ticular exciting cause which, being known, may be avoided, the disease imposes simply more or less inconvenience; but if the paroxysms are liable to be produced by various causes which cannot be guarded against, it is truly a grievous affliction; and it is calamitous, of course, in proportion to the frequency with which the paroxysms recur, and their severity.

Asthmatics are not infrequently long-lived; yet, that it may contribute to shorten the duration of life, cannot be doubted. The labored efforts of breathing in the paroxysms contribute to the development and increase of emphysema. During the paroxysms, also, the circulation through the lungs being impeded, the right ventricle and auricle must be unduly distended with blood returned by the systemic veins, and hence the affection contributes to dilatation of the right side of the heart. The chances of long life are lessened by these lesions. Moreover, if the paroxysms are frequent and severe, they can hardly fail to impair the powers of life, and diminish the ability to resist other diseases. If asthma secures, to a certain extent, exemption from pulmonary tuberculosis and pneumonitis, this advantage is perhaps overbalanced by the fact that pneumonitis, when it does occur, is apt to prove fatal, and that the supervention of a severe attack of bronchitis is apt to destroy life.

TREATMENT. The management of asthma embraces, first, the treatment of the paroxysms, and, second, the treatment in the intervals.

During the paroxysm the objects of treatment are to lessen the suffering and bring the paroxysm to an end as speedily as possible. The measures for these objects have reference to spasm as the essential pathological condition. The measures to relieve spasm are various, each of which proves efficacious in some cases and not in others. Frequently the past experience of the patient is the best guide as to the particular measure which will be most likely to afford relief. In cases of asthma unaccompanied by bronchitis, I have known a full opiate quickly and completely successful; but, in the larger proportion of cases, it will not succeed in cutting short the paroxysm, nor afford marked relief. Of other narcotics, stramonium is best suited to this affection. The usual mode of administration is to smoke the dried leaves or fibres of the root either in a pipe or prepared as a cigarette. It is undoubtedly true that this measure in some persons acts like a charm, and may be confidently relied upon as a prompt and effectual mode of obtaining relief. But, in the great majority of cases, it either produces no effect, or merely mitigates the severity of the paroxysm. Assafoetida, dracontium, or skunk-cabbage, and the Indian hemp have been found to be sometimes efficacious. The ethers, given internally, are to some extent useful as palliatives, and occasionally produce complete relief.

Marked relief is frequently obtained, and the paroxysm is sometimes cut short, by nauseant remedies, viz., antimony, ipecacuanha, lobelia inflata, and common tobacco. The two remedies last named are especially efficacious in a certain proportion of cases. The common tobacco will be more likely to be successful if the patient be not accustomed to its use. With a view to the relief of spasm, these remedies need not be carried to the extent of producing vomiting; if not effectual when nausea is induced, it will be useless, if not injurious, to push them further. I have known a paroxysm to be arrested at once by bloodletting, but this is a measure too potent to be employed except occasionally in plethoric persons.

The inhalation of the vapor of chloroform or ether is a measure of great value in the treatment of asthma. Not infrequently the paroxysms are com pletely controlled by it, the patient passing, in the space of a few moments, from a condition of great suffering into one of ease and comfort. These

cases are among those which afford the most striking examples of the resources of practical medicine. The dry bronchial rales which, before the inhalation, were loud and universally diffused over the chest, sometimes disappear as soon as complete relief is procured by the inhalation, a fact proving conclusively the existence and cessation of spasm. Unhappily this measure, like the others, is only efficacious in a certain proportion of cases. It should be tried always, provided there are no circumstances to contraindicate it. Its employment should never be intrusted to the hands of the patient.

It is hardly necessary to say that if there be ground to suppose the attack to have been brought on by overloading the stomach or by constipation, an emetic or cathartic is indicated. And, of course, the patient is to be removed from the action of any known exciting cause, such as the emanations from hay, feathers, etc. The apartment should be large, high, and airy. Warm and stimulating pediluvia are useful as palliatives. Strong coffee, taken hot, is generally highly useful as a palliative. Another palliative measure, which sometimes proves to be curative, is to be added. This consists in diffusing throughout the apartment the fumes of burning nitre-paper, that is, bibulous paper dipped in a saturated solution of the nitrate of potassa, and dried. Some patients find great relief, and occasionally the paroxysms are arrested by this measure.

The treatment in the intervals has for its object prevention of the paroxysms. The removal of the predisposition would be the most effectual mode of accomplishing this object. This, however, is not to be expected, and the object is to be attained by measures having reference to circumstances which increase or act upon that susceptibility of the bronchial muscular fibres constituting the predisposition to the affection.

When, owing to a peculiar idiosyncrasy, paroxysms are excited by a particular cause, such as emanations from hay, feathers, etc., avoidance of exposure to the cause, if possible, is obviously indicated. It is doubtful if any remedy will produce insusceptibility to the action of the particular cause, or secure exemption so long as the operation of the cause continues. In the cases of summer asthma which have come under my observation, a great variety of remedies have been tried, but all without avail. The patient must either endure the continuance of the affection for several weeks, or he must seek a situation where he is not exposed to the exciting cause, whatever it may be.

In a large proportion of cases, the liability to paroxysms is more or less favored by the existence of habitual or chronic bronchitis. The relief or cure of the latter affection, in these cases, is the immediate object of treatment. The iodide of potassium should always be tried. I have known patients who were rendered comparatively comfortable as regards the recurrences of asthma by the use of this remedy, which will be useful in proportion to its curative effect on the bronchitis. The chlorate of potassa is sometimes useful, and the other measures indicated in cases of chronic bronchitis are to be employed.

If measures addressed to the bronchitis prove ineffectual, or if the paroxysms recur when bronchitis does not coexist, and they are not referable to particular causes which may be avoided, nothing is to be depended on but change of locality. And it is probable that most asthmatics may find some situation in which they will be comparatively, if not entirely, free from the affection. Facts showing the immunity obtained by change of residence are remarkable, as illustrative of the apparent capriciousness of this affection. Persons residing in the country often find relief by living in cities or large towns. A change from the most salubrious part of a city to a part where

the atmosphere is smoky and insalubrious, as regards the general health, sometimes secures exemption from this affection. A change of apartments from one story to another, or to a different exposure, has been known to prove effectual. There are no fixed laws with respect to the best climate or situation for asthmatics: each case has its own law, which is only to be ascertained by experience. In commencing trials of change of locality, a situation should be selected in which the climatic influences are the opposite of those belonging to the situation in which the patient resides: that is, if he live in the country, the city may be tried, and vice versa; if on the seashore, an inland situation, and vice versa; and so with regard to temperature, moisture, elevation, etc. The principle to be acted on is, that there is a locality in which each martyr to this complaint will suffer less, and perhaps be entirely free from it, and the plan should be to make repeated trials until the desired spot is found. I could cite from the cases which have come under my observation several in which this plan has proved successful. It is to be enjoined, wherever practicable, so soon as it is evident that other measures will not secure the patient against the suffering incident to the frequent recurrence of the affection.1

СНАРТER VIII.

Pulmonary Hemorrhage-Bronchorrhagia-Pneumorrhagia-Pulmonary Gangrene-Pulmonary Edema-Carcinoma of Lung-Hydatids.

PULMONARY hemorrhage occurs under the following different circumstances: First, and most frequently, the hemorrhage is into the bronchial tubes, giving rise to the spitting of blood or hæmoptysis. Adopting the suffix expressive of hemorrhage, with the name of the anatomical situation, this variety of pulmonary hemorrhage should be called Bronchorrhagia. Second, it occurs from the rupture or ulceration of bands of pulmonary substance which traverse tuberculous excavations, these bands sometimes containing vessels of sufficient size to occasion a copious hemorrhage. It is, then, an accident occurring in the course of pulmonary tuberculosis, and gives rise almost invariably, if not always, to hemoptysis. Third, the blood is contained within the air-cells, and may escape into the interstitial areolar tissue, and coagulation takes place in these situations: that is, the blood is extravasated, constituting what is commonly called pulmonary apoplexy, and usually, under these circumstances, there is hæmoptysis. The latter form of pulmonary hemorrhage may be distinguished as pneumorrhagia. In the second of these three varieties, the hemorrhage is so uniformly and plainly incidental to one affection, viz., pulmonary tuberculosis, that it will suffice to simply refer to it here. Bronchorrhagia and Pneumorrhagia, however, not being so constantly symptomatic, each of a particular affection, and sometimes occurring when the pathological connection of the hemorrhage is not obvious, claim some consideration independently of the affections in which they are liable to occur.

On the therapeutic influence of locality, and other topics relating to the history, management, etc., of asthma, the reader may consult with advantage the excellent treatise by Henry Hyde Salter, M. D., republished by Blanchard & Lea, 1864.

Bronchorrhagia, or bronchial hemorrhage, exists in the great majority of the cases in which hæmoptysis occurs. The latter term should be limited to the spitting of blood; and it should be applied only to the cases in which pure or unmixed blood is expectorated. It is not properly applicable to the mucus streaked with blood which belongs to the history of bronchitis, nor to the blood intimately mixed with mucus in the rusty expectoration of pneumonitis. A true hæmoptysis is the raising of blood, and blood only.

It is important to determine, when blood is ejected from the mouth, whether it come from the air-passages. It may come from the stomach, from the posterior nares, and from the mouth or fauces. If it come from the stomach, it is ejected by acts of vomiting; it is likely to be commingled with other contents of the stomach, emits the characteristic acid odor of the latter, and has a black grumous appearance due to the action of the gastric acids. If it come from the posterior nares, it is in the form of dark solid sputa, which are removed by acts of hawking. If it come from the mouth or fauces, the fact may generally be ascertained by a close inspection of these parts. When it comes from the air-passages, it is raised by acts of coughing, which are generally not violent; the blood rises into the trachea and larynx, and is expelled with slight efforts. In the majority of cases, the blood is liquid, of a bright arterial hue, and contains air-bubbles in more or less abundance. If, however, the hemorrhage have taken place slowly into the bronchial tubes, and remained there for some time before being expectorated, it undergoes coagulation, and acquires a dark or almost black appearance.

The amount of hæmoptysis varies much in different cases. It is sometimes quite small, a drachm or so of blood only being raised; usually, however, when the amount is relatively small or moderate, several drachms or a few ounces are expectorated. Not infrequently the amount is considerable. It is not rare for patients to lose, during an attack of hæmoptysis, from half a pint to a pint of blood, and sometimes a much larger quantity. The blood is expectorated with more or less rapidity. The continuous duration of an attack of hæmoptysis may vary from a few minutes to several hours and even many days, in the latter case, of course, the blood escaping slowly. Occasionally the flow of blood is so rapid that it escapes simultaneously from the nose and mouth; and death by suffocation may result from the accumulation in the air-passages. In proportion as it is rapidly discharged it is less frothy than when the quantity expectorated with each act of coughing is small. When the hemoptysis is rapid and abundant, if the patient be not in advanced phthisis, the bursting of an aneurism should be suspected. It is to be borne in mind that this is a source of hæmoptysis, an aneurismal tumor sometimes opening into a bronchus or the trachea. The hemorrhage from this source, however, is not always at first abundant and rapid, the opening being, for a time, too small for the free escape of blood. In cases of phthisis advanced to the cavernous stage, the hæmoptysis may be rapid and abundant, leading sometimes to fatal syncope, the hemorrhage being due to the opening of a vessel contained in one of the bands of pulmonary tissue which frequently traverse tuberculous cavities.

In the majority of cases, bronchial hemorrhage is, in some way, pathologically connected with pulmonary tuberculosis, and, from the frequency of this connection, it is important as a diagnostic symptom of that disease. Not infrequently it is the first event which awakens the attention of patients to the existence of pulmonary disease. In a large proportion of cases, it occurs more or less frequently during the progress of tuberculosis. In a certain proportion of cases, it precedes the deposit of tubercle; or, at all events, it occurs when coexisting physical signs do not afford evidence of a deposit, these signs becoming developed, sooner or later, after its occurrence.

Hæmoptysis should always excite a strong suspicion of either existing or impending tuberculous disease; yet its significance in this respect was undoubtedly overestimated by Louis is his treatise on phthisis. Louis, having questioned a large number of patients affected with various diseases other than tuberculosis, and finding that spitting of blood had taken place in no instance save after injury of the chest or when the catamenia were suppressed, concluded that this symptom rendered the existence of tuberculosis infinitely probable. Since the publication of that work, however, it has been found that cases are not very infrequent in which hæmoptysis is not accompanied nor followed by either the symptoms or signs of tuberculous disease. My own clinical records furnish several cases of this kind. But a paper recently communicated by Prof. John Ware contains statistical information of special value with reference to this point. Prof. Ware, in this paper, gives the results of an analysis of 386 cases of hæmoptysis, noted in private practice during a period of about forty years. Of these cases, in 62 recovery from the bronchial hemorrhage took place, and the patients afterward were either known to be living in ordinary health, or to have died of other diseases having no connection with the existence of tubercles. The length of time during which this immunity continued varied from two to thirty-seven years. In addition to these cases, in 52 a similar complete recovery took place, and, so far as known, there was no development of tuberculous disease, but the entire subsequent history of these cases had not been obtained. Making allowance for the probable occurrence of a small deposit of tubercle which underwent arrest and did not return, in a certain proportion of the cases, these facts show that neither the existence of tuberculosis nor a strong proclivity thereto is to be positively predicated on the occurrence of bronchorrhagia. They show, moreover, that, as regards any immediate or remote evils, bronchial hemorrhage may be quite innocuous.

Bronchorrhagia is incidental to certain cardiac lesions, especially those involving obstruction at the mitral orifice. These lesions lead to bronchial hemorrhage by inducing pulmonary congestion. It may occur in connec tion with morbid conditions of the blood and tissues, which lead to hemor rhages from the mucous membrane in different situations, as in purpura hemorrhagica and scorbutus. It occurs occasionally in asthma. It may be produced by violent and prolonged muscular exertion, without the coexistence of any pulmonary or cardiac affection, and it has been observed to occur from muscular exertions, not excessive, if conjoined with diminished pressure of the atmosphere in elevated situations, as in ascending high moun tains. It may be produced traumatically by injuries and wounds of the chest. It may occur as a secondary hemorrhage when the menses are suppressed. Well-authenticated cases of this kind have been reported, but they must be exceedingly rare. I have never met with an example, and the 386 cases analyzed by Prof. Ware did not include a single case in which the hemorrhage could be considered as supplementary to the menses. Exertion and mental excitement, by their effect on the circulation, may act as exciting causes, if, from pulmonary disease or other circumstances, a predisposition exists; but clinical observation shows that, in the larger proportion of cases, the hemorrhage takes place without any other exciting cause. It takes place not infrequently during the night time.

The occurrence of hæmoptysis generally occasions much alarm and anxiety. If patients are seen at the time, more or less of the nervous agitation and disturbance of the circulation which may be found, is attributable to the

On Hæmoptysis as a Symptom, by John Ware, M. D., etc. Publications of the Massachusetts Medical Society, 1860.