Pulmonary pathology with special emphasis on bronchial asthma

Abstract 1.1. In addition to our original series—thirty-one males and seventeen females—of so-called "fatal asthma," we wish to add an entirely new one which has been accumulated in the past five years. Each individual has been subjected to a more critical post-mortem examination because of the interest created by our original work. The new series contains four female children, twenty-five adult females, and fifty-seven adult males. None of these case records has been previously published. 2.2. The diagnosis of "asthma" has been made on each patient and frequently has appeared on the death certificate. We have carefully reviewed the records for each patient and have indicated in the chart whether the diagnosis was at any time tenable, and if so, whether the condition was present in the last ten to twelve hours of life. A great majority of these individuals have been under our personal observation for an extended period of time. 3.3. The series of four children seems too small a group to permit many conclusions, but they have failed entirely to demonstrate evidence of "general lymphoid hyperplasia." 4.4. The adult females averaged 46.2 years at death, and this figure is approximately a mid-point between the average of all cases published prior to 1937 and our series of forty-eight patients reported at that time. The duration of dyspnea in those who probably had had asthma varies from six to sixty-five years with an average of nineteen years. Protracted and rather typical asthma may leave few stigmata in the pulmonary tissue. In others, atypical asthma of relatively short duration may result in many changes in the lungs. In but seventeen of the twenty-five patients in this group did the diagnosis of bronchial asthma appear possible. 5.5. The male patients were similarly grouped and their average age at death was 55 years, a figure considerably in excess of the average of 48 years which represents all cases reported prior to 1937, and still somewhat in excess of the average age of 52 years for our original series published at that time. Although, in general, the life expectancy of females is greater than that of males, the trend seems definitely to be the reverse in our own as well as other series of "fatal asthma." In approximately 42 per cent (twenty-four patients) of the males, it appeared that asthma had been present at some time during life. In fact, it averaged approximately thirty years in duration. 6.6. A wide variety of conditions simulated the clinical and pathologic findings of asthma. Among the male patients especially, these conditions may have been present in many instances for a long period before the onset of asthma. They varied from most marked interstitial emphysema in the youngest male, to extensive atelectasis of all five lobes in the third male of the series. As other examples of the predisposing conditions, one might mention distortion of the thorax and pressure from without the respiratory and pulmonary vascular tree, as well as conditions due to actual diseases of the lung and of the heart and great vessels. Pulmonary fibrosis due to a long-standing tuberculosis or pneumoconiosis, as well as proved bronchitectasis are some of the more common pulmonary conditions which have induced the symptoms of asthma. Rheumatic heart disease of long duration, as well as hypertension and syphilitic aortitis with or without aneurysm, are the more conspicuous among the circulatory dysfunctions which engender asthma, and this condition may be clinically a counterpart of true allergic asthma rather than the orthodox cardiac asthma. 7.7. Conspicuous abnormalities of the heart and circulation rarely, if ever, result from bronchial asthma. 8.8. A considerable number of patients in this, as well as in other series, died shortly after the use of morphine sulfate. It would appear that this drug is definitely contraindicated, although it must be admitted that several individuals were in a near moribund state when the drug was employed. 9.9. We are in complete accord with the concise conclusion of Tuft 7 that "there is at present no known pathologic picture either gross or microscopic which may be considered characteristic or pathognomonic of asthma."