There can be little doubt that this child was suffering from enlarge ment of the bronchial glands. The character of the attacks; accompanied by hoarseness of the voice, the bleeding from the nose, the fulness of the jugular in the neck and of the superficial veins of the chest, the hollow breathing at the apices without sign of disease of lung, and the venous hum heard at the upper part of the sternum when the head was retracted—indicating some pressure set up in that position upon the left inuominate vein—all these signs were very suggestive of glandular enlarge ment. The child had a scrofulous appearance and was living in a cold, damp situation. She was treated with iodide of iron and cod-liver oil, and was sent to pass the winter at Bournemouth, whence she returned greatly improved.
This subject of glandular enlargement in the mediastinum has been already considered in another place. The reader is therefore referred to the chapter on scrofula for fuller details with regard to the phenomena produced by the lesion and the signs by which its presence may be ascer tained (see pages 182 and 183).
The intrusion of a foreign substance into the bronchus is sometimes a cause of paroxysmal dyspncea. This accident may be suspected if a first attack come on quite suddenly at or shortly after a meal, or under circum stances which justify the assumption, as when a child is playing with small objects which might readily slip into the larynx. In such a case, if the ob ject be a small one, the breathing is not always affected at once ; and if some cough and discomfort are excited at the first, these symptoms almost invariably subside, to return after a longer or shorter interval. Professor Henoch has reported the case of a girl, aged nine years, who went to bed apparently in good health, but was restless, complaining of discomfort during the night. Towards the morning she was seized with extreme dysp ncea and cyanosis. The child was taken to the hospital, where no signs of pulmonary disease could be detected. Shortly after her return home she began to vomit large quantities of undigested food, amongst which were found pieces of a hard-boiled egg which she had hurriedly swallowed on the previous evening. When the vomiting had subsided the girl had a good night's rest and the elyspncea did not return. In this case Dr. Henoch attributed the dyspncea to irritation of the gastric filaments of the vague ; but it seems more probable, as Dr. Birkart has suggested, that the symp toms were clue to actual bronchial obstruction by a portion of the imper fectly masticated food. The ordinary symptoms produced by the presence in the air-tubes of a foreign substance, and the means by which the cause of the dyspncea may be recognised, are treated of more fully in another chapter (see page 527).
The diagnosis of bronchial asthma has usually to be made by exclu sion, no other cause being found to which the access of dyspncea can be attributed. When called to a child who is said to be suffering from attacks of severe dyspncea, unaccompanied by laryngeal strider, we should first of all suspect the presence of enlarged bronchial glands. If the most careful examination fails to detect the existence of any such lesion ; if we find that in the interval of such attacks the child is well and hearty, with out albuminuria or sign of disease of the heart ; that the seizures came on under the influence of a pulmonary catarrh ; and that the only physical signs discoverable consist in a certain hyper-resonance of the percussion note with an occasional click or coo of rhonchus, we may conclude that we have to do with a case of bronchial asthma.
Prognosis.—If the child be in such a position in life that proper meas ures can be taken for his relief, his prospects are not unfavourable. If he can be sent away to a proper climate, be warmly dressed and carefully attended to, dyspncea from enlarged bronchial glands or from bronchial asthma is usually recovered from. The most serious forms of paroxysmal dyspncea are those which result from the presence of a foreign body in the air-passages ; from interstitial pulmonary cedema in Bright's disease ; and from clotting in the pulmonary artery. In the last of these, few cases recover. In the case of Bright's disease when the illness is of the acute form, we may have hopes that if the immediate danger can be tided over, the child may eventually recover. If the renal mischief be chronic, the prognosis is very unfavourable. When the dyspncea is due to the entrance of a foreign body into the air-passages, the prognosis is given elsewhere (see page 533).
Treatment.—If the child be first seen during an attack we are forced to treat the dyspncea without reference to its cause. Strong mustard poultice should be applied to the chest and moved about from one place to another over the front and back of the thorax. Secretion should be promoted by giving hot liquids to drink ; and a very useful form is that composed of a dessert-spoonful of liq. ammoniac acetatis, diluted with three or four times its bulk of hot water. Trousseau recommends the burning of stramonium leaves in the room ; but this is a very uncertain remedy and has lately fallen out of favour in the case of the adult. The fumes of nitre paper are preferred by some. Enough should be used to make the atmosphere thick with the nitrous vapour. If we can discover that the child has lately swallowed some indigestible food or notice any undue distention of the -abdomen, it will be well to relieve the stomach by an emetic dose of ipecacuanha wine.