CHAPTER XIX. ASTHMATIC PHTHISIS. Usually originating in Inflammation-Arrested Phthisis passing into Asthma-Asthma passing into Phthisis. MOST of the following cases may be considered of inflammatory origin, the original attacks being either in the bronchi, or near the roots of the lungs, so as specially to affect these tubes. Therefore, they have presented symptoms and signs of bronchial dyspnoea, with wheezing and convulsive cough. Their pathology has been noticed at pp. 38, 63, and 72. The first of the group show a declining tendency from asthma to consumption, the decay of the latter loosening the bonds of the former. In the last cases, on the other hand, the converse change has taken place, consumptive lesions being healed by a contractile process which has produced asthma-that is, constriction of the bronchi and dilatation of the air-cells. Some of these features may be traced in many of the histories of the other longer cases. CASE 55.-Asthma passing into Phthisis. A young gentleman, aged 17, consulted Dr. Williams, July 6, 1860. He stated that one of his uncles on his mother's side was asthmatic, and that he himself had been subject for the last two years to attacks of asthmatic bronchitis. His breath had become permanently short for six months, and in the last two he had attacks of difficult breathing every night. Loud wheezy prolonged breathing in both sides of chest. Percussion clear.- A mixture of stramonium, squill, iodide of potassium, and carbonate of potash, was ordered to be taken twice a day, and a compound assafoetida pill combined with extract of stramonium, to be taken at night. July 20, 1865.-Was much relieved, but had frequent recurrence of ASTHMA PASSING INTO PHTHISIS. 209 dyspnoea till last September, when the cough increased, and the wheezing diminished. Expectoration scanty and tinged with blood, and yellow only when patient has fresh cold. Obstruction sounds and wheezing all over the chest, but no dulness or tubular sounds.-Oil was ordered in nitric acid and quinine, and an inhalation of creasote, chloroform, and conium, to be used at night. October 28.-Has gained flesh and strength, but cough is troublesome and convulsive. A mixture, containing iodide of potassium, conium, poppy and squills, was prescribed. February 8.-Living at Hastings, and much better. Has gained 11 lbs. Lost cough in December till last few days, when it returned. Physical signs the same. October 8.-Went to Torquay in March, when cough diminished, but became worse on patient leaving off oil, to which he returned in May, and again improved, Lately cough bad, and some pain in upper right chest, where coarse crepitation and tubular sounds are audible above the scapula.Ordered syrup of hypophosphite of iron with glycerine and infusion of quassia; and tincture of iodine to be painted on the chest. June 29, 1867.-Passed the winter at St. Leonards and Ventnor, taking oil and iron regularly, and gained flesh and colour; but lately pale, and cough tight. Has had several asthmatic attacks, and breath is very short. Coarse crepitation and tubular sounds above right scapula; dry whiffy sounds above the left scapula. Sputa of two kinds: some opaque, yellow, and heavy, the rest frothy and transparent.-Ordered to continue taking oil, with iron and strychnia. October 19.-The cough and tight breathing became worse after taking the iron, and so nitric acid and quassia were substituted, and a pill of Indian hemp and stramonium given at night. Patient found that the asthma was worst when at Ascot, better at St. John's Wood, but best at Croydon, where he has been seven weeks, and gained strength, but not flesh. Large eroaky crepitation sounds in upper left chest. This patient was alive in the autumn of 1868, suffering much from asthma and convulsive cough. The largeness of the crackling and croaky sounds at the left apex, together with the opaque purulent character of part of the expectoration, rendered it probable that small cavities had formed between the emphysematous portions of the lung. The cough and occasional fits of dyspnoea were asthmatic, but the emaciation and aspect of the patient were consumptive. CASE 56.-Asthma passing into Phthisis. A gentleman, aged 48. August 7, 1860. He had been subject for seven years to attacks of bronchial asthma, which were much relieved by iodide of potassium and stramonium, prescribed by Dr. Williams in 1856; but they recurred this summer more severely, and were accompanied by more Р Tubular sounds are heard above the right opaque expectoration than usual. scapula, and whiffy sounds below. iodide of potassium, squills, and stramonium, nux vomica, and glycerine, was prescribed. June, 1861.-Has had several attacks: one in April, which was severe, but was much relieved by medicines, and he has been free since. May 20, 1862.-Wintered well at Hyères, with fewer asthmatic attacks; but in April had hæmoptysis amounting to i., which recurred on the journey home. Tubular sounds and crepitation in upper portions of both sides of chest.-Was ordered cod-liver oil in a tonic of phosphoric acid, calumba, and orange. September 29, 1862.-Taken oil well, and has gained flesh. Expectoration streaked with blood. Crepitation still in upper right chest. May, 1863. Wintered well at Cannes, having only two attacks of asthma, which were relieved by taking stramonium pills and burning nitre-paper. Has taken no oil for three months. Dry tubular sounds in upper right chest: no wheeze.-To repeat oil, with nux vomica tonic. October 17, 1864.- Wintered in Italy, and was well till June, when, out fishing, caught cold, and inflammation of the lungs followed, with bloody sputa, and worse cough ever since. Lost 12 lbs. Loud tubular sounds, and some wheeze in right upper chest: some wheeze in upper left. May, 1865.-Improved, gaining flesh, and partially losing cough; but went late to Hyères, and had severe cold and cough for two months. Had lately hæmoptysis amounting to iij. Dulness; tubular sounds in upper right chest; slight crepitation in upper left.-Ordered oil in a tonic of sulphuric acid and calumba. April 6, 1866.-Wintered at Torquay and Ventnor. Always cough, with increased yellow expectoration. Has suffered little from asthma, and has lost flesh and strength. November 25, 1869.-Has remained in England the last two winters and was well till fresh cold last May, but improved in the summer. In October was chilled, and has ever since had bad cough, opaque expectoration, short breath, and great loss of flesh. No asthmatic symptoms. Dry cavernous sounds above right scapula, dulness and tubular above left. Deficient motion, crepitation, and obstruction sounds in left front.—To continue oil with phosphoric acid and calumba. Not seen since; death reported in 1870. CASE 57.-Asthma verging into Phthisis. A clergyman, aged 45.-First consulted Dr. Williams January 8, 1861. He had been subject to eczema from childhood, and to asthma till he was 25, when he visited Corfu. Since then he had only occasional attacks; but last May a severe one occurred. He has not been well since. Nevertheless, continued active in his duties till six weeks ago, when he was laid up with cough, rusty expectoration, fever, and pain in right side of chest. Lately, ASTHMATIC BRONCHITIS TENDING TO PHTHISIS. 211 the cough has ceased, but the patient is losing flesh and strength. Patches have appeared again on his arms for the last nine months. Dulness and tubular sounds in upper part of right chest, chiefly above scapula. Slight bronchophony above left scapula.-Was ordered oil, with mixture containing iodide of potassium; stramonium at night, in case of asthma returning. June 22, 1862.-Has been to Madeira; and improved for six weeks, Then had severe asthma for one month; then returned to England, and has been improving under stramonium and oil. Lately has been taking beer and wine, and has had long sittings in Convocation, and the eczema is increased. -Arsenic solution in gentian mixture was prescribed. September 20, 1866.—Has been much better in skin and breath, suffering rarely, and attacks slight, till last January, when he had an attack of cough, with fever, which was treated by stimulants. Since then the cough has been very bad, with purulent expectoration and night-sweats. A great loss of flesh. Increased dulness, and large tubular sounds in upper right chest. Some obstruction sounds in upper left, in addition to the usual bronchial rhonchi. Under oil and hypophosphite of soda and phosphoric acid he improved much in flesh and strength, and the cough and expectoration abated. July, 1867.-Wintered at Cannes, and continued to improve. Has lately increased in weight one stone. In the last fortnight has had fresh cold; cough moderate. Strength good, and regularly does duty. Expectoration still purulent. Physical signs greatly improved. February 27, 1869.--Spent the following winter at Cannes, and was quite well, able to be much in the open air; but no medicines were taken. In the spring, however, the legs became edematous (no albumen in urine), and remained so more or less up to the present time. In October cough came on, with copious expectoration, first bloody, since very thick and opaque, accompanied by feverish symptoms and much loss of flesh, but the patient has been better lately. No albumen can be detected in the urine. More dulness, and large tubular or cavernous sounds in right upper chest, chiefly below clavicle. Breath not clear at left apex. Dry whiffy emphysematous breathing below. To resume oil, with phosphoric acid and strychnia, and paint the chest with tincture of iodine. August 9, 1870.-Improved much again during the summer, gaining weight and strength, and losing oedema. Remained at home during winter, being quite equal to public duties. In the last month some return of cough, with opaque expectoration, streaked with blood. Patches of eczema have also appeared. Had left off medicine for several months. Dulness in upper right diminished, but occasional click with the tubular sounds.-Oil and tonic to be resumed. August 14, 1871.-Pretty well through last winter; but always opaque expectoration and dulness in upper right. Has lately lost a daughter, aged 15, from acute tuberculosis. CASE 58. Asthmatic Bronchitis passing into Phthisis. A widow lady, aged 35, April 17, 1865. Last autumn had severe cold and cough, with much oppressive dyspnoea, and not quite free since, although exerting her voice much in public recitations and teaching elocution. A fortnight ago had a fresh cold, and since has suffered much from oppressed breathing, cough, and purulent expectoration. No fever now. Loud sibilant and mucous rhonchi in every part, but some breath-sound and clear stroke-sound throughout. Mixture of bromid. potass. squill conium and hop: acetum canthar. lin. May 12, 1865.-Symptoms gradually abated, but still some cough, opaque expectoration, and short breath. Has lost flesh. Rhonchi have cleared up in most parts, but at and above right scapula there is coarse crepitation. -To take oil with mixture of phosphoric acid, calumba, and nux vomica. February 22, 1866.-Improved much in every respect during summer, but never quite lost cough and expectoration, nor the crepitus at right apex. In November had fresh cold, with symptoms of bronchitis, as before; expectoration being purulent or opaque. Improved under similar treatment, but confined to the house. Has taken salines during attack, and oil and tonic in intervals, and so regains flesh and strength. 1871.-In 1868 married again; and has since lived in the country, subject to the attacks in the winter as before. In one, hæmoptysis to the amount of a tablespoonful occurred daily for a week. In more recent examinations, the coarse crepitus, with tubular breath and voice, has continued in the right suprascapular region; and the same signs to a less degree on the left side, but without distinct dulness. Some emphysematous clearness and bulging were manifest in the dorsal regions. Decided tendency to wasting is manifest during and after each attack; but this, and the copious opaque expectoration, have been controlled by steady perseverance with oil and tonics. CASE 59.-Emphysema. Contractile Disease of root and apex. H. K., aged 54, admitted to U. C. Hospital, January 3rd, 1846. A potman at a public-house. In last fourteen years had suffered from colds and cough from exposure, and has had pretty constant short breath since, increasing much of late years, and has several times sought relief in hospitals. Always much worse in winter, and his present attack came on in November, with cough and dyspnoea, greatly disturbing his rest. Expectoration formerly very viscid, and sometimes rusty and partly opaque. Often pains of chest, worse on left side. On admission, extreme dyspnoea, dusky skin, cold extremities, frequent violent fits of cough. Pulse frequent, hard, and sometimes irregular. Tongue much furred. Dulness in upper right, most at sternal end of clavicle. Percussion clear in lower dorsal regions. Breath very wheezy, with prolonged expiration. Inspiration obscure, |