Asthma In The Medical Casebook

 

This Week

This week we’ll have a look at asthma. Like our subject last week [diabetes], a common and important medical condition in the present day, and a far more serious disease in the Victorian era, when some quite entertaining treatments were used.

 

The Illustrator

In our chapter below, we have a beautiful illustration of Sherlock Holmes in disguise, drawn by Alex Holt. Alex has written the following bio of himself:-

Alex Holt is an artist specialising in original ink illustrations. He has a special interest in Comic Art, single image illustrations and covers. Alex is a student of the Edinburgh Atelier of Fine Art. He works in private commissions and commercial projects. More of his work can be found in Instagram @alexholtart.

 

Asthma

Asthma + Sherlock

There are just two references to asthma in the stories. We firstly return to “The Sign Of Four”. Watson and Athelney Jones, Scotland Yard detective, are waiting for Holmes in Baker Street, towards the conclusion of the case.

A heavy step was heard ascending the stair, with a great wheezing and rattling as from a man who was sorely put to it for breath. Once or twice he stopped, as though the climb were too much for him, but at last he made his way to our door and entered. His appearance corresponded to the sounds which we had heard. He  

was an aged man, clad in seafaring garb, with an old pea-jacket buttoned up to his throat. His back was bowed, his knees were shaky, and his breathing was painfully asthmatic. As he leaned upon a thick oaken cudgel his shoulders heaved in the effort to draw the air into his lungs. He had a coloured scarf around his chin, and I could see little of his face save a pair of keen dark eyes, overhung by bushy white brows and long side-whiskers. Altogether he gave me the impression of a respectable master mariner who had fallen into years and poverty.

The seafaring gentleman refuses to speak to anyone but Sherlock Holmes, so the three of them settle to wait uncomfortably.

He came across sullenly enough and seated himself with his face resting on his hands. Jones and I resumed our cigars and our talk. Suddenly, however, Holmes’s voice broke in on upon us.

“I think that you might offer me a cigar too,” he said.

We both started in our chairs. There was Holmes sitting close to us with an air of quiet amusement.

“Holmes!” I exclaimed. “You here! But where is the old man?”

“Here is the old man,” said he, holding out a heap of white hair. “Here he is – wig, whiskers, eyebrows, and all. I thought my disguise was pretty good, but I hardly expected that it would stand that test.”

“Ah, you rogue! cried Jones, highly delighted. “You would have made an actor and a rare one. You had the proper workhouse cough, and those weak legs of yours are worth ten pounds a week.”

 

“Sherlock disguised as a sailor.”

© Alex Holt

Though Holmes disguises himself as a sailor earlier in the same story, this is the first detailed example in the canon of Holmes’s skill in disguising himself. Watson failing to spot Holmes in disguise becomes a running gag featured in a number of the stories.

I think we can also see in this excerpt that it was written by a doctor – this is a detailed description of someone with breathing problems – and likely written by someone who has met patients with asthma. 

We then head to “The Adventure Of The Norwood Builder”. The client of the story is John Hector McFarlane.

“Have a cigarette, Mr MacFarlane,” said he, pushing his case across. “I am sure that, with your symptoms, my friend Dr Watson here would prescribe a sedative. The weather has been so very warm these last few days. Now if you feel a little more composed, I should be glad if you would sit down in that chair, and tell me very slowly and quietly who you are, and what it is that you want. You mentioned your name, as if I should recognise it, but I assure you that, beyond the obvious facts that you are a bachelor, a solicitor, a Freemason, and an asthmatic, I know nothing about you”.

Familiar as I was with my friend’s methods, it was not difficult for me to follow his deductions, and to observe the untidiness of his attire, the sheaf of legal papers, the watch-charm, and the breathing which had prompted them. Our client, however, stared in amazement.

Here, asthma is used as an example of Sherlock’s famous skills of deduction. Interestingly, this being a later story, Watson is able to follow Holmes’s deductions without Holmes’s help, and we don’t get a detailed explanation of the reasoning. Maybe Conan Doyle is allowing Watson to exhibit some of his skills as a general practitioner. This is not a mile off the process I would carry out as a GP, as a patient enters the room. The patient is breathless and wheezy – I need to think about lung conditions. The patient is unkempt – I need to ask about their social situation, and ask a sensitive question exploring mental health issues. The patient is spreading mud everywhere and smells of manure – they are a member or our farming community, who generally don’t come to see me unless there is something seriously wrong. 

“The Adventure Of The Norwood Builder” is a rather odd tale of revenge on an unknowing family member. The villain of the piece, Oldacre, frames MacFarlane for his own murder [as retribution for MacFarlane’s mother rejecting him]. Sherlock, of course, sees through the plot, and exposes Oldacre [a builder], hiding in a secret room he has constructed. 

One interest of the story is the use of fingerprints. The tale is set in 1894, and Oldacre plants one of MacFarlane’s bloody fingerprints at the supposed crime scene. The pioneering work “Finger Prints” by Francis Galton [41], which demonstrated the uniqueness of fingerprints, was written only two years earlier, in 1892. It took another 10 years before they became accepted in British criminal investigations, so Conan Doyle was ahead of his time having Holmes using a fingerprint as a forensic tool.     

 

Asthma In Victorian Times 

Asthma is best regarded as an epileptic discharge causing the plain muscular tissue of the bronchi to contract spasmodically. It may be called a respiratory epileptic fit and is manifested in attacks of shortness of breath of fearful intensity. [5]

We restrict the term to those cases in which the difficulty of breathing occurs distinctly in paroxysms of longer or shorter duration, which at their worst cannot exceed two to three days, and more generally last only a few hours. [8]

I’m sure any asthmatic readers will be horrified at the prospect of having an attack lasting several days, or one bad enough to be compared to a seizure.

Asthma is rather more common in males and is apt to appear during the first decade of life. [5]

The asthmatic physique is rather characteristic; the features denote seriousness, the shoulder are high, the back rounded; there is leanness of body, but a wonderful capacity for mental work – the typical asthmatic is a thin neurotic. Sometimes the asthmatic is of the fat gouty apoplectic type. [5]

The relatives of asthmatics are often of neuropathic stock; neuralgia, megrim, epilepsy, are common in their family histories; so also are eczema, gout and urticaria. [5]

A description of a typical asthmatic that I hope will entertain my asthmatic readers.

Eczema and urticaria are indeed linked with asthma. The other links don’t exist though. Megrim is a rather fine old word for migraine.

The exciting causes of these bronchial spasms are various. In some persons there is no apparent reason for the attack; in others it is brought on by the inhalation of irritating fumes or of disagreeable vapours. In some it is preceded by digestive troubles, or by inflammation of the bronchial mucous membranes; in others, again, an interruption to the free circulation of blood in the lung, or a disturbance in the sexual organs or in the urinary secretions, seems to occasion it. [3]

Some asthmatics suffer if they come near dogs, horses or monkeys, and, by bearing this in mind, you may often obviate attacks over which drugs seem to have but slight control. [6]

So the Victorian understanding of asthma triggers was pretty good, though with some rather odd additional concepts. I am intrigued by monkeys being mentioned as one of the 3 animals that may trigger attacks. However, at the time they were fairly common pets, initially brought home by sailors, and then actively imported for the domestic animal market.

The asthmatic paroxysm is very alarming and the patient’s appearance is very distressing to witness. Open mouth, facial spasm, raised shoulders, body bent forward, hands and shoulders fixed, are obvious features; short violent jerky inspiration and prolonged feeble laboured expiration both fail to give relief; sweating often breaks out, the breathing may not be quickened in number, but the pulse becomes frequent, small and often irregular: there is some cyanosis and the temperature is not raised. [5]

At the end commonly of some hours the fit passes off with copious expectoration, and as suddenly as it came. But it may last for days, ameliorating in the daytime, exacerbating at night, and only easing gradually. [3]

The focus of modern asthma care is the use of inhalers to prevent asthma exacerbations. It has thankfully become rare to see this sort of dramatic, scary presentation.

Treatment during an attack. The exciting cause has usually been removed before the attack has come on. But occasionally you may discover that the bowels are overloaded, and you then commence your treatment with an aperient; in children a dose of castor oil is suitable, in adults calomel and colocynth, or a purgative enema answers best. [6]

You must allay the irritation of the bronchial tubes by having the patient placed in a large and well-ventilated room, which in the winter should be properly warmed. [6]

In severe cases all the supplementary muscles of respiration are called into play, and you will find it most advantageous to let him sit in front of a low table, with the elbows supported by books or cushions. Many have to spend whole nights in this posture, until the severity of the attack has passed away. [6]

In almost every case you will afford relief by inhalations. When the patient is unaccustomed to tobacco a cigar is often sufficient, or the stramonium or datura tatula may be employed. The French “antiasthmatic cigarettes” are still more valuable. Blotting paper soaked in a strong solution of nitre, and afterwards dried and set on fire upon a plate placed near to the patient, seldom fails to lessen the dyspnoea. “Himrod’s remedy” sometimes answers when all others fail. [6]

A cup of hot and strong coffee is commonly useful, and in slight cases offers immediate relief. In other instance small quantities of gin or whisky are more efficacious. [6]

Treatment – The patient’s own views of the best mode of relieving his attacks are worth consideration. [5]

So a splendid range of treatments – the asthmatics amongst you might want to try smoking a cigar, having a strong expresso, and a tot of whisky, next time you have an attack. Along, of course, with the traditional Victorian laxatives to clear the bowels.

Datura stramonium is a plant otherwise known as Jimsonweed or Devil’s snare. Historically this was a key ingredient in “Witches flying powder”, a hallucinogenic drug reputedly used by witches to allow them to travel on beasts and broomsticks. Himrod’s remedy was a popular commercial product, mainly consisting of the same ingredient.

Though to finish our Victorian treatment section, a fine [but unexpected] statement of early “patient-centred medicine”, as we would practice today.

Treatment for the prevention of asthma. The first and most essential point is to ascertain if the residence of the patient is unsuitable. Some are free from the attacks in the midst of a crowded city, others only in the open country; one patient will be best at a considerable elevation above the sea, another on low ground; most suffer at the seaside. [6]

As a general rule, you must insist upon as little food being taken as will suffice to maintain health, and a neglect of this precaution will often provoke a severe attack. [6]

When the digestive and eliminative organs have been regulated it is advisable for you to attempt to improve the nutrition of the nervous centres. If anaemia is a prominent symptom you may use iron, if this is not present you may with greater advantage prescribe zinc. A long course of arsenic is indicated when you find an eczematous eruption has existed, or has alternated with the asthma. Where there is undue excitability of the nervous system strychnia, with or without iron or quinine, will be found more beneficial. [6]

Understandably the Victorian doctor had little idea how to prevent asthma attacks, other than by modifying environmental conditions. Starving the patient, coupled with the use of arsenic and strychnine, would clearly have been disastrous measures.

 

“Victorian asthma inhalers – one splendidly called a Dr Watson’s tin.” [22]

 

Next Week

We’ll have a look at a disease that readers will likely know less about than diabetes and asthma – typhoid fever. Several of the infectious diseases covered in the book rarely occur in the UK any more, yet were serious population health issues in the Victorian period. This was also a disease that Sir Arthur Conan Doyle showed a particular interest in.

Buying The Book

The Medical Casebook of Sherlock Holmes and Dr John Watson is available from all good bookstores including Amazon USA, Barnes and Noble, Amazon UK and additional formats like Kindle.