Physician to the Northampton General Infirmary.

THE accompanying case of spasmodic asthma due to pneumogastric irritation has the causes and symptoms of that distressing though interesting malady so well marked, that a detailed account with remarks thereon may be worthy of being recorded in the pages of the Practitioner.

S. W., aged 23, in service as cook, dark hair, fair rosy complexion, moderately well nourished, native of a village near Northampton, was in the enjoyment of full and robust health until twenty years of age. She never had any previous pulmonary ailment, her only illness having been an acute attack of rheumatism in early life.

At that age she went into service as cook in a low-ceiled kitchen with stone floor, where all the cooking was performed by gas-stoves. The room was hot and close, and the smell from the burning gas often very offensive.

A few weeks afterwards she was seized in the middle of the night, during a first sound sleep, with tightness and oppression of the chest, suffocative shortness and quickness of breathing, inability to take a full inspiration, with a wheezing and whistling respiration. This would last some two hours, when cough would supervene, with expectoration of some phlegm gradually increasing in quantity for the ensuing four or five hours, when with the increase of expectoration the spasm would subside, the tightness of the chest relax, and the breathing become slower, fuller, easier, and more tranquil. The attack would last with abating severity until about three o'clock in the afternoon, or a

general period of twelve hours from its commencement at 3 A.M., when she would feel herself quite well again.

These attacks recurred every third week, occasionally only keeping off until the expiration of the month, appearing each time of the catamenial period. It should be mentioned here that later on, when the fits became more frequent, they were always attended by a menorrhagic loss. She admits that she was very neglectful of the state of her bowels, being usually very constipated, and that she subsequently learnt to anticipate an attack from noticing that the urine became for some days previously very turbid with a heavy red deposit.

Attributing her illness to living in the impure atmosphere of this gas-cooking kitchen, she changed her situation to another in Northampton, where the kitchen was larger, airier and above ground, and with open fire cooking. Here the attacks were less frequent, coming on only at the monthly periods, always at 3 A.M., and lasting until the middle of the following day. Owing to the regularity of their recurrence and her consequent inability to do her work, she had after twelve months to leave that place, when she returned home to a bleak exposed village. Here she fared worse, the seizures being more frequent and lasting longer.

About this time, namely the latter end of 1872, she discovered that eating pork any how cooked, salted beef, ham, pastry, cheese, frizzled bacon, taking ale or porter at supper-time, or any exposure to night air, generally brought on an attack at 3 A.M. the following morning; but there was this difference noticed in the seizures induced under those circumstances, namely, that they were unattended by any uterine flux.

She had then been advised to limit her beverage to weak brandy and water, and upon the accession of every attack to take two tea-spoonfuls of ipecacuan wine, to induce vomiting, which was always followed by speedy marked relief.

In January 1873 she engaged herself as cook with a family at Silsoe, in Bedfordshire, a low-lying, damp locality. Here the attacks recurred at the same hour every Sunday morning for a period of ten weeks, and were always attended with uterine hæmorrhage. She assigned as a probable reason, the extra amount of domestic work on the Saturday.

She being apparently a very confidential servant and no mean culinary artiste, the family on visiting Cheltenham took her with them. There, for the first four of a seven months' residence, she had an immunity from any attack; during the latter three months they returned, and during the last fortnight she had two more violent attacks, lasting two days on both occasions, attended by menorrhagia of three days' duration.

The urine, as I have before mentioned, was always heavily loaded before the fits; subsequently it became limpid and very much in excess of the usual amount of secretion.

Of her own accord she mentioned that she had been much vexed with herself that previous to these attacks she had felt so mentally excited, touchy, irritable in temper, and even quarrelsome with her many fellow-servants, it being a large establishment.

Saving the cough and expectoration on the subsiding of a fit, she was during the interval entirely free from either; though conscious of an amount of wheezing at the chest for a length of time afterwards, but not aware of any such noisy respiration previous to an attack coming on, which she described as "sudden and during sound heavy sleep." She returned home from Cheltenham last August, and finding herself no better, but rather worse (even though every care as to diet and exposure was observed), at her parents' home, took lodgings in Northampton in the beginning of November, when she came under my notice.

As I was not then in possession of the above history, her weekly attacks of asthma were considered as owing partly to constipated bowels, deficient renal secretion, to hysteria, and possibly sleeping in a too-crowded room. She was prescribed an aperient pill with a stimulant alkaline antispasmodic, with instructions to have better ventilation in the sleeping room, and, an attack coming on, to produce a vomit by ipecacuan wine, after drinking freely of warm barley water.

As she did not manage herself to my satisfaction, I admitted her to the infirmary, thereby affording myself more favourable opportunities of judging of the predisposing and exciting causes of the malady.

There was no lesion of the cardiac action, it being equable

and normal; slight bronchitic râles over the upper lobes of both lungs and middle lobe of right; the bowels much constipated; the urine scanty, thick, and depositing lithates in abundance.

The treatment was directed to daily gentle opening of the bowels, increasing and neutralising the excessively acid secretion of the kidneys, with counter-irritation of the chest by an iodine solution.

Before the alvine and renal functions could be brought into activity she had an attack at the usual hour in the morning, attended by a profuse hæmorrhagic discharge. This was so much in excess as to call for some suppression, which was accomplished by a few doses of cannabis indica; an antimenorrhagic remedy, first brought under the notice of the profession by, and of which I hope hereafter to say something in, the Practitioner.

There was only one other severe attack whilst in the house, due I believe to a little over-indulgence in roast beef and plumpudding last Christmas Day.

There were several threatenings of attack, which by the administration of a few minims of chloroform at first, and lastly by a pill of one grain of the extract of belladonna, were averted.

She left the house after seven weeks' residence, expressing herself better than she had been for the past three years.

There are many points in the pathology of this case deserving of consideration, especially in connection with that mysterious complaint, hay asthma.

Admitting the moot point of the muscular irritability and contractility of the bronchi and smaller ramifications of airtubes, I would confine myself entirely to the probable predisposing and exciting causes of such spasmodic action.

In the first place, we may justly assume that the continued breathing of heated air, charged with much mephitic moisture from gas-burning in a close room, was a source of irritation of the pulmonary plexus of the vagus.

Secondly, that the depuration of the blood from carbonic acid must have been much interfered with by the quantity existing in the respired air.

Thirdly, we may be justified in assuming that lengthened

irritation of the pulmonary plexus would be reflected on to the gastric plexus.

Fourthly, deficient function, alvine and renal, would induce, in excess neurosis of the great sympathetic.

Fifthly, that imperfect oxygenation of the blood may account. for the excessive acidity and loaded condition of the urine; as also an amount of hepatic congestion evidenced by the attendant uterine flux under the irritation of habitually constipated bowels.

Sixthly, it should be carefully borne in mind that whenever the main lines of the nervous organisation of animal life, all connected together by innumerable interlacing filaments, have from one cause or other been subjected to frequently recurring excitation, they acquire an irritability which from any slight cause impressed upon any one point or link in the chain, whether central or peripheral, may throw the whole group into disturbed action.

In reference to this last, as merely explanatory of the case in hand, I would suggest for consideration those wonderful and unintelligible symptoms evidenced in periodic epilepsy, which are seldom if ever fully developed in a first attack (there being initial stages) of the malady, the causes of which I am sure and certain in very many instances the discerning physician can check and remove if on their outset they come under treatment, but, neglected, "vires acquirit eundo," become confirmed, and then too often baffle the highest remedial treatment.

During the past few years a theory of sleep has been propounded, as due to slight venous congestion and to the sedative influence upon the cerebral organs from an excess of carbon in the circulation. If this may be assumed, it may also be inferred that, in cases where, from continued breathing of a moist, hot, impure air, the arterial fluid has too much the character of the venous from deficient decarbonisation, and where not only sleep would be much heavier and sounder, but the lungs would be labouring in their function of adequately excreting effete. matter from the system, there would, in consequence, be an active predisposing cause of irritation of the pulmonary branches of the vagus. Again, if this condition persists in the female economy on the approach of the menstrual period, when some

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