As commonly met with in the child, paroxysmal dyspncea, i.e., dyspncea occurring in paroxysms with intervals of complete intermission, is a result of the following causes : Stridulous laryngitis.
Pressure upon the trachea or a large bronchus by swollen bronchial glands.
Obstruction of a bronchus by a foreign body.
True bronchial asthma, occurring often in the course of chronic bron chitis and emphysema.
Of these the first-named disease is fully considered elsewhere. It re quires no further notice in this place, as the severity of the laryngeal symp toms at once indicates the seat of the impedient to respiration. The other forms of paroxysmal dyspncea are often confounded together under the common name of " asthmatic attacks." Dyspncea arising from the press ure of enlarged bronchial glands and the difficulty of breathing induced by the presence of a foreign body in the air-tubes are described in other parts of this treatise. They will, however, be again referred to in discuss ing the diagnosis of asthma.
Bronchial asthma is comparatively seldom met with in the child. When it occurs-at this period of life, it appears to be almost invariably the con sequence of whooping-cough or catarrhal pneumonia. The seizures always assume the "catarrhal form ;" indeed, the subjects of the disease are usually sufferers from emphysema of the lungs, and the attack of dyspncea occurs as a consequence of a fresh catarrh. In many cases the child comes of a gouty family, and sometimes the pulmonary disease appears to be hereditary. The tendency to asthma is occasionally associated with a ten dency to general eczematous eruption ; and Dr. West states that he has never known eczema to be very extensive and very long continued without a marked liability to asthma being associated with it. The two affections may alternate—the one subsiding when the other appears—as in the case of a boy of six years old referred to by Caillaut ; but they may be also co existent, and the cure of the one is often followed by the disappearance of the other.
The exciting causes of the attack appear to be in most cases the inhala tion of some irritating matters, either in fine dust or vapour, directly into the air-tubes. A paroxysm sometimes follows an indigestible meal, or is induced by food imperfectly masticated and hurriedly swallowed. It has been consequently suggested that irritation of the gastric filaments of the pneumogastric may be reflected to the pulmonary branches of the nerve, and through them set up spasm of the tubes. But the theory of reflex
action is surely exposed to a severe strain by such an explanation.
Without expressing any opinion upon the vexed question of the nature of the asthmatic seizure—whether it be a pure neurosis (as is commonly held) or not—I may observe that it is at least curious that in children, whose tendency to nervous spasm of every kind is one of the physiological peculiarities of early life, pure asthma should be an affection so rarely met with ; that while general convulsions may be induced by peripheral irrita tion of various degrees of severity, while spasmodic contraction lof the glottis may be set up by a trifling laryngeal catarrh, an attack of paroxys mal dyspnoea from spasmodic occlusion of the smaller air-tubes should be a phenomenon of such infrequent occurrence. That it is extremely rare there can be no doubt. Of the recorded cases of asthma in young children there are very few in which direct pressure upon the bifurcation of the trachea or a main bronchus by enlarged bronchial glands can be excluded. I have seen many cases of so-called asthma in the child, but have rarely failed to find evidence of swelling—often of considerable swelling—of these glands.
Symptoms.—Asthmatic children, as has been said, are usually the sub jects of emphysema. This condition often gives little evidence of its pres ence until the lungs are attacked by a fresh catarrh. The breathing then becomes excessively oppressed, so that the child is unable to lie down in his bed. The face is pale, with a dusky tint round the mouth and eyes; the eyes arc staring and congested ; the mouth is open ; the lips are purple ; the nostrils work violently, and the forehead is covered with beads of sweat. The child is very restless, throwing about his arms, and his face expresses great suffering. His heart acts violently and irregularly, but the pulse is small and weak. When the chest is uncovered, all the respiratory muscle; are seen to be in action, but the chest remains fully distended and moved but slightly at each breath. There is little hurry of breathing on accoun of the increased length of expiration, and the temperature is not elevated The cough is usually short and dry, but not at a11 paroxysmal.