Mr. W——, an elderly gentleman, was seized with asthma during the hot part of last summer; he always waked from his first sleep with difficult respiration, and pain in the middle of his sternum, and after about an hour was enabled to sleep again. As this had returned for about a fortnight, it appeared to me to be an asthma complicated with the disease, which Dr. Heberden has called angina pectoris. It was treated by venesection, a cathartic, and then by a grain of opium given at going to bed, with ether and tincture of opium when the pain or asthma required, and lastly with the bark, but was several days before it was perfectly subdued.
This led me to conceive, that in this painful asthma the diaphragm, as well as the other muscles of respiration, was thrown into convulsive action, and that the fibres of this muscle not having proper antagonists, a painful fixed spasm of it, like that of the muscles in the calf of the leg in the cramp, might be the cause of death in the angina pectoris, which I have thence arranged under the name of painful asthma, and leave for further investigation.
From the history of the case of the late much lamented John Hunter, and from the appearances after death, the case seems to have been of this kind, complicated with vertigo and consequent affection of the stomach. The remote cause seems to have arisen from ossifications of the coronary arteries; and the immediate cause of his death from fixed spasm of the heart. Other histories and dissections are still required to put this matter out of doubt; as it is possible, that either a fixed spasm of the diaphragm, or of the heart, which are both furnished with but weak antagonists, may occasion sudden death; and these may constitute two distinct diseases.
Four patients I have now in my recollection, all of whom I believed to labour under the angina pectoris in a great degree; which have all recovered, and have continued well three or four years by the use, as I believe, of issues on the inside of each thigh; which were at first large enough to contain two pease each, and afterwards but one. They took besides some slight antimonial medicine for a while, and were reduced to half the quantity or strength of their usual potation of fermented liquor.
The use of femoral issues in angina pectoris was first recommended by Dr. Macbride, physician at Dublin, Med. Observ. & Enquir. Vol. VI. And I was further induced to make trial of them, not only because the means which I had before used were inadequate, but from the ill effect I once observed upon the lungs, which succeeded the cure of a small sore beneath the knee; and argued conversely, that issues in the lower limbs might assist a difficult respiration.
Mrs. L——, about fifty, had a small sore place about the size of half a pea on the inside of the leg a little below the knee. It had discharged a pellucid fluid, which she called a ley-water, daily for fourteen years, with a great deal of pain; on which account she applied to a surgeon, who, by means of bandage and a saturnine application, soon healed the sore, unheedful of the consequences. In less than two months after this I saw her with great difficulty of breathing, which with universal anasarca soon destroyed her.
The theory of the double effect of issues, as above related, one in relieving by their presence the asthma dolorificum, and the other in producing by its cure an anasarca of the lungs, is not easy to explain. Some similar effects from cutaneous eruptions and from blisters are mentioned in Class [I. 1. 2. 9]. In these cases it seems probable, that the pain occasioned by issues, and perhaps the absorption of a small quantity of aerated purulent matter, stimulate the whole system into greater energy of action, and thus prevent the torpor which is the beginning of so many diseases. In confirmation of this effect of pain on the system, I remember the case of a lady of an ingenious and active mind, who, for many of the latter years of her life, was perpetually subject to great pains of her head from decaying teeth. When all her teeth were gone, she became quite low spirited, and melancholy in the popular sense of that word, and after a year or two became universally dropsical and died.
M. M. Issues in the thighs. Five grains of rhubarb, and one sixth of a grain of emetic tartar every night for some months, with or without half a grain of opium. No stronger liquor than small beer, or wine diluted with twice its quantity of water. Since I wrote the above I have seen two cases of hydrops thoracis, attended with pain in the left arm, so as to be mistaken for asthma dolorificum, in which femoral issues, though applied early in the disease, had no effect.
[12]. Stridor dentium. The clattering of the teeth on going into cold water, or in the beginning of ague-fits, is an exertion along with the tremblings of the skin to relieve the pain of cold. The teeth and skin being more sensible to cold than the more internal parts, and more exposed to it, is the reason that the muscles, which serve them, are thrown into exertion from the pain of cold rather than those of respiration, as in screaming from more acute pain. Thus the poet,
Put but your toes into cold water,