In arriving at a prognosis it is all-important to inquire into the severity and frequency of the attacks, as violent paroxysms at short intervals soon lead to incurable complications. It is also essential to ascertain the condition of the patient during the intervals between the paroxysms: if at that time he feels well and does not suffer with shortness of breath, we may infer that as yet no organic change has occurred; if, however, he complains of more or less dyspnoea during the intervals, we may safely conclude that some organic disease has set in and that the case is incurable. Salter attaches great importance to the persistence of expectoration during the intermissions, regarding it as indicative of bronchitis, and therefore as an unfavorable indication: to use his own words, "Spitting is one of the worst signs in asthma."
Briefly, those cases may be regarded as favorable in which the patient is young and has no inherited tendency to the disease, is free from the many complications of asthma, and in whom the attacks are light and occur at long intervals. On the other hand, all cases may be regarded as unfavorable in which the patient has reached or passed the middle period of life, has inherited a tendency to asthma, if the attacks are severe with short intervals, or if he has some one or more of the secondary affections of the disease.
TREATMENT.—The treatment of bronchial asthma consists of measures to mitigate and relieve the paroxysms and prevent their recurrence.
A. Of the Paroxysm.—A patient suffering with an attack of asthma will generally instinctively assume the position in which he can use the muscles of respiration to the greatest advantage, but if found in the recumbent posture he should be advised to sit up in bed and grasp the knees with his hands, so as to gain a position which admits of the more ready entrance of air into the lungs. In severe cases it is better to have him rise from the bed and support the head with the hands, the elbows resting on a table in front of him. An ingenious suspension-apparatus, intended to promote the comfort of persons suffering with severe dyspnoea, was extensively advertised several years ago, and may possibly still be furnished by the instrument-makers. It consists of a cross-piece suspended from the ceiling, to which straps are attached for supporting the shoulders without in any way pressing upon the chest; it is also provided with a band for the support of the head. In severe and protracted cases, when, notwithstanding the patient's exhaustion, he is unable to rest upon pillows, such an arrangement might afford great relief. If not undressed, the clothing should be so arranged as to interfere as little as possible with the respiratory movements. An abundant supply of fresh air is essential, and to secure this one or more windows should be thrown open.
Asthma being the most capricious of diseases, remedies often acting differently in each individual case, it is well before commencing treatment to follow Salter's advice and inquire of the patient what remedy has usually afforded the most prompt relief in previous attacks, and thus avoid the risk of prolonging suffering by using remedies which, although apparently indicated, may in his case, owing to peculiar idiosyncrasies, prove to be useless or even injurious.
We have seen that the disease is often due to some special cause, such as the inhalation of an atmosphere laden with the perfumes of certain flowers, with ipecac, dust, etc., the removal of which, if practicable, should of course precede all attempts at treatment. The condition of the stomach and bowels should be inquired into, and if found overloaded they should at once be relieved, the one by an emetic and the other by enema.
In the absence of any hint afforded by the previous experience of the patient the choice of the remedial agent will depend upon the severity of the attack. In the majority of cases, when severe, no remedy will afford such prompt relief as the subcutaneous injection of morphia. To be effective, the dose should be a full one, a fourth to a third of a grain, either alone or, if there is likelihood of this occasioning nausea, combined with one one-hundredth to one-eightieth of a grain of sulphate of atropia. The writer is aware that the use of opium and other hypnotics in bronchial asthma is discouraged by one of the most distinguished authorities on that disease, Salter, who claims that they are not only worthless, but often injurious. He believes that sleep tends to promote the paroxysm, reflex action being much more active then than during the waking hours, and that any agent which induces such a condition is necessarily contraindicated—that, in his opinion, in addition to exalting reflex action, it acts prejudicially, as "by lowering sensibility it prevents that acute and prompt perception of respiratory arrears which is the normal stimulus to those extraordinary breathing efforts which are necessary to restore the balance." These objections, although supported by scientific evidence, are insufficient to cause the abandonment of an agent which in the hands of others has proved so prompt and efficacious in relieving the terrible sufferings of asthma, and Salter himself admits that since writing the above he has had cases in which it has been of signal service. A serious objection to its use is that the dose has to be increased as the patient becomes accustomed to its use. In confirmation of its marked beneficent effects, I give the following extract from Steavenson's treatise on asthma. Describing his own experience, he says:23 "Sedatives and antispasmodics I should consider most serviceable drugs, but above all in value I should place the hypodermic injection of morphia. This has never failed to relieve an attack in myself, and I have never seen it fail in other patients. The objection to it is that if often used the dose must be increased; but it is better to increase the dose of morphia than suffer the agonies of asthma and allow those organic changes in the constitution to take place which I have described when speaking of the pathology of the disease. I have now used morphia for five years, but my attacks are so quickly relieved and so reduced in frequency that I have never yet had to increase the dose I commenced with—namely, one-sixth of a grain."
23 Op. cit., p. 29.
Having administered the morphia, other measures for the relief of the patient should be resorted to. The feet and hands should be immersed in hot water to which a small quantity of mustard has been added. Dry cups between the shoulder-blades or sinapisms over the chest or epigastrium often afford marked relief.
If, on account of the existence of an idiosyncrasy on the part of the patient or from other causes, opium cannot be employed, we have in chloral hydrate a substitute which is almost as efficacious and perhaps even more prompt. Next to morphia, it is the most valuable remedy, and many esteem it superior to that drug, over which it possesses the advantage of not being followed by the disagreeable effects which so often succeed the administration of opiates. It should be given in doses of thirty or forty grains, and repeated if the paroxysm does not yield.