Chapter XII: Part 12

In the first stage of acute attacks involving the bronchi of both lungs in vigorous adult persons, and especially if the inflammation extends into the smaller tubes, causing much dyspnoea and dry râles, there is no single remedy that will so certainly and speedily check the intense engorgement of vessels in the bronchial membranes, and thereby gain time for the action of other remedies, as one prompt and liberal abstraction of blood by venesection. In cases of a little less severity, and in children, the application of from two to twelve leeches to the upper and anterior part of the chest, the number being regulated by the age of the patient, will be a good substitute for the venesection. And in case leeches are not at hand extensive dry cupping over both the anterior and posterior parts of the chest may be applied with much benefit. Immediately after the venesection, leeching, or cupping, and without these in cases of only ordinary severity, the whole chest may be enveloped in an emollient poultice or in folded napkins wet in warm water and covered with oiled silk. At the same time the following combination may be given internally: {179}

No. 1. Rx. Liquoris ammonii acetatis, (60.0 c.c.) fluidounce ij;
Tincturæ opii camphoratæ, (75.0 c.c.) fluidounce iiss;
Vini antimonii, (15.0 c.c.) fluidounce ss;
Tincturæ veratri viridis, (6.0 c.c.) fluidrachm iss.

M.--Sig. Give to an adult 4 cubic centimeters or 1 teaspoonful in a tablespoonful of water every two, three, or four hours, according to the severity of the case. The same may be given to children, the dose being properly adjusted to the age of the child.

If the tongue be coated, the bowels inactive, and urine high-colored, from 6 to 30 centigrams (grs. j-v) of calomel, according to the age of the patient, may be given, and followed in four or five hours by a saline laxative sufficient to procure two or three evacuations from the bowels. Under the influence of these remedies the high fever and great sense of soreness and oppression in the chest which exist in the first stage of the more acute cases in previously healthy subjects rapidly diminish, giving place to more moist râles, easier breathing, and some expectoration. As soon as such amelioration of symptoms has been obtained, the mixture containing veratrum viride should be discontinued, and the following formula substituted in its place:

No. 2. Rx. Syrupi scillæ comp. (45.0 c.c.) fluidounce iss;
Tincturæ sanguinariæ, (15.0 c.c.) ounce ss;
Tincturæ opii camphoratæ, (60.0 c.c.) fluidounce ij.

M.--Sig. Give to an adult 4 cubic centimeters in a little additional water every three or four hours.

If the patient suffers much from severe sore pain in the head, aggravated by coughing, or from nervous restlessness, the addition of bromide of potassium, 16 grams (drachm iv), to the above formula will render it more efficient in relieving these symptoms and in promoting rest. Under such quieting and expectorant influences, aided by a mild laxative when needed, the cough, soreness, and oppression in the chest, and all other active symptoms, diminish from day to day, and convalescence ensues in from seven to nine days.

If after the first three or four days the temperature rises in the evening and the cough becomes more troublesome, interfering with rest during the first part of the night, followed by some sweating in the early morning, a single dose composed of sulphate of quinia from 3 to 6 decigrams (gr. v-x), pulverized sanguinaria-root 3 centigrams (gr. ½), and codeine 16 milligrams (gr. ¼) given between six and eight o'clock each evening for three or four evenings, will often contribute to the rest of the patient and hasten the establishment of convalescence.

Cases are sometimes met with, especially in patients debilitated by previous ill-health or age, in which the fever subsides after the first three or four days, leaving the patient with a feeling of unusual weakness, a deep harassing cough, copious muco-purulent expectoration, and little or no appetite. In such cases tonics and the more stimulating class of expectorants are indicated. A mixture of equal parts of the syrup of Prunus virginiana, syrup of senega, and camphorated tincture of opium, given in doses of 4 cubic centimeters or one teaspoonful every four or six hours, and 13 centigrams (gr. ij) of quinia three times a day, will often cause a rapid improvement in all the symptoms. In some of the cases last described there is added to the other symptoms a troublesome nausea and disposition to vomit with the paroxysms of coughing, in which I have found the following formula a good substitute for the mixture containing the prunus virginiana and senega:

No. 3. Rx. Acidi carbolici, (0.50 grams) gr. viij;
Glycerinæ, (30.0 c.c.) fluidounce j;
Tincturæ opii camphoratæ, (60.0 c.c.) fluidounce ij;
Aquæ, (60.0 c.c.) fluidounce ij.

{180} M.--Sig. Give 4 cubic centimeters (fluidrachm j) or 1 teaspoonful before each mealtime and at bedtime, giving the quinia a little after the meals.

If more anodyne influence is required to procure rest at night, 16 milligrams (gr. ¼) of codeine may be added to the teaspoonful of carbolic acid mixture given at bedtime. If, as sometimes happens in cases of acute bronchitis, both of the catarrhal and capillary varieties, the inflammation invades some of the lobules of the lungs, as indicated by undue rise of temperature, greater expansion of the wings of the nose during inspiration, with short expiration, and diminished resonance with fine crepitation over limited portions of the chest, I have found the most certain and speedy relief to follow the application of a blister over the seat of the pneumonia and the internal use of the following formula:

No. 4. Rx. Ammonii chloridi, (12.00 grams) drachm iij;
Antimonii et
potassii tartratis, (0.13 grams) gr. ij;
Morphiæ sulphatis, (0.20 grams) gr. iij;
Extract, glycyrrhizæ fluidi, (30.0 c.c.) fluidounce j;
Syrupi, (90.0 c.c.) fluidounce iij.

M.--Sig. Give to adults 4 cubic centimeters (fluidrachm j) or 1 teaspoonful, mixed with a tablespoonful of water, every three or four hours until some relief is obtained, and then at longer intervals. For children the doses must be diminished in proportion to the diminution of age. Quinine and laxatives may be used in these cases under the same indications as in uncomplicated bronchitis.

In the severe attacks of capillary bronchitis in young children many writers recommend emetics, and subsequently nauseating doses of antimony or ipecacuanha. But I have not seen sufficient benefit result from emetic doses of these agents to compensate for the early prostration, and sometimes continued gastric irritability, which they induce. I prefer the proper application of leeches at the very beginning, followed by emollient applications to the chest, and the same remedies internally as already mentioned, aided, perhaps, by an earlier use of quinine and digitalis if the cardiac action becomes weak and frequent. In all this class of cases, however, much caution should be exercised in regard to the use of opiates, either alone or in combination with other remedial agents, lest their narcotizing influence should diminish the force and frequency of the respiratory movements too much, and encourage the accumulation of the inflammatory products in the smaller bronchi to such a degree as to produce apnoea or death by the exclusion of air from the alveoli or air-cells of the lungs. And yet just enough of these quieting agents to diminish excitability and allay excessive restlessness is as desirable in children as in adults.

In the plastic or pseudo-membranous form of bronchitis it is an object of much importance, in the first stage, to limit the amount of plastic exudation, and later to hasten the loosening and disintegration or discharge of such layers of false membrane as may have formed on the bronchial mucous surface. For these purposes alterative doses of calomel may be given alternately with the doses of the formula containing the liquor ammonii acetatis already given (see Formula No. 1) during the first twenty-four hours, and subsequently pretty full doses of the iodides of sodium or potassium or of the bicarbonates. In acute cases in children, when the symptoms indicate that the false membrane is loosening and the dyspnoea is great, an emetic that will induce prompt and free vomiting may hasten its expulsion and afford much relief.

In the cases which have been described as rheumatic bronchitis of the more acute or active grade I have seen the most prompt and satisfactory degree of relief follow the administration of the following combination of remedies in the early stage: {181}

No. 5. Rx. Sodii salicylatis, (25.00 grams) drachm vj;
Glycerinæ, (15.00 c.c.) fluidrachm iv;
Vini colchici radicis, (25.00 c.c.) fluidrachm vj;
Syrupi scillæ compositi, (45.00 c.c.) fluidounce iss;
Tincturæ opii camphoratæ, (60.00 c.c.) fluidounce ij.

M.--Sig. Give 4 cubic centimeters (fluidrachm j) every three or four hours in a little additional water.

In several cases in which this grade of inflammation was located chiefly in the smaller bronchi, causing very distressing and persistent dyspnoea, I have found an equal mixture of the wine of colchicum-root and the acetated tincture of opium, given in doses of 25 to 30 minims every three hours at first, to afford more relief than any other remedies I could use; and after some degree of relief had been obtained, by lengthening the interval between the doses to four or six hours and continuing it a few days, all the symptoms were removed. When the disease occurs in old persons, accompanied by severe paroxysms of coughing and only a scanty and very viscid mucous expectoration, much benefit may sometimes be derived from the use of the carbonated alkalies, such as the carbonate of ammonium or bicarbonate of sodium, dissolved in an equal mixture of the fluid extract of the Phytolacca decandra, liquor ammonii acetatis, and camphorated tincture of opium, in such proportions that the patient will get 3 decigrams (gr. v) of carbonate of ammonium in each dose of the mixture.

It is proper to remark that there are many mild attacks of bronchitis, caused by exposure to sudden and severe meteorological changes, which if seen during the first twenty-four hours can be speedily arrested by a hot or stimulating foot-bath and a full dose of the compound powder of opium and ipecacuanha (Dover's powder), taken in the evening, and followed the next morning by a saline laxative and two or three moderate doses of quinine during the day. Similar results can also be obtained in some cases by the use of any agents that will allay irritability and at the same time produce a free or copious elimination from the skin and kidneys. An efficient diaphoretic dose of pilocarpine, or a full warm bath, followed by two or three moderate doses of quinine, will succeed well if employed in the initial stage of the disease. Unfortunately, but few cases come under the care of the physician until after this stage is past.

TREATMENT OF CHRONIC BRONCHITIS.--Most of the cases of chronic bronchitis are treated satisfactorily by a more moderate use of the same remedial agents that have been recommended in the acute and subacute grades of the disease, aided by a judicious regulation of diet, dress, and exercise. In the great majority of cases of the ordinary chronic catarrhal variety of bronchitis the formula already given, numbered 4, or the one numbered 2, if given to adults in doses of 4 cubic centimeters (fluidrachm j) before each meal and at bedtime, mixed with a tablespoonful of water, will afford the necessary relief without confining the patient to the house. If the bowels become constipated while using either of these prescriptions, the evil may be obviated by taking one of the following pills every evening:

No. 6. Rx. Extract. hyoscyami, (2.00 grams) gr. xxx;
Ferri sulphatis, (2.00 grams) gr. xxx;
Pulveris aloës, (2.00 grams) gr. xxx;
Pilulæ hydrargyri, (2.00 grams) gr. xxx.

M. et ft. pil. No. XXX. If one pill taken every evening does not prove sufficient to prompt one natural intestinal evacuation each morning, another can be taken after breakfast. The patient should adhere to a plain, nutritious, and easily digestible diet, avoiding the use of all varieties of alcoholic drinks, wear good warm underclothes of flannel all the time, and take moderate daily outdoor exercise so long as the strength will permit.

{182} In addition to the several remedies that have been mentioned as applicable to the treatment of the different varieties of acute and subacute bronchitis, there are many others that have been found more or less beneficial in the treatment of chronic cases. Among the more important of these are the iodide of potassium and sodium, the grindelia robusta, eucalyptus globulus, oenothera biennis, cimicifuga racemosa, asclepias tuberosa, balsams copaiba and tolu, gum benzoin, turpentine, cod-liver oil, and the hypophosphites of sodium, calcium, and iron; and a still larger number that have been used for inhalation. As a general rule, when the cough is harsh and the expectoration scanty, with the predominance of dry râles, such remedies as the muriate and iodide of ammonium and the iodides of potassium and sodium, given in conjunction with small doses of antimony and some mild anodyne, will produce the best effects. On the other hand, if the expectoration is abundant and of a muco-purulent character, the balsamic and terebinthinate remedies, given in connection with such tonics as the lacto-phosphate of calcium, phosphate of iron, sulphate of quinia and strychnia with codia, hyoscyamia, or lupulin, at night to procure rest, will afford the greatest relief. In some of these cases I have obtained very good effects from a combination of two parts of the syrup of iodide of calcium with one of the fluid extract of hops, given in doses of 4 cubic centimeters (fluidrachm j) each morning, noon, tea-time, and bedtime.

When chronic bronchitis is complicated with pharyngitis and laryngo-tracheitis, much palliative influence may be obtained by judiciously-directed inhalations, either in the form of vapor or atomization. But when the disease is limited to the bronchi alone, inhalations have much less influence over its progress or in relieving the more distressing symptoms. And unless the nature of the material used is judiciously selected with reference to the particular stage and grade of the disease, the inhalations will be more likely to do harm than good. There are two conditions of the bronchi met with in different cases of chronic bronchial inflammation to which local applications can be made in the form of vapor with much benefit. The first is indicated by an abundant purulent or muco-purulent expectoration, sometimes fetid and at other times not. For such the full deep inhalation of aqueous vapor impregnated with some antiseptic and anodyne will be of great service. One of the best combinations that can be used for this purpose is that of carbolic acid with camphorated tincture of opium in the proportion of 2 grams of the former (gr. xxx) to 90 cubic centimeters (fluidounce iij) of the latter; 4 cubic centimeters (fluidrachm j) of this mixture may be put into 250 cubic centimeters (fluidounce viij) of hot water in an inhaling-bottle and the vapor inhaled freely, five minutes at a time, two or three times each day.

The second condition alluded to is characterized by a persistent, harsh, irritating cough, with little or no expectoration, indicating a sensitive and congested condition of the mucous membrane with diminished secretion. Such cases may generally be much relieved by adding to the antiseptic and anodyne mixture just given some one of the oleo-resin or balsamic preparations, of which perhaps none are more efficient than that which is known in the shops as oil of Scotch pine. Four cubic centimeters (fluidrachm j) of this may be added directly to the quantity of the other ingredients already given, and then used in the same manner. The combination thus used appears to allay the morbid sensitiveness and speedily establishes a better secretory action.

There is another important class of cases met with most frequently in persons of both sexes between twelve and twenty years of age. They present a narrow, imperfectly-developed chest, with so sensitive a condition of the bronchial membrane that every trifling exposure to cold and damp air renews the vascular hyperæmia and cough, until both become permanent and the morbid process extends into the connective tissue of the pulmonary lobules, {183} establishing what some call interstitial pneumonia and others fibroid phthisis. In the earlier stage of all this class of cases the systematic daily practice of full, deep inhalations of pure atmospheric air, coupled with a judicious exercise of the muscles of the chest and arms, will do more to remove all symptoms of bronchial disease and preserve the general health of the patient than all the medicines that have been hitherto devised. There is much evidence in favor of using compressed air for inhalation in these and some other cases of bronchial inflammation. The late F. H. Davis of this city, who during his brief professional career gave much attention to the treatment of diseases of the respiratory organs, and had good opportunities for clinical observation, says, when speaking of the same class of young subjects, that "the inhalation of compressed air for from five to ten minutes once or twice a day produced marked and rapid improvement in all the cases. The size of the chest on full inspiration was increased from one-half inch to one inch in the first month, and a habit of fuller, deeper breathing and a more erect carriage was established."[8] But he adds, with proper emphasis, that the inhalations to be permanently curative must be continued faithfully for many months, and be accompanied by a judicious regulation of all the habits of life.

[Footnote 8: See paper read before the Chicago Society of Physicians and Surgeons, April, 1877, on "The Respiration of Compressed and Rarefied Air in Pulmonary Diseases."]

Every physician of much practical experience knows, however, that, in defiance of all the remedies and methods of treatment hitherto devised, there are many cases of chronic bronchial inflammation which will continue, and be aggravated at every returning cold season of the year, so long as the patient lives in a climate characterized by a predominance of cold and damp air with frequent and extreme thermometric changes. And yet a large proportion of these, by changing their residence to a mild and comparatively dry climate, either greatly improve or entirely recover. Consequently, in all the more severe and persistent cases such a change is of paramount importance, and should be made whenever the pecuniary circumstances of the patient will permit. Probably the best districts in our own country to which the class of patients under consideration can resort are the southern half of California, the more moderately elevated places in New Mexico and the western part of Texas, Mobile in Alabama, Aiken in South Carolina, and most of the interior parts of Georgia and Florida. My own observations lead me to the conclusion that the unfortunate invalid, suffering from any grade of chronic bronchial inflammation, can find in some of the regions named all the relief that could be gained in the most celebrated health-resorts on the other side of the Atlantic. But adherence to strictly temperate and judicious habits of life, with regular daily outdoor exercise, is essential to the welfare of the invalid in whatever climate he may choose to reside.

In the foregoing pages I have said nothing concerning the management of those cases of asthma, emphysema, interstitial pneumonia, etc. which often occur either as complications during the progress of bronchial inflammations or as sequelæ, simply because they will all be fully considered in the articles embracing those topics in other parts of this work.

{184}

BRONCHIAL ASTHMA.

BY W. H. GEDDINGS, M.D.

SYNONYMS.--Asthma convulsivum (Willis); Spasmus bronchialis (Romberg); Asthma nervosum; Krampf der bronchien.

DEFINITION.--A violent form of paroxysmal dyspnoea, not dependent upon structural lesion; characterized by wheezing respiration, with great prolongation of the expiration, and by the absence of all symptoms of the disease during the intervals between the attacks.

HISTORY.--Derived from the Greek [Greek: asthmatnô] to gasp for breath, the term asthma was employed by the older writers to designate a variety of affections of which embarrassed respiration was the most prominent symptom, thus including a great number of diseases which a more extended knowledge of pathology has since distributed among other nosological groups. By the earlier authors simple embarrassment of breathing was designated as dyspnoea; if attended with wheezing it was called asthma; while those forms in which the difficulty in respiration was so great as to prevent the patient from lying down were appropriately styled orthopnoea (Celsus). Ignorant to a great extent of pathological anatomy and unprovided with the improved methods of physical diagnosis which we now possess, they described as asthma not only the dyspnoea due to cardiac and pulmonary diseases, but also that occasioned by affections of the pleura and greater vessels. Covering such an extensive range of territory, it was found necessary to subdivide the disease into a number of varieties, each author classifying them according to his conception of the cause, seat, and nature of the trouble. Some of these--_e.g._ a. dyspepticum--still find a place in medical literature, but the vast majority of them, having ceased to be of any practical significance, have been discarded, and are now only interesting as examples of the crude and fanciful notions which prevailed in an age during which science rather retrograded than advanced.[1] Of the writers of this period, Willis in the seventeenth century is especially worthy of notice as being the first to describe the nervous character of asthma. Without discarding the accepted forms of the disease, he mentions another variety, characterized by spasmodic action of the muscles of the chest, to which he gave the name asthma convulsivum.

[Footnote 1: "Van Helmont, discarding the ancient doctrine of the four humors, attributed asthma to an error of the Archeus, which he conceived to be enthroned in the stomach and to constitute the source of all diseased as well as of all healthy phenomena. This principle, he supposed, sent forth from the stomach a peculiar fluid, which, when it became diseased, gives rise to a morbid state of the parts to which it was conveyed. He moreover imagined that this fluid sometimes mixed itself with the male semen, and thus formed a compound which, as one of its constituents is the means provided by nature for the propagation of the species, possesses the power of generating a disease of hereditary character. Thus, when this compound was conveyed to the articulations, he affirmed it produced gout, and when it took its direction to the lungs it then occasioned asthma" (_Baltimore Med. and Surg. Journ. and Review_, Baltimore, 1833, p. 300).]

The improvement in physical diagnosis resulting from the brilliant discoveries of Auenbrugger and Laennec greatly curtailed the domain of asthma. {185} With the aid of auscultation and percussion it was discovered that most of the cases hitherto regarded as asthma were only symptoms of some organic disease. Many distinguished authorities, particularly of the French school, went so far as to declare that there existed no such disease as asthma, and that in every case the dyspnoea and other phenomena described under that name were merely symptoms of some organic affection.

Although very generally received at first, it was not long before this too-sweeping reform encountered opposition from various quarters. Cases were observed with marked asthmatic symptoms in which, after death, the most careful examination failed to reveal the slightest trace of textural lesion. The discovery by Reisseisen of muscular fibres even in the minutest bronchi, and the demonstration of their electric contractility by Longet and Williams, afforded a ready explanation of these cases, and led to the opinion--which has since been generally received--that asthma in the modern acceptation of the term is simply a neurosis. The more recent theories in regard to the nature of asthma will be more fully discussed in the portion of our article devoted to the pathology of the disease.

SYMPTOMS AND COURSE.--The following description of an attack of asthma by Trousseau, who was himself an asthmatic, is perhaps the best that has ever been written: "An individual in perfect health goes to bed feeling as well as usual, and drops off quietly to sleep, but after an hour or two he is suddenly awakened by a most distressing attack of dyspnoea. He feels as though his chest were constricted or compressed, and has a sense of considerable distress; he breathes with difficulty, and his breathing is accompanied by a laryngo-tracheal whistling sound. The dyspnoea and sense of anxiety increasing, he sits up, rests on his hands, with his arms put back, while his face is turgid, occasionally livid, red, or bluish, his eyes prominent, and his skin bedewed with perspiration. He is soon obliged to jump from his bed, and if the room in which he sleeps be not very lofty he hastens to throw his window open in search of air. Fresh air, playing freely about, relieves him. Yet the fit lasts one or two hours or more, and then terminates. The face recovers its natural complexion and ceases to be turgid. The urine, which was at first clear and was passed rather frequently, now diminishes in quantity, becomes redder, and sometimes deposits a sediment. At last the patient lies down and falls to sleep."

The next day the patient may feel well enough to pursue his accustomed avocation, and may remain free from all symptoms of the disease until another attack comes on; but more frequently he is confined to the house, if not to bed, the slightest exertion being sufficient to cause dyspnoea; and during the following night there is a repetition of the paroxysm.

If unchecked by treatment, the disease may continue for days, weeks, and in some instances even for months, the paroxysms often increasing in severity until, as in other nervous affections, it ultimately wears itself out.

There is no regularity in the occurrence of the attacks. In some cases they recur every few days, while in others there may be an interval of weeks or months between the seizures. Even in the same case, although the individual paroxysms of the attack may come on at the same hour, there is, except in rare instances, no regularity in the recurrence of the attack itself; and when it does recur at a certain time it is almost always due to some cause which, as in hay asthma, exerts its influence only at that particular period.

In the great majority of cases asthma comes on without any warning whatsoever, but occasionally it is preceded by certain sensations which to the experienced asthmatic are a sure indication that an attack is impending. With some it is only a feeling of ill-defined discomfort; others complain of various disorders of the digestive system--a sense of dryness of the mouth and pharynx, uncomfortable distension of the epigastrium with eructation of {186} gases from the stomach, and more or less obstinate constipation. A troublesome itching of the skin often precedes the attack. Some experience a feeling of constriction around the throat; a profuse secretion of clear urine is a symptom of this stage. Frequent gaping, frontal and occipital headache, are mentioned; but far more constant than all of these are certain symptoms indicative of a mild grade of acute catarrh of the respiratory organs--coryza, with swelling of the Schneiderian membrane and discharge from the nostrils, sneezing, redness of the conjunctivæ with increased lachrymation, and later, as the irritation extends downward, more or less cough.

The attack almost always comes on after midnight, and, as a rule, between the hours of two and six o'clock in the morning. Salter states that nineteen out of twenty cases occur between two and four A.M. There are, however, occasional exceptions to this rule; sometimes the patient is attacked soon after retiring, and Trousseau cites the case of his mother, who always had her attacks between eight and ten in the forenoon, and also that of a tailor, whose paroxysms invariably came on at three o'clock in the afternoon. Indeed, there is no hour of the twenty-four during which the seizure may not take place. Various attempts have been made to explain why it is that the paroxysms of asthma almost invariably occur during the latter half of the night. Many attribute it to a stasis of blood in the lungs caused by the recumbent posture of the patient, while others claim that it is due to a dulling of reflex impression, the patient during sleep failing to perceive the necessity of breathing. Germain Sée, who discredits both theories, inquires why, if the above explanations are correct, does the attack not come on soon after retiring, as is the case with the dyspnoea of cardiac diseases.

The paroxysm of asthma develops very rapidly, but not so suddenly as is claimed by many authors, several minutes to half an hour or more elapsing before it attains its full height.[2]

[Footnote 2: Germain Sée in _Nouveau Dictionnaire de Médecine et de Chirurgie_, tome iii. p. 617, Paris, 1865.]

The patient, experiencing an urgent desire for breath, instinctively places himself in the position most favorable for the ready admission of air into the lungs. If in bed he sits up, and, resting on his hands or grasping his knees with them, he so fixes the body that the muscles of respiration may work to the greatest advantage. The shoulders are drawn up and the head thrown back. The expression of the face is one of great anxiety--pale at first, then red, and as the attack increases in severity assumes a dusky, bluish tint; the mouth is partially opened, the nostrils are dilated; the eyes, the conjunctivæ of which are much injected, are prominent, with a wild, staring look; and the forehead is moist with perspiration. Others in their desperate struggle for breath spring from the bed, throw open the window, and, regardless of everything save what they believe to be impending suffocation, recklessly gasp in the cold night air. Sometimes the sufferer prefers to kneel before a table or some other article of furniture, supporting his head with his hands. Whatever posture he assumes, he is actuated by the one impulse of placing himself in the position that will enable him to use to the greatest advantage the muscles of respiration and their auxiliaries. The sterno-cleido-mastoid muscles are contracted to the utmost, and, projecting like hard cords, with the aid of other muscles draw the chest upward. The patient instinctively avoids every unnecessary exertion as having a tendency to aggravate his dyspnoea; he speaks but little, and when questioned usually replies with a motion of the head.

In ordinary respiration the inspiratory movement is twice as long as the expirium, the latter, except in forced expiration, being a purely passive act. In asthma this rule is reversed, the expiratory movement being four or five times as long as the inspirium, and is often so slow that it fills the whole of {187} the pause which usually intervenes between the completion of one respiration and the beginning of another. It is sometimes so slow "that it seems as though the lung would never empty itself." In the desperate struggle for breath the respiratory muscles are exerted to the utmost in futile endeavors to expand the chest; with each inspiration there is an elongation of the thorax, but no lateral movement. The chest moves up and down, but there is no expansion; "the muscles tug at the ribs, but the ribs refuse to rise" (Salter), the walls of the chest remaining immovable.

Notwithstanding the all but tetanic contraction of the diaphragm, there is during each inspiration a sinking in of the epigastrium, and in severe cases also of the spaces above and below the clavicles. During expiration the abdominal muscles, especially the recti, are hard and tense, the pressure thus exerted being sometimes sufficient to expel the contents of the lower bowel and bladder.[3] The transversus is also tightly contracted, and a cross furrow above the umbilicus indicates that the contraction of its upper half is opposed to the contents of the abdomen forced down by the distended lung (Biermer). Although the dyspnoea is great, there is no increase in the frequency of the respirations so long as the patient remains quiet, but, on the contrary, they are often less frequent than in health. This slowing of the respiration is also observed in the dyspnoea from laryngeal stenosis in croup, etc.; but in these cases we do not have the prolonged expiration which is so characteristic of asthma (Biermer). At every breath which the patient takes there is a peculiar wheezing sound which may be heard distinctly all over the room; it is usually heard only during expiration, but some authors (Biermer) claim that it is also audible during inspiration.

[Footnote 3: Bamberger's case, as quoted by Riegel, _Ziemssen's Pathologie u. Therapie_, Leipzig, 1875, Band iv. 2, S. 282.]

On auscultating the chest it will be found that the ordinary vesicular murmur is either entirely absent, or if heard it is only over very limited areas. In the place of it we have an endless and ever-changing variety of dry sounds, such as whistling, cooing, mewing, snoring, etc., technically styled sibilant or sonorous ronchi. They are usually equally diffused over both lungs, but are sometimes confined to one. The sibilant râles afford an index of the degree of spasm, being in mild cases equally audible during both inspiration and expiration, while in severe attacks they are louder during expiration (Biermer). That the vesicular murmur cannot be heard is due not only to its being masked by the louder ronchi, but also to the absence of the condition necessary for its production, the spasmodic constriction of the bronchial tubes or their plugging with tough, viscid mucus preventing the entrance of sufficient air to produce the sound. Sometimes a hitherto occluded tube becomes pervious, and we have vesicular respiration where a moment before only dry sibilant râles were heard. Usually at the close of the attack, when cough sets in, there are occasional moist râles. These become more frequent as the expectoration becomes more abundant. Frequently, however, the paroxysm terminates much more abruptly, the spasm relaxes, and the air rushing through the tubes gives rise to puerile respiration.

During the paroxysm there is, even in the early stages of asthma, more or less distension of the lungs, measurement of the chest showing that its circumference is four to eight centimeters greater than before the attack (Beau). This transitory emphysema, which must not be confounded with that due to structural changes observed in old cases, disappears with the attack, and the lung returns to its normal condition. This distension causes the exaggerated resonance obtained by percussion which is one of the most constant symptoms. At the base of the lung, especially posteriorly and laterally, there is a peculiar modification of the percussion sound to which Biermer has applied the name Schachtelton, from its resemblance to the note produced by striking {188} an empty pasteboard box. Besides this exaggerated resonance, it will be found that the line of dulness on the right side, which marks the upper border of the liver, is fully two inches lower during the paroxysm than before, and that the area of cardiac dulness is somewhat diminished by the overlapping of the distended lung-tissue (Riegel). Another peculiarity elicited by percussion, and to which Bamberger was the first to direct attention, is that in some rare cases instead of moving vertically the line of hepatic dulness remains unchanged during both acts of respiration.

Toward the close of the attack the congested mucous membrane of the bronchi begins to secrete, and there is more or less cough. The matter expectorated consists at first of little balls of tough, semi-transparent mucus not much larger than a pea. It is exceedingly tenacious, and is raised with great difficulty. Examined under the microscope, the sputum is found to consist "of a great number of corpuscles, some of which are polyhedral in form with rounded angles; they are pale, homogeneous, and slightly granular. At first sight they resemble pus-corpuscles, but they are much larger, less circular in form, and have no nucleus. In addition to these corpuscles there are others which are oval, elongated, fusiform, and sometimes linear in shape, but all of them appear to be of the same nature and possess the same refracting power as the corpuscles first mentioned. They are all of them agglomerated in a sort of viscous matter."[4] The expectoration often contains blood, and in some rare instances profuse hemorrhages have been known to occur. Sometimes the matter has particles of soot and coal-dust intermingled with it, the so-called carbonaceous sputum (Sée). In addition to the cells above described, the sputa contains small yellowish-green masses or threads in which are imbedded the peculiar octahedral crystals which Leyden has ingeniously connected with the etiology of asthma, and to which we shall again have occasion to refer.[5] Ungar has recently also discovered crystals of oxalate of lime in the sputa.

[Footnote 4: Germain Sée, _Nouveau Dictionnaire de Médecine et de Chirurgie_, pp. 612, 613; also, Salter, _Asthma, its Pathology and Treatment_, Am. ed., p. 944.]

[Footnote 5: Riegel, in _Ziemssen's Handbuch d. Pathologie u. Therapie_, vol. iv. 2, pp. 268, 285.]

Laryngoscopic examination reveals more or less congestion of the air-passages. "In ordinary respiration the glottis is widely open during inspiration, and at each expiration the arytenoid cartilages approach each other so as to narrow the glottis; but in the labored respiration of asthma the glottis is fixed in the condition of expiration; that is, the glottis is narrowed, and the air enters and is expired through the same narrow space."[6]

[Footnote 6: Steavenson, _Spasmodic Asthma_, p. 23.]

The embarrassment of respiration and the pressure of the air in the distended alveolæ by impeding the capillary circulation of the lungs prevent the left auricle from receiving its full supply of blood; hence the pulse is small and weak during the paroxysm, but regains its natural volume as soon as its immediate effects are over. The action of the heart, like every other phenomenon of asthma, is subject to constant variation. At one moment it beats tumultuously, while at the next its action may be so feeble as to cause temporary syncope (Sée). The venous blood, unable to overcome the obstacles to its passage, is forced back into the vessels, causing distension of the cervical veins and the jugular pulse sometimes observed in severe attacks. The bluish hue of the face in bad cases is due to cyanosis resulting from insufficient aëration of the blood. The paroxysm is unattended with fever, the temperature, if altered at all, being rather below than above the normal. Coldness of the face and hands is quite a common symptom in protracted cases.

In addition to the nervous sensations described among the premonitory symptoms, patients have been known to suffer from disturbances of a more {189} serious nature during the paroxysm. In some instances there is complete loss of consciousness, and Riegel[7] states that such cases have been known to have tetanic convulsions of the trunk and extremities.

[Footnote 7: _Loc. cit._ p. 285.]

The course of an attack of asthma is in most cases quite typical, the paroxysms recurring nightly for an indefinite period, and usually increasing in severity until, as in epilepsy and other nervous diseases, it finally exhausts itself. On awaking from the sleep which usually succeeds the final paroxysm the patient, unless the attack has been very mild and of short duration, feels weak and exhausted, but there is no tendency to the recurrence of the dyspnoea; on the contrary, he may expose himself with perfect impunity to the causes which at other times would be certain to produce an attack. The chest feels stiff and sore, the cough and expectoration diminish, and in a few days disappear, and if the disease has produced no organic lesion the patient returns to his usual state of health.

DURATION.--The duration of asthma, except in young persons and in those rare cases in which the cause can be discovered and removed, is very indefinite, the disease lasting for years, if not for life. As the patient grows older the attacks become less severe, but are more frequent. Sometimes a case which has recurred for years and defied the most energetic treatment will all at once recover of itself.

SEQUELÆ.--Although bronchial asthma is essentially a neurosis, and therefore purely functional in its character, it is rare for it to continue for any great length of time without causing some organic affection of the lungs or heart.

The most common sequel of asthma is emphysema. The bronchial tubes being more or less completely closed, either by contraction of their muscular fibres or by plugs of thick, viscid mucus, the air pent up in the parts beyond the obstruction is subjected to the negative pressure produced by the exaggerated inspiratory act, becomes rarefied, and, in obedience to the diminished resistance induced by the partial vacuum in the thorax, causes distension of the air-cells. This condition continues until, the tubes having again become pervious, the natural elasticity of the lung-tissue, aided by the expiratory muscles, forces out the air and permits them to return to their natural size. This is the transitory emphysema to which we have already alluded. Germain Sée[8] regards it as analogous to the paralytic emphysema which occurs the moment the pneumogastric is divided. With repeated attacks the air-cells lose their elasticity and remain permanently dilated. Owing to the constant distension, the walls of the alveolæ become more and more attenuated, until, finally giving way, two or more of them coalesce, forming one large cell. The symptoms of this condition are the same as those of ordinary vesicular emphysema.

[Footnote 8: _Op. cit._, p. 637.]

Owing to partial occlusion of the afferent bronchi and the altered conditions of pressure mentioned, the blood accumulates in the capillaries during the paroxysm, the lung-cells do not receive their adequate supply of air, and oxygenation is imperfect. In the early stages of the disease this congestion is only temporary, and disappears with the removal of the obstruction, but in those cases in which the attacks are severe and frequent the vessels lose their contractility and remain permanently congested.

The state of chronic congestion just mentioned is occasionally attended with serous exudation into the interalveolar tissue, which by pressing upon the adjacent air-cells causes their obliteration. This oedema, with the remains of the compressed air-cells and the viscid mucus stagnating in the finer tubes, forms the little islets of carnified tissue known as lobular pneumonia.

The most frequent change observed in the bronchial tubes in old cases of asthma is hypertrophy of their muscular fibres, causing thickening of their {190} walls and diminished calibre. In other cases they are dilated, but this condition is due more to the concomitant bronchial catarrh than to the asthma.

Obstructed in its course through the lungs, the venous blood accumulates in the pulmonary artery, and, pressing back upon the right ventricle, excites it to increased action, which in the course of time leads to hypertrophy of its muscular fibres and dilatation of its cavity.

In the early stages of asthma, the face is usually pale during the intervals between the paroxysms, but when the latter become more frequent the impeded circulation causes stasis in the peripheral vessels. The imperfectly-oxygenated blood gives the face a dusky hue, and in severe cases it may become bluish or even violet-colored. The eyes are prominent, owing to the enlargement of the orbital veins (Sée), and the conjunctivæ congested and watery.[9]

[Footnote 9: For a description of symptoms of the above-mentioned secondary affections the reader is referred to the articles on EMPHYSEMA and HEART DISEASE.]

ETIOLOGY.--Predisposing Causes.--Every one is not liable to asthma, and the fact that out of a large number exposed to its exciting causes only a few are attacked justifies the assumption that there is an inherent tendency to the disease. That this tendency is hereditary in its nature is conceded by every prominent writer on asthma except Lebert, who believes this to be only occasionally the case. Thus, of 35 cases collected by Salter, heredity could be traced in 14, of whom 7 inherited the disease from the father, and the remainder from grandparents and other relations. Ramadge gives an instance in which the disease appeared in four generations: an asthmatic father had four children, three of whom inherited the disease; one of the daughters married, and of her two children one became asthmatic; the other escaped, but the disease reappeared in one of her children.[10]

[Footnote 10: Germain Sée, _op. cit._, p. 668.]

The hereditary tendency may skip one generation, as is the case with Steavenson,[11] who inherited asthma from his grandfather, his father's generation having been entirely free from the disease. In other cases it may alternate with some other neurosis or with gout or rheumatism; for instance, the children of an asthmatic father may be epileptic or gouty and the grandchildren asthmatic, or the asthmatic tendency may develop in one child of an asthmatic family and the gouty diathesis in another. It is by no means necessary for the hereditary transmission of the disease that the father should be asthmatic when the child is conceived, as there are many cases recorded in which asthma developed in children whose fathers had completely recovered before they contracted marriage and never had any subsequent return of the disease.

[Footnote 11: W. E. Steavenson, _Spasmodic Asthma_, London, 1882, p. 8.]

All authorities agree that asthma is much more frequent among males than females. Of Théry's cases, 60 were females and 80 males. The more recent statistics of Salter show that the males exceed the females in the proportion of two to one. This undue frequency of a purely nervous disease among males appears at first to be at variance with the generally-received opinion that such affections pertain rather to the female sex; but on investigating the ages at which the attacks first come on it will be found that between the fifteenth and thirtieth years--that is, during the period when sexual function is most active--the proportion is reversed, females being attacked much oftener than males.

Asthma occurs more frequently in childhood than at any subsequent period--a fact which may be explained by the great susceptibility of young children to catarrhal affections of the air-passages and to the frequent occurrence at that age of measles and whooping cough (Salter). Of 225 cases collected by Salter, 71 occurred before the tenth year, and of these, 10 began during the first year, the youngest of them being only fourteen days old at the time of {191} the attack. From ten to twenty it occurs less frequently than at any other period of life, but from that age to the fortieth year there is a steady increase in the number of cases. During the next decade, from forty to fifty, the disease diminishes in frequency, and from that period on the number of cases continues to grow smaller and smaller with advancing years, comparatively few commencing after the fiftieth year.

The following tabular statement, compiled by Salter, shows the comparative frequency of asthma during the various periods of life:

From 1 to 10 years, 71 cases. | From 40 to 50 years, 24 cases.
" 10 to 20 " 30 " | " 50 to 60 " 12 "
" 20 to 30 " 39 " | " 60 to 70 " 4 "
" 30 to 40 " 44 " | " 70 to 80 " 1 "

These figures demonstrate the fallacy of the popular idea that old people are especially liable to asthma. Its prevalence during the later periods of life is due to the fact that while, on the one hand, the affection rarely causes death, on the other it is scarcely ever curable except during childhood, and thus the cases contracted at different ages accumulate and form a large aggregate as life advances.

Those cases occurring in childhood and late in life are likely to be associated with more or less bronchial catarrh, while those which come on when the body has attained its fullest development are almost invariably purely nervous in character.

The period of life at which asthma commences is an important element in the prognosis of the disease, the cases occurring in early childhood being likely to end in recovery, while those coming on later in life are exceedingly protracted in their course and liable to lead to organic diseases of the heart or lungs.

Asthma does not appear to be influenced by the seasons, some authors claiming that it is most frequent in summer, while others maintain that the greatest number of cases occur in winter.

Exciting Causes.--Bronchial asthma being a neurosis of the pneumogastric nerve, its exciting causes may be divided into those which act upon the nerve directly, and those which are reflected from more remote parts or organs.

In the first class the irritant may act upon the nerve at its origin in the medulla oblongata or upon some part of its continuity. Various poisons, organic or inorganic, when introduced into the system may so change the character and composition of the blood as to interfere with the nutrition of the respiratory centre, and thus cause more or less embarrassment of respiration; but the attacks of dyspnoea due to these causes are more continuous than those of ordinary asthma, and are wanting in many of the symptoms which we have described as characteristic of that disease. These forms of dyspnoea are usually the result either of some constitutional disease or of some poison introduced into the system, both of which act by diminishing the proportion of red corpuscles in the blood. Of this we have examples in the dyspnoea sometimes observed in syphilis and malarial fever and in lead and mercurial poisoning--the so-called a. saturninum and a. mercuriale. It is true that there have been instances in which the paroxysms of asthma have come on at regular intervals and have yielded to quinine, but it is not regarded as proved that such cases were due to malarial poisoning (Sée).

Enlarged bronchial glands pressing upon the pneumogastric nerve may cause asthma, and this explains why it is so frequent in children after attacks of measles and whooping cough (Williams and Biermer). Others have remarked that asthma is often coincident with hypertrophied tonsils (Schaeffer). In the great majority of cases the exciting cause does not act directly upon {192} the pneumogastric nerve, but upon the skin or some other remote organ, whence it is transmitted to the nervous centre and reflected back through the nerves of respiration to the bronchi.

Biermer believes that the irritant in many cases, instead of being directly transmitted to the medulla oblongata, causes a fluxion to the exposed mucous membrane. He thinks that the absence of catarrhal symptoms is more apparent than real, the evidences of congestion being unappreciable during the early stages of the disease. According to Riegel,[12] the action of the irritant may be explained in one of three different ways--viz. 1st, both the spasm and the fluxion may be the common result of the irritant; 2d, the catarrh may cause the spasm; or, 3d, the spasm may secondarily produce catarrh.

[Footnote 12: _Op. cit._, p. 256.]

Although cold may not be so frequent a cause of asthma as was formerly supposed, low temperature undoubtedly acts as an irritant upon the terminal branches of the respiratory nerves, especially the pneumogastric, and in the manner just described may produce spasmodic contraction of the bronchi. The effect of cold is of course much more deleterious when it is associated with sudden changes and diminished barometric pressure, high winds from the east and north being particularly prejudicial. Aside from its meteorological characteristics, the locality itself exercises a potent influence in the production of asthma; and here, again, we have an example of the capricious character of the disease. A patient who for years has suffered with asthma may change his residence and find immediate relief, but of the special factors which engender the disease in one place and cure it in another we know as yet but little. It is, however, a generally acknowledged fact that removal from the country to a crowded city will often diminish the severity and frequency of the attacks, and English writers mention numbers of cases of asthma which have been permanently cured by a prolonged residence in the foggy atmosphere of London. A very slight change is often sufficient to afford relief, and sometimes removal to another part of the same city is all that is necessary. The town of Aiken in South Carolina is divided by a ravine into two sections: the elevation, soil, and exposure are alike in almost every respect, but persons have been known to suffer severely with asthma on one side and to enjoy perfect exemption from it on the other. A gentleman who resides at Bath in the same neighborhood is perfectly free from asthma at his home, but invariably has an attack as soon as the train begins to cross the Savannah River at Augusta, which is only a few miles distant. More remarkable still is the case mentioned by a French writer of a young man who was unable to sleep in the front rooms of a house without having a paroxysm, but who did not experience the slightest inconvenience when he occupied the back rooms.