TREATMENT.

Before beginning any treatment whatever, the patient must first be examined with regard to any disease of the lungs, heart, or kidneys; besides this, one must look for holding points for the belief in a decided result of the rhinosurgical treatment, and it is best always to be very reserved in expressing anything to the patient as regards the influence a local treatment may have upon the asthmatic attacks. I always consider it a great mistake to begin a local treatment of the nose in those cases where the clinical picture gives no decided support to the belief in a causal connection between the nasal disease and the asthmatic attacks; it is, in these cases, only when the patient himself wishes it, after he has vainly tried every other treatment, that one ought to begin the rhino-surgical treatment, but the result will probably be negative with regard to the asthma, though it may otherwise do the patient some good by curing his nose (see case No. 25).

As asthma first of all, as remarked above, depends upon a central complaint of the nervous system, and only the separate attacks are supposed to be caused by reflexes from the peripheral nerves, in these cases those of the mucous membrane, the treatment must be in several divisions which reciprocally supplement one another.

I. The general strengthening treatment, which specially aims at the increased reflex irritability of the medulla oblongata, must consist in strengthening hygiene, fresh air, good fare, methodical bodily exercise, sea-bathing, sea-trips, a stay in the country, etc.

Besides this, one must give the patients iron or arsenic, and apply such remedies as are known to have a strengthening influence on the nervous system. Daily cold or temperate washings of the whole or only the upper part of the body are, when carefully applied, of very good use. This strengthens the nervous system and counteracts the disposition to frequent colds which are so fatal for asthmatic people. We may also here mention treatment with compressed air, particularly in pneumatic chambers, which often has a surprisingly good effect upon asthma, although as a rule it lasts only a short time. The cause of this effect is partly that the respiration becomes deeper and easier, the oxidation of the organism more thorough, and the patient's general condition is improved; and partly that the compressed air has very good therapeutic qualities in all cases of chronic catarrh in the air passages, both of the nose, the larynx and the bronchi.

II. The local nasal treatment must be conducted according to the usual rhino-surgical principles. It is necessary to be very thorough, that is, to continue the treatment until the nasal complaint is cured; it often takes months of work, and requires great patience both of the operator and of the patient. Armed as we now are with well constructed instruments, and in possession of cocaine, by means of which nearly all operative treatment can be made absolutely free from pain, the treatment is not very encroaching, particularly when there is time and opportunity to proceed slowly, and distribute the treatment over a good stretch of time.

III. Hereto must be added a number of remedies that are applied during the asthmatic attacks, and which relieve or stop them, amongst which smoking with saltpetre paper or with a mixture of pulverised saltpetre and lobelia leaves is deservedly the best enumerated. I do not, however, intend to enumerate all the different remedies which in the course of time have been

recommended for asthma, as every more important manual of pathology will give all the necessary information.

If we now briefly sum up the result of this work it will be as follows:

I. That asthma must be considered as a bulbar neurosis.

II. That the bulbar neurosis, which consists in an excessive reflex irritability of the respiratory centre, may be, though comparatively seldom, accompanied by a state of general nervousness, and in this case as a rule has the same etiological origin as hysteria or neurasthenia (whether it be inherited or acquired).

III. That the bulbar neurosis may develop after weakening factors, such as child-birth, bleeding, continued fever, etc.

IV. That the bulbar neurosis sometimes appears in otherwise apparently healthy individuals without any trace of other nervous phenomena, and in these cases it is presumedly the result of frequent and strong irritations, which are conducted to the respiratory centre from the nasal fibres of trigeminus, (to which the irritation of other nerves, specially of the laryngeal and pulmonal fibres of the pneumogastric nerve, may be added).

V. That an asthmatic attack in many cases may originate from the mucous membrane of the nose if only the necessary condition and the increased bulbar reflex-irritability be present, and that, ceteris paribus, irritations conducted to the medulla oblongata from any sensitive nerve whatever, are capable of causing an asthmatic attack.

VI. That it is possible in some cases, by suppression of the peripheral irritations, e.g., in one case by a careful treatment of a

chronic nasal catarrh, to stop definitely the asthmatic attacks, but that this in many cases first succeeds after also having applied a generally strengthening treatment which aims at the central nervous complaint.

VII. That one ought, in every case of asthma, to examine the nasal cavity, and eventually, if the form of the disease and the objective state give a right to suppose a decided connection between the asthmatic attack and the nasal complaint, to put the patient under competent treatment.

VIII. That nasal diseases may accidentally accompany cases of asthma, without having any etiological connection with the asthmatic attacks.

I have in the above attempted a description of the relation between asthma and the nasal diseases, from the point of view from which it, in accordance with our present experiences, must be considered. The exclusive etiological importance of the nasal pathology with regard to asthma, which it has at first been. attempted to vindicate, has been duly restricted. Although Hack, in his first enthusiasm over the seemingly wide bearing of his new observations, shot far beyond the mark, his great merit consists in the fact that he extended our views and brought within our reach a number of complaints, which up to that time had been almost entirely unnoticed by the medical world in general. It may be that his conclusions were partly wrong, because they went too far, but at any rate he gave the impulse to a diligent investigation of this question, which made it possible to decide the proper limits for the importance of the nasal diseases with regard to a number of neuroses and specially to asthma. It has been seen that many cases of asthma can be influenced by local treatment of the nose, and that some cases

can be entirely cured; but we have also seen that as asthma depends upon an affection of the central nervous system, a local treatment of the peripheral organs from which the nervous attack proceeds, is not always sufficient to cure the disease, and it must always be remembered in treating such cases as these, that one generally has to do with a suffering person, who is not merely an appendix to his nose (Kurz).*

* Kurz, Ueber Reflexhusten, Deutsch. med. Wochensch., 29th March, p. 247 1888.