Synonyms.—Spasmodic Asthma; Nervous Asthma; Bronchial Asthma.

Definition.—A paroxysmal dyspnea, due to alterations in the smaller bronchial tubes of a spasmodic and temporary character, and attended by more or less constitutional symptoms.

Etiology.—Heredity, sex, season of the year, and age predispose to asthma. It has been estimated that in fifty per cent of all cases there is a family history of paroxysmal dyspnea. More males suffer from asthma than females, the ratio being about two to one. If we except hay asthma, winter and early spring are the months most favorable to this disease.

About thirty per cent of all cases occur before the age of ten, twelve per cent between the ages of ten and twenty, and eighty per cent before the age of forty.

Exciting Cause.—All writers agree that there is an abnormal condition of the respiratory center or of its paths of communication, but the exact nature of the exciting cause or causes is not known.

It may be due, in some cases, to bronchial irritation, or acute bronchitis; at least this may give rise to a paroxysm. Inhalations of certain vapors or fumes, or irritating dust, and sometimes the odor of plants or animals, is sufficient to bring on an attack.

A very large per cent of cases are due to reflex causes, the disturbance being at a distant part, as the stomach, uterus, ovaries, urethra, or rectum. Emotional excitement may be the excitant, or it may be secondary to obstructive rhinitis, or growths in the nasal passages, cardiac lesions, hepatic wrongs, and chronic nephritis.

Pathology.—There are no characteristic anatomical changes in asthma. In some there is hyperemia of the bronchial mucosa, with a characteristic exudate. In others there may be slight thickening of the mucosa, and in a great many there are no perceptible changes, showing clearly its reflex character.

Where the disease is secondary, the anatomical changes are confined to the primary organ; as in cardiac asthma, the changes will be in the heart; in renal asthma, in the kidneys, etc.

Symptoms.—The attack generally begins suddenly, though prodromal symptoms are not uncommon, and consist of a sensation of uneasiness or constriction in the larynx, oppression or tightness in the chest; chilly sensations, digestive disturbances, profuse diuresis, and marked depression of spirits.

The attack most frequently commences in the night, after the patient has gone to sleep, he being awakened by a sense of suffocation or inability to fill his lungs. The dyspnea is marked, and the patient desires his window thrown open that he may get fresh air. There is great anxiety; the face becomes pale, often cyanotic, showing imperfect aeration of the blood; the pulse is rapid but feeble; the face, and sometimes the entire body, is covered with a cold sweat; the extremities become cold, and the temperature not infrequently becomes subnormal. The patient is unable to lie down, the most comfortable position being a sitting posture, the hands grasping some object for support, thus bringing to his assistance tlie accessory muscles of respiration.

The breathing is characteristic, being of a wheezing character that can be heard for quite a distance. Although, owing to spasmodic contraction, the air enters the lung with difficulty, the patient experiences still greater labor in expiration or emptying the lungs, the wheezing being more pronounced on expiration than on inspiration.

The dyspnea is increased by paroxysms of coughing, which at first are quite severe and attended by expectoration of a tenacious viscid mucus. Later the cough is looser and the mucus raised with ease.

The sputum of asthma is characteristic and consists of small, jelly-like balls floating in their mucin. These balls, "perles" of Laennec, are mucous molds of the small bronchioles, and when unrolled are found to be spiral in form, known as Curschmann's spirals, he being the first to describe them. There are also found in many cases, octahedral crystals, asthma crystals, first described by Leydon. They are identical with the crystals found in semen and in the blood in leukemia.

Physical Signs.—Inspection reveals the chest large and barrel-shaped, due to inability to expel the air from the lungs.

Percussion usually gives hyper-resonance, though sometimes the note is normal.

Auscultation in the early stage reveals sibilant rales, of various grades in pitch, becoming moist as the disease progresses.

The duration of the paroxysms is variable, lasting from a few minutes to hours, or days. Often the patient experiences relief toward morning, and through the day is comparatively comfortable, although the breathing is hurried. The following night there is a repetition of the experience of the previous night, which may continue for several nights before obtaining complete relief. Sometimes months elapse before there is a recurrence, the frequency depending somewhat upon the exciting cause.

Diagnosis.—The diagnosis is easy, the paroxysms of dyspnea usually occurring in the night, the wheezing respiration and the peculiar sputum, leave no room for doubt.

Prognosis.—The prognosis is favorable-as to life, but few patients dying from asthma, and only those where it is due to primary cardiac lesions; but it is unfavorable as to a permanent cure, unless due to reflex causes, when a correction of the exciting cause may give prompt and permanent relief.

The permanent cures from medication, however, are not frequent enough to warrant a cure by the use of remedies.

Treatment.—The treatment of asthma will be first to relieve the paroxysm, and then to ascertain, if possible, the exciting cause, and direct our treatment toward a permanent cure.

Lobelia is recognized by all schools as an efficient remedy during a paroxysm of asthma. To be effectual, however, it should be carried to the point of nausea, and when the paroxysm is due to an overloaded stomach, it should be carried to a thorough emesis. An infusion of the emetic powder is quite effective where emesis is desired.

Perhaps the most successful agent is morphia, used hypodermically, one-fourth to one-third of a grain being used at a dose. The most serious objection to this remedy is the danger of leading the patient into the morphine habit.

The inhalation of chloroform will frequently give relief, but the effects are apt to be transient. One or two perles of the nitrate of amyi, crushed in the handkerchief and inhaled, usually gives speedy relief. The patient should be in bed when this is used, for the agent often produces dizziness and sometimes fainting, and if not in bed the patient may fall to the floor. In very difficult breathing the agent may be given internally, a dram to simple syrup and water, 1 ounce each. M. Teaspoonful every three or four hours.

Inhalations from cigarettes made from lobelia, belladonna, and stramonium leaves proves of much benefit in many cases, or the coarsely ground herbs may be burned in a dish and the fumes inhaled. Nitrate of potassium may be added to the other agents, and adds much to its effectiveness.

For the radical cure the case must be carefully studied, to find the exciting cause or causes that give rise to it. In one case it may be due to endometritis or a diseased ovary; in another, rectal or urethral disturbances are responsible for the paroxysms. In such cases, a curettement, or possibly an ovariotomy, will be the only means of relief, while the removal, of hemorrhoids, papilla, rectal pockets, fissures, etc., will work wonders in effecting a permanent cure.

Any wrongs in the general health must be corrected, and such remedies as aesculus, grindelia, and penthorum may be given three or four times a day with the hope of overcoming the tendency to a return of the disease.

The nose, larynx, and bronchi should receive a careful examination; and if any local trouble exists, it should be removed. The patient should be shielded from irritating dust, pollen, gaseous or chemical fumes, and any and all forms of irritation.

In some cases a change of climate promises the only relief, although it is difficult to determine the right locality for each patient. One does better in the mountains, while another derives more benefit in the lake regions of Wisconsin and Michigan, while the States of Florida, Texas, New Mexico, Arizona, Colorado, and California offer relief to others.

The Eclectic Practice of Medicine, 1907, was written by Rolla L. Thomas, M. S., M. D.