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paroxysm are so much more pronounced and marked, and constitute so much the body of the malady-while those of the disease generally, in opposition to those of the paroxysm, are rather the phenomena of the intervals, and consist of certain permanent conditions influencing the paroxysms, or produced by them.

As in epilepsy we have premonitory symptoms, in the form of the aura epileptica, spectra, and other subjective phenomena; then the establishment of the paroxysm; then those conditions of the nervous and muscular systems which constitute its climax; and then its abatement and the post-epileptic sleep: so in asthma we have certain precursory symptoms, and then the attack in its accession, perfect establishment, and departure.

The precursory symptoms of a fit of asthma are liable to great variety in different individuals; some persons never experience any, but having been guilty of some imprudence, or the regular period of an attack having recurred, the seizure of the dyspnoea upon them is the first indication of its approach. But I think that the majority of asthmatics do know that an attack is coming on them by certain feelings in themselves, or certain conditions of which they are aware. These symptoms generally show themselves on the night previous to the attack; but in some cases for a longer time. The patient will feel himself very drowsy and sleepy, will be unable to hold his head up or keep his eyes open, and that without having undergone any particular fatigue or done anything that could account for it.* I remember one case in which this was very strikingly marked, the asthmatic always knew when he was going to be ill the next day by the extreme drowsiness that overpowered him at night; he would go sound asleep over his reading or writing, or whatever he might be engaged in, and that at an carly hour of the evening. It was in vain for him to rouse himself, in spite of all his efforts, and in spite of the prophecies of those about him that he was going to be ill, and his own convictions of what awaited him, to bed he must go. And probably any resistance of these feelings would have been of no avail, and would neither have postponed nor modified the attack; the asthma was not the result of the heaviness, but the heaviness merely indicated the approach of the asthma; it was the commencement of that particular nervous condition of which the succeeding respiratory phenomena were but the more complete development: in fact, it must be looked upon as an integral part of the paroxysm. I find this precursory drowsiness to be the commonest of all the premonitory symptoms of asthma.

Others, again, know by extreme wakefulness and unusual mental activity and buoyancy of spirits, that an attack awaits them; and I knew one case in which an attack of ophthalmia always ushered in the asthma: the man was liable to inflammation of his conjunctiva, it was always worse before his attacks than at any other time, and he invariably knew by the state of his eyes when he was going to suffer a

*Floyer was perfectly aware of this premonitory sign, having noticed it in his own person. "There appears," he says, "a great dulness and fullness of the head, with a slight headache, and great sleepiness on the evening before the fit."

paroxysm. It might be thought that this was a case of mere catarrh, that the asthma was caused by the inflammation of the eyes creeping down through the nasal mucous membrane into the air-passages; but this was clearly not the case-there was no coryza, no bronchitis-the ophthalmia was strumous, and I believe that an exacerbation of the strumous cachexia, a more debilitated, and therefore a more irritable condition of system, was the cause alike of the inflammation of the conjunctiva and the spasm of the air-tubes. At other times the precursory symptoms are connected with the stomach, and consist of loss of appetite, flatulence, costiveness, and certain peculiar uneasy sensations in the epigastrium; but here I think we have something more than mere premonitory sigus; I think the relation of these symptoms to the spasm which follows is often that of cause and effect.

Of all the circumstances attending the commencement of an asthmatic paroxysm, none is more constant than the time at which it occurs. This is almost invariably in the early morning, from three to six o'clock. There are some cases in which the usual time is the evening-some just after getting into bed, before going to sleep, and some in which there is no particular time, but the attack may come on at any hour of the day or night, on the occurrence of some exciting cause, such as a fit of laughter, a full stomach, change of wind, &c. In nineteen cases out of twenty, however, the dyspnoea first declares itself on the patient's waking in the morning-or, what is much more common, wakes him from his sleep when he has had but half a night's rest. Now I think there are two reasons for the attack coming on at this time; one is the horizontal position of the body-the other, the greater facility with which sources of irritation, and, indeed, any causes of reflex action, operate during sleep than during the hours of wakefulness. The first cause acts thus: when a person lies down and goes to sleep, the recumbent position favours the afflux of blood to the right side of the heart, and therefore to his lungs; in addition to this, the position of the body places the muscles of respiration at a disadvantage; add to this, the diminished rate at which the vital changes go on during sleep; lastly, add to this, the lowered sensibility of sleep which prevents the arrears into which the respiration may be getting from being at once appreciated; and I think we have a sufficient explanation both of the time at which the attack generally comes on, and of the amount of dyspnoea that may accumulate before the asthmatic is roused from his slumbers. He goes to bed quite well, perhaps; the position of his body and the torpor of sleep soon throw his lungs into arrears, and they become congested; this goes on for some time, gradually increasing, without producing any particular effect: by and by, however, this pulmonary congestion reaches such a pitch that it becomes itself a source of great local irritation, and gives rise to asthmatic spasm; this, in its turn, cuts off the supply of air and increases the congestion, and thus the congestion and the asthma-the cause and the effect-mutually augment one another, till they produce such an amount of dyspnoea as is incompatible with sleep, and the patient suddenly wakes with all the distress of an asthmatic paroxysm

full upon him. Now in this case all the causes I have mentioned act together, but we know that each individually has its separate agency in producing the effect, because by removing any one of the causes, you may prevent the result; we know that the position of the body has to do with it, because an extra pillow may prevent the attack; we know that the disadvantage at which the muscles of respiration are placed during sleep has to do with it, because the attack may in some cases be prevented by laying the head on the arm, so as to make the shoulder a fixed point from which the accessory muscles of respiration can act.* Lastly, we know that the greater proneness to excitomotory action during sleep has to do with it, because some asthmatics do not dare to go to sleep after the commission of any imprudence, whereas they may be guilty of any irregularity with impunity if they only keep awake for some time afterwards. I know one asthmatic who often sits up half the night after taking a supper (breathing perfectly freely), because he knows that if he goes to sleep his asthma will come on him immediately; but by thus sitting up till his supper is fairly digested, his stomach empty, and the source of irritation thus removed, he may go to sleep fearlessly and have a good night's rest.

One cannot help seeing the striking resemblance that exists between this and the orthopnoea of cardiac disease; only in the one case the extreme dyspnoea is brought about by the obstructed circulation through the lungs; in the other, by the sparing amount of air admitted through the obstructed bronchi; in both, the congestion of the lungs is first induced by the position of the body, and the sense of arrears-the besoin de respirer-blunted, and the respiratory efforts postponed, by the insensibility of sleep. But in the orthopnoea the violent and extraordinary respiration that succeeds the starting from sleep soon re-establishes the balance; whereas in the asthma the constriction of the bronchi which persists after waking precludes the admission of the necessary amount of air, and the dyspnoea remains.

One curious circumstance with regard to time is that it may be varied according to the intensity of the cause-the more intense the source of irritation the shorter will the sleep be before the asthma puts a stop to it. I once knew an asthmatic who was always awoke by his disease with an earliness proportionate to the size of the supper he had taken; certain airs disagreed with him as well as food before sleeping, and if the two causes acted conjointly he would wake with asthma much earlier than if they acted singly: thus, if he went to a place that did not agree with him, he might wake about five o'clock with his asthma; the same if he ate a supper in a place that did agree with him; but if he ate a supper when staying at a place that did not agree with him, he would get no sleep after two or three o'clock; this may seem singular and an over refinement, but it is strictly true; I have watched it over and over again.

* An asthmatic friend, with whose case I am familiar, tells me that he always sleeps much better on a sofa than a bed; no amount of bolstering can impart to a bed the comfort and ease of a sofa. This he attributes to the fixed support that the side of the sofa affords on which to rest his arm, and the leverage thereby furnished for the accessory muscles of respiration.

How essentially characteristic of the disease this occurrence of the attack in the early morning is-how inherently a part of it-is shown by the fact that, in the great majority of cases, at this time and at this time alone will the attack come on, at whatever time in the twentyfour hours the exciting cause may be applied. For instance, in some cases over-exercise will bring on an attack, in many cases that have come under my care this has been so; but although the asthma was in these pretty sure to follow such over-exertion, it never came on immediately, never till the next morning; the exertion might be followed at the time by a little shortness of breath not much exceeding that of a healthy person, which would speedily and entirely disappear, and the patient would pass the rest of the day, and go to bed, in perfect health; but as surely as possible he would be awoke the next morning at the usual time with his asthma. And it would make no difference at what time of the day the over-exertion had been taken, morning or evening; at the stated time and at that only, neither earlier nor later, would its results declare themselves. Now here we have an exciting cause actually and inevitably bringing on an attack, but powerless to do so, its effect suspended, as it were, and laid dormant, until the characteristic time had come round. Nothing could show, as I think, more clearly than this both the tenacity with which the disease sticks to its favourite time of occurrence, and its essentially nervous nature. For through what but through the nervous system could such exciting causes maintain their influence suspended, and, finally, produce their effects after so long an interval, during which the respiratory and circulatory systems had been in a normal and tranquil condition?

I have always believed that this morning occurrence of asthma is the result of the causes I have mentioned, the horizontal position and sleep, and the conditions of circulation and respiration that they induce, and I cannot but believe that this is its true explanation. But about six months ago a case came under my observation which seemed to imply that this feature of asthma was an essential part of its natural history, and not dependent ou external circumstances. The case was that of a night porter, whose duties compelled him to turn day into night and night into day. He went to bed at seven o'clock in the morning, and slept through the early part of the day. But though the ordinary times of sleeping and waking were thus transposed, the asthma came on at the usual time, from five to six in the morning, towards the end of his vigil, when he was up and awake, and when none of the determining causes that I have mentioned could have been in operation. If the asthma had come on in this case at a time having the same relation to sleep and recumbency as in ordinary cases, it would have made its appearance about eleven or twelve o'clock in the day. This case certainly looks as if the particular period that the paroxysm affects depended on some inherent and inveterate habit of the disease. But the teaching of a single case like this is not to be taken in contravention of reason, or unsupported by further evidence. It is, however, I think, worth putting on record, and worth bearing in mind. One of the symptoms frequently attendant on the first stage of an

attack of asthma is profuse diuresis; the patient will half fill a chamber-pot with pale, limpid water, exactly like the urine of hysteria. This abundant secretion generally comes on soon after the asthma commences, but I have known it come on so carly that the patient was awakened from his sleep by the distension of his bladder, when the difficulty of his breathing was only just commencing. It generally lasts for the first three or four hours, and then ceases altogether. I believe the secretion of this abundant white urine to be of the same nature as the hysterical urine that it resembles-that it is nervous; and I regard it, as I have shown elsewhere,* as one of the many evidences of the nervous nature of asthma.

Another early symptom which I have often observed is neuralgic pains-a deep-seated aching in the limbs and joints; the testicles, too, are very apt to be affected with it, and I knew one case in which the testicle and the tibia, from the knee to the ankle, were always affected on the same side, sometimes the right testicle and tibia only, sometimes the left, sometimes both; but always the tibia and testicle on the same side. The pain is constant, deep-seated, and wearying.

Let us now consider the phenomena by which an attack of asthma is generally ushered in. The patient goes to bed in his usual health, with or without premonitory symptoms; he goes to sleep and sleeps for two or three hours; he then becomes distressed in his breathing, and dreams, perhaps, that he is under some circumstances that make his respiration difficult; while yet asleep the characteristic wheezing commences, sometimes, without disturbing the patient himself, to such a degree as to wake those in the same or an adjoining room, as if a whole orchestra of fiddles were tuning in his chest ; perhaps he half wakes up and changes his position, by which he gets a little ease, and then falls asleep again, but only to have his distress and dreams renewed, and again partially to wake and turn. Shortly the increasing difficulty quite wakes him, but only perhaps for a minute or two; he sits up in bed in a miserable half-consciousness of his condition, gets a temporary abatement, sleep overpowers him, and he falls back, to be again awoke and again sit up; and so this miserable fight between asthma and sleep may go on for an hour or more, the dyspnoea arousing the sufferer as soon as sleep is fairly established, and sleep again overpowering him as soon as the wakefulness and change of position have a little abated the extremity of his sufferings. By and by the struggle ceases, sleep is no longer possible, the increasing dyspnoea does not allow the patient to forget himself for a moment, he becomes wide awake, sits up in bed to lie back no more, throws himself forward, plants his elbows on his knees, and with fixed head and elevated shoulders labours for his breath like a dying man.

When once the paroxysm is established, the asthmatic offers a very striking and very distressing spectacle. If he moves at all it is with great difficulty, creeping by stages from one piece of furniture to another. But most commonly he sits fixed in a chair, immovable, unable to speak, or even, perhaps, to move his head in answer to ques

* Med. Chir, Review, July, 1858.

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