache--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 ipecacuanha, 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 bad placed her in a position of safety, ran down two flights of stairs to procure the restoratives that were usually administered; 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 intluence of alarm that had alone enabled 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.*
7. Again, the periodicity of asthma implies its nervous nature—that is, such a periodicity as characterizes asthma. There are three kinds of periodicity 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 periodicity 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 standardthat is, though tolerably constant in the same individual, it differs very widely in different cases-the period is peculiar to each case, is an integral part of the pathological condition. This last kind of periodicity, and this alone, it is that points at all to the nervous nature of a disease.
d. Furthermore, the associated and precursory symptoms of an asthmatic 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 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.
&. Another circumstance in favour of this view, in fact consistent with no other, is the possible absence of appreciable 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 causet gives an opportunity of examining his lungs, they may be found apparently in every way healthy-no trace of inflammation or its products, the vesicular structure perfectly normal, the passages 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 throngh the nervous system,
8. 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 exceptions, 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; but the essence of the disease is nervous.
The only excep
* 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 labour.
+ 1 say from some other cause, because if asthma kills, it always does so by producing organic change in the heart or langs, or both,