patient should be resorted to. The feet and hands should be immersed in
hot water to which a small quantity of mustard has been added. Dry cups
between the shoulder-blades or sinapisms over the chest or epigastrium
often afford marked relief.
If, on account of the existence of an idiosyncrasy on the part of the
patient or from other causes, opium cannot be employed, we have in
chloral hydrate a substitute which is almost as efficacious and perhaps
even more prompt. Next to morphia, it is the most valuable remedy, and
many esteem it superior to that drug, over which it possesses the
advantage of not being followed by the disagreeable effects which so
often succeed the administration of opiates. It should be given in
doses of thirty or forty grains, and repeated if the paroxysm does not
yield.
The inhalation of chloroform has long been esteemed as a potent agent
in overcoming the bronchial spasm. One would naturally suppose that the
use of such a powerful sedative as chloroform would be a dangerous
proceeding in a disease which, like asthma, is attended with so much
embarrassment of respiration and circulation; but experience does not
justify this fear, and Salter, who has used it with good effect in 12
out of 13 cases, assures us that he has administered it "in the very
agony of the worst attacks; that, so far from fearing it under such
circumstances, it has been able to relieve the intensest asthma that
nothing else would reach; that he has given it, and that he has never
seen any bad effects from it." He goes on to state that as chloroform
relaxes the bronchial spasm, and thus removes the cause of the
"asphyxial stoppage, the intensity of the apnoea, so far from being a
reason against the administration of chloroform, is the great reason
for its immediate employment." He considers neither muscular weakness
of the heart nor valvular disease as any contraindication to its
administration, provided the circulation is not materially affected.
According to Stokes, the paroxysm is not entirely suppressed by
chloroform, but returns as soon as the patient passes from under its
influence; hence it must be repeated as occasion may require. It should
always, if possible, be given at the commencement of the paroxysm, and
should never be allowed to produce complete insensibility, nor should
so seductive a remedy be left in the hands of the patient. The danger
of the self-administration of chloroform is only too well attested by
the frequent accounts in the journals of persons found dead in their
beds from the effects of that agent, death in such cases being usually
due to the patient's {203} unconsciously leaving the handkerchief over
the mouth and continuing to inhale the chloroform after having become
insensible. When given sufficiently early, a few whiffs may be all that
is necessary to overcome the paroxysm; and this repeated as soon as it
threatens to return, will often enable us to control the symptoms
without resorting to larger quantities.
An old and still very popular treatment--said to have been introduced
by an American, Nicholas Frisi,[24] in 1843--consists of the inhalation
of the fumes of burning saltpetre or in smoking cigarettes made of
paper which has been soaked in a saturated solution of that substance.
Inhaled into the bronchi, it is supposed to act as an anæsthetic, and
produces relaxation of the constricted bronchial muscles. In point of
efficiency these inhalations rank quite high, and are probably more
generally used than any other remedy. Aside from the relief which they
undoubtedly afford, this method derives much of its popularity from
being within easy reach of the patient himself. The preparation of the
papers is exceedingly simple: A sheet of bibulous paper is dipped into
a saturated solution of the nitrate of potassa prepared with cold
water; after drying it is divided into strips of the size required.
These papers are burnt before the patient, the windows and doors of the
apartment having been previously closed to prevent the escape of the
fumes. Nitrate of potassa has been prepared in a variety of other ways
for the use of asthmatic patients, one of the most convenient of which
is the Kidder pastilles so extensively used in this country. Another
method is to roll the paper prepared as above into cigarettes, the
smoke of which is inhaled by the patient. The nitre is best used early
in the attack, but is also beneficial when the paroxysm is at its
height. The efficacy of this treatment is attributed by Germain Sée to
the formation of protoxide of nitrogen and carbonic acid gas, which act
as an anæsthetic, and perhaps also to the particles of carbon in the
smoke floating in the air, a smoky atmosphere being beneficial to many
asthmatics.
[Footnote 24: Germain Sée, _op. cit._, p. 709.]
The smoking of the Datura metel having been found efficacious in asthma
in India, Anderson of Madras in 1802 sent some of the leaves to Gen.
Gent, an English officer, by whom they were introduced into England.
Simms of Edinburgh, believing that the Datura stramonium might prove
equally good, tested it with such good results that it soon came into
general use, not only in asthma, but in other forms of dyspnoea. This
is the ordinary Jimson or Jamestown weed which is so widely distributed
over the Southern, Middle, and Northern States, and, like nitrate of
potassa, is much used, not only by the profession, but largely as a
household remedy for asthma. The dried leaves are either smoked in a
pipe or in the form of a cigarette. The effects, however, are quite
uncertain, sometimes acting like a charm, while at others it affords no
relief; its physiological action is that of a sedative. Of late years
another species of Datura has been introduced--the Datura tatula. Its
properties and uses are similar to those of stramonium, but it is
supposed to be less narcotic.
Belladonna and its alkaloid, atropia, are often used in the treatment
of asthma, but their action is uncertain and often unsatisfactory. The
three last-mentioned remedies are also used in combination, as in the
well-known Espic cigarettes, the formula for which, according to
Trousseau, is as follows, viz.:
Rx. Fol. belladonnæ, gr. vj;
Fol. hyoscyami, gr. iij;
Fol. stramonii, gr. iij;
Fol. phillandrii aquatic. gr. j;
Ext. opii, gr. ¼;
Aq. lauroceras, q. s.
{204} The leaves, after being cut up, should be thoroughly mixed, after
which they are moistened with the cherry-laurel water, in which the
opium has been previously dissolved. The wrapper of the cigarette is
also soaked in the same solution and dried. One or two of these
cigarettes should be smoked during the attack. Abbott has been very
successful with belladonna applied as a spray (drachm j of the extract
to one ounce of water) when the spasm threatens.
Tobacco is a powerful depressant, and in those who are unaccustomed to
its use is an invaluable remedy in asthma. In the uninitiated it
excites nausea, vertigo, cold sweats, and other symptoms of relaxation
which Salter not inaptly compares to those of sea-sickness. "The moment
this condition can be induced the asthma ceases, as if stopped by a
charm." It may, however, be asked whether the remedy is not worse than
the disease. Those who retain a vivid recollection of the horrible
consequences of their first smoke will hesitate before prescribing
tobacco for one unaccustomed to its use. There are many who, not
wishing to lose the beneficial effect of tobacco in asthma, never smoke
unless a paroxysm threatens.
Lobelia, like the above also a depressant in its action, was formerly
much employed in asthma. It is still used, but its effects are
disagreeable and by no means certain.
The intimate nervous connection which exists between the lungs and
stomach would naturally lead us to anticipate good results from
emetics. In asthma, as in laryngismus stridulus, an emetic often
affords prompt relief and arrests the paroxysm. The nausea which
precedes the act of vomiting, acting as a depressant, causes relaxation
of the spasm, while the emesis by unloading the stomach removes an
important source of irritation. Like tobacco and lobelia, remedies of
this class are only beneficial when pushed far enough to produce the
symptoms of depression and collapse to which we have alluded; these
once established the relief is usually complete. Tartar emetic and
ipecacuanha are the representatives of this class most used in asthma.
Tartar emetic, owing to the excessive and long-continued depression
which it occasions, is now rarely employed, having been almost entirely
superseded by ipecacuanha, which is equally efficacious and more
prompt. Its effects also disappear more rapidly than those of antimony.
Like other remedies intended to cut short the paroxysm, ipecacuanha
should be given as early as possible. It should be taken in full doses
of at least twenty grains.
Bromide of potassium, as is well known, acts upon the vaso-motor
nerves, causing contraction of the arterioles of the brain and spinal
cord, and thus inducing a state of partial anæmia which results in a
lessening of the irritability of these organs, quieting muscular spasm
and inducing sleep. These effects would naturally lead to its
employment in spasmodic asthma. Although occasionally used with success
in shortening the paroxysm, it is better adapted, as suggested by
Riegel, for use during the intervals, when, if given continuously, it
sometimes diminishes the severity of the paroxysms and causes them to
recur less frequently.
Nitrite of amyl, a most valuable addition to our materia medica, has
been extensively used in the treatment of asthma, but the reports of
the results attained are too contradictory to admit of our forming any
just estimate of its merits. The general opinion is that it relieves
the dyspnoea and makes the patient for the time being more comfortable;
and this accords with my own experience. The usual method of
administration is to drop one or more minims upon a handkerchief and to
inhale the vapor. It is also used internally, and, in the single case
that has come under my observation, with benefit. The following case,
reported by Pick and cited by Riegel,[25] is instructive as showing the
favorable effects of nitrite of amyl: "The case was that of a medical
student who from his youth onward had suffered with {205} asthmatic
troubles, which increased as he grew older and had proved rebellious to
all remedies. Nothing except expectorants and narcotics afforded him
the slightest amelioration of his symptoms. On inhaling nitrite of amyl
he experienced immediate relief, which lasted for some time after the
inhalation. He was enabled to breathe deep and with comparative ease.
The relief afforded was but transitory, but, on the other hand, was so
sure that the patient resorted to it whenever the attack came on." The
same writer reports two other cases in which he succeeded by means of
nitrite of amyl in relieving the paroxysms and in increasing the
interval between them.
[Footnote 25: _Op. cit._, p. 295.]
More agreeable to the taste and at the same time more effectual than
the potassium iodide is hydriodic acid. It is best administered in the
form of a syrup, preferably that prepared by Gardener of New York.
Salter, who appears to have had more experience with alcohol than any
other writer, narrates the case of an elderly Scotch lady who, having
exhausted all the known medicines and other agents used in asthma, was
finally relieved by full doses of whiskey. This was invariably
successful, but the dose, of course, had to be increased as the disease
grew older. He also mentions another case in which nothing except
chloroform afforded any relief. This he describes as the severest he
has ever witnessed. "I have never seen or heard of spasms so violent or
that seemed 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
on the same street with myself, and, although 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 at my house at
night. All remedies except the chloroform had failed, when one day his
nurse advised him to try brandy. It afforded him almost instantaneous
relief. He took enormous quantities of it, the first day a quart, and
in the course of two months as much as twelve gallons. The spasm
invariably stopped as soon as he took it, and for the last five months
that he was under observation he had only what he called a 'thickness,
a tight, constricted breathing,' several times during the night."
Salter is particular in stating that the brandy should be given strong
and hot.
Another stimulant highly recommended by Salter is coffee. In stating
his objections to the use of opium it will be remembered that one of
his reasons for not availing himself of that remedy was that it caused
sleep, and that the exaltation of reflex action in that state favored
the asthmatic paroxysm. Coffee, being a strong excitant of the nervous
and vascular system, has the contrary effect and keeps the patient
awake. It should be prepared as a strong infusion without the addition
of either sugar or milk and given some time before the expected
paroxysm. Administered in this manner, he claims that coffee will
relieve two-thirds of all cases of asthma. The relief afforded is,
however, very unequal, being in some cases complete, while in others it
is only slight and transitory.
Quebracho in the form of an extract has been much used of late years in
the treatment of asthma and other affections attended with dyspnoea. It
has been found quite useful in mild cases.
The induced electrical current has been recommended by Schaeffer as a
means of cutting short the paroxysm. His method is to place one pole on
either side of the neck immediately below the angle of the jaw and in
front of the sterno-cleido-mastoid, so as to cover the course of the
pneumogastric and sympathetic nerves. The current should be
sufficiently strong to enable the patient to feel the passage from one
side of the throat to the other. It is applied for fifteen minutes
twice a day for six days, twelve sittings being usually sufficient to
afford relief. When the current is first applied it not {206}
infrequently causes dilatation of the pupils, but this is succeeded by
contraction when the treatment begins to manifest its beneficent
effects.
_B._ During the Intervals between the Paroxysms.--The diet and daily
regimen of the asthmatic should be most carefully regulated, the best
and most skilfully directed treatment being of little avail if these
important matters are neglected.
The asthmatic patient should be encouraged to pass much of his time in
the open air, but the amount of walking he should do will of course
depend upon his strength and freedom from secondary affections of the
heart and lungs. In a case of simple uncomplicated asthma the more the
patient walks the better he will feel; but this is not to be construed
to mean that he is to walk until exhausted; on the contrary, his walks
should at first be quite short, proportioned to his strength and wind,
and then gradually extended, but under no circumstances should he be
allowed to overfatigue himself. With a view to keeping the skin in the
best possible condition the body should every morning be sponged with
water, the temperature of which must be suited to the condition of the
patient. If he be feeble and anæmic, the water should be tepid, but
whenever admissible cold is to be preferred. After the bath it is
essential that the skin be thoroughly rubbed with a coarse towel until
it becomes slightly reddened. The cold bath properly used not only
invigorates the system generally, but by enabling the body to stand the
vicissitudes of temperature diminishes the risk of the patient's taking
cold.
The intimate relations existing between the lungs and stomach, and the
fact that asthmatics usually suffer at the same time with dyspepsia,
make the question of diet an all-important one. Their meals should
consist of good, nutritious food, rigidly excluding all heavy,
indigestible substances, such as cheese, nuts, dried fruits, etc. The
meals should be taken at regular hours, and, as asthma almost always
comes on at night, it is important that the principal repast should be
in the morning or early part of the afternoon, and that any food taken
between that and the hour for retiring should be of the lightest
possible description. The more empty the patient's stomach, the better
will be the chances of his passing a good night. Alcoholic drinks,
coffee, and other stimulants should only be allowed when prescribed as
medicines, as they have a tendency to aggravate the hyperæmia of the
air-passages, which is one of the prominent features of the disease.
Constipation should of course be carefully guarded against.
Aside from the apparently well-established fact that asthmatics do
well, and often remain so, in the damp, foggy air of crowded cities, we
have no means of determining beforehand what locality will suit a case
of asthma. Change of climate in such cases is a mere matter of
experiment, but when such change is determined upon the patient should
at first try a place which is in every respect the reverse of the one
he has previously lived in. If his former residence was in a city, he
should remove to the country; if the old place was dry, the new one
should be damp; if he has lived in a flat, low country, let him try the
mountains; and vice versâ. As already stated, removal from the pure air
of the country to the foul, smoky air of a city densely populated often
affords complete relief, but so soon as the patient returns to his old
home the asthma reappears and is as bad as ever.
As regards its capriciousness as to locality, I quote the following
interesting case from Salter's work on asthma: "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 intention was to
wait for an attack, and as soon as one came on to present himself 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 {207} his mortification,
not only without experiencing one, but without any difficulty of
breathing whatever. His health altogether improved; he slept well and
gained flesh. Being tired of waiting, he went back to Scotland without
having seen his physician at all, 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 all
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 anything--eat, drink, sleep. The consequence was he gained
flesh and strength, and went back to Scotland looking quite a different
man. This was the invariable result."
Having once found a place which agrees with him, the asthmatic should
remain there, as change of climate when no good is effected often does
harm.
Arsenic has long been a favorite remedy in asthma, and is undoubtedly
of great value in a number of cases. It was used in the form of a vapor
by Dioscorides, and, notwithstanding its poisonous properties, has
always occupied a prominent place in the therapeutics of diseases of
the air-passages. In Styria and other parts of Lower Austria arsenic is
habitually eaten by many of the peasants to enable them to breathe more
readily while climbing over their elevated mountains and to endure the
fatigue incidental to their long pedestrian journeys. The same habit is
said to prevail in China, where, however, it is not taken internally,
but is smoked mixed with tobacco. Its physiological effects are thought
to be due to the increased oxidation of the blood which it promotes, as
is proven by the great increase of urea observed after its
administration. The blood thus oxygenized stimulates the vital centre,
and thus the nerves and muscles of respiration are incited to increased
activity, as a result of which the respirations become freer and more
easy. Those who believe in the herpetic diathesis derive an additional
indication for its administration from the good effects which it
manifests in cutaneous diseases. It is best administered in the form of
liquor potassii arsenitis (Fowler's solution), giving at first only
three drops in a wine-glassful of water after each meal, and increasing
the dose one drop each day until the patient takes thirty drops in
twenty-four hours. Should any toxic symptoms supervene--pain in the
stomach or diarrhoea, puffiness of the lids or redness of the
conjunctiva--the arsenic should be at once suspended, and not resumed
until they shall have subsided. Thus given, it is quite safe. Trousseau
recommends its use in the form of cigarettes, which are prepared as
follows: "Twenty grains of the arsenite of potassium are dissolved in
half an ounce of water, and a sheet of bibulous paper soaked in this
solution until it is all taken up. The paper is then dried and divided
into twenty equal pieces, which therefore contain one grain arsenite of
potassium each. Each paper is then rolled in the form of a cigarette.
In smoking them the patient should endeavor to inhale the smoke into
the bronchi. He should take only four or five whiffs once a day."
Iodide of potassium often affords most satisfactory results in the
treatment of asthma, but in many cases it fails entirely. It is a drug
which must be given for a long period at a time, occasionally for
weeks, before it manifests its effects, and want of perseverance may
account for its failure in many cases. It forms one of the chief
ingredients in Aubrée's antiasthmatic elixir, the formula for which is
somewhat uncertain. According to Trousseau, it is as follows: {208}
Rx. Rad. polygalæ, gr. xl;
Coque c. aqua fervida, ounce iv _ad_ ounce ij;
Filtrat, adde Potass. iodid. drachm iv;
Syrup, opii, ounce iv;
Spts. vin. gallic. ounce ij;
Tr. coccionellæ, q. s. _ad_ coloraud.
Filtra.
Of this Trousseau states three tablespoonfuls are taken "in the morning
fasting, at noon, and in the evening, until the asthma disappears."
Each dose contains no less than forty-five grains of the iodide of
potassium and four-fifths grain of extract of opium. Aubrée himself
always insisted that each dose should be followed by a "tablespoonful
of chocolate pastille, which neutralizes the irritating action of the
iodide of potassium."[26]
[Footnote 26: Trousseau, _op. cit._, p. 656.]
A remedy resembling in its effects the one just mentioned is
nitro-glycerine. It is administered in the form of a one per cent.
alcoholic solution, in doses of half a drop, increased to three should
the smaller dose prove inefficient. Its effects manifest themselves in
from three or four minutes to a quarter of an hour, and disappear
within an hour after its administration. The dose should be increased
with great caution, as a single drop of the above solution has been
known to produce alarming symptoms. The euphorbia pilulifera, much
lauded by Australian physicians for its wonderful effects in bronchial
asthma, promises to rank as an invaluable remedy in the treatment of
that disease. It is best administered in the form of a decoction
prepared by steeping one ounce of the fresh, or half that quantity of
the dried plant, in two quarts of water, and simmering it down to one
quart. The dose of this decoction is three or four wineglassfuls during
the day, the last dose preferably in the evening, after supper.[27]