In such instances the malady comes on gradually. At first it is only during a catarrh that any shortness of breathing is expe rienced ; by and by it recurs more frequently, and with greater severitv, either without the presence of catarrh, or terminating in it; and' depends on such a variety of causes, that it is almost im pmsible to assign the true one. The paroxysm may be excited by local or atmospheric causes, or by derangement of stomach: it is unattended with fever, the sldn generally being cold, and often covered with moisture : the prominent fact is inability to fill the chest with air, as manifested by the gasping for breath, and by the want of breath-Round in the lungs, while there is no permanent cause of obstruction at the larynx or in the trachea, the patient having been quite free from dyspncea before the paroxysm began, and knowing full well that he will be free from it as soon as it is over.
In a very large number of these cases there is some degree of emphysema ; and the more the lungs are thus altered, the more easily is the asthma excited, the more severe is it while it lasts, and the longer its continuance. But there are oases in which we can trace no emphysema, and we are cognizant of nothing but the spasm by which the air is prevented from entering the lungs with its ordinary freedom. The paroxysms are most apt to occur at night; and, besides the immediate object of shortening their duration, we have to consider their relation to local causes, or disordered stomach, with a view to their prevention. It is not unusual to find that certain persons suffer from an attack of spas modic asthma each night that they sleep in a particular locality, and are perfectly free from it as soon as they remove elsewhere.
Hay-asthma is really a catarrh, and has nothing of the parox ysmal character. It cannot be distinguished from ordinary catarrh, except by its recurring at the same season of the year, by its being excited in the immediate proximity of its known cause, or by its surprising and almost immediate cessation on removal from such proximity : these discoveries are more frequently due to accident than to skilful diagnosis.
All other so-called asthmatic cases may be resolved into changes in the permanent condition of the lungs, or diseases of the heart and bloodvessels.
§ 9. Plithisis Pulmona/18.—The existence of tubercles in the lungs is only the local expression of a general disease called by some a blood-crasis, by others a diathesis. Allied to scrofula, it is placed in the table of diseases among the chronic blood ailments, but its most constant manifestation is in disease of the lungs; and it was therefore thOught better to defer its consideration until we had reviewed the other diseases of these organs.
In its characteristic form and advanced stage both general symptoms and local phenomena are so distinct that no disease is more readily or more surely recognized : in exceptional oases it is not unfrequently mistaken for other diseases, while they in their turn are liable to simulate phthisis : in its early manifesta tion it is very important to be able to recognize it while yet latent, and before its symptoms are fully developed. Its sadly fatal
course makes the conscientious practitioner view these early phe nomena with great anxiety, and study their relations with the greatest care ; as the dread in which it is universally held serves as a never-failing resource for the fraudulent and the avaricious, who pretend to detect phthisis when it does not exist, and promise a cure alike to those whom they thus deceive as to the true nature of their malady, and to those whom they delude with false hopes as to the powers of art, when their case is already past recovery.
The history comprises several points of considerable value in diagnosis: loss of relatives from diseases of the chest under what ever name, especially those occurring at the period of adolescence; accounts of previous illnesses and ailments of the patient himself; and the mode in which his present attack has commenced. It must be regarded as unfavorable when cough has begun without preceding catarrh or coryza, but has been from the first dry and hacking; when during its continuance, or at its beginning, there has been luemoptysis of the amount of a teaspoonful or more; and when in the progress of the case the dry cough has been changed for one accompanied by thin mucilaginous rice-water sputa, and that form of expectoration has been followed by thick yellow phle gm.
The general symptoms very often indicate the presence of hec tic : the skin, especially that on the palms of the hand, being at times dry and hot, while at others it is bedewed with excess of moisture; there are also night-sweats, the pulse is quick and weak, the tongue frequently patchy, and sometimes preternaturally red, shining, or smooth. Along with this we have the particular in dications of remarkable thinness of the skin, which can be pinched up, as if it were detached from the subcutaneous structure, and clubbing of the nails, with the occasional presence of diarrhoea: any signs of emaciation are of value when not traceable distinctly to disease of the chylopoietic viscera. The patient's appearance sometimes betrays weakness, with a mixture of languor and ex citability; the eye brilliant, the cheek pale, with a hectic flush, and the whole aspect delicate. The respiration is observed to be quick, while the patient has no feeling of dyspncea, and does not seek by posture to relieve his breathing. No complaint of cough, perhaps, is made till it be inquired after; there may be mention of wandering pains in the cheat, of a feeling of tightness, or per haps of local pain from intercurrent pleurisy. The voice is very often characterized by a slight degree of hoarseness, which, as the disease proceeds, may ultimately terminate in complete aphonia.