Asthma

Asthma (Gr. ἆσθμα, gasping, whence ἀσθμαίνω, I gasp for breath), a disorder of respiration characterized by severe paroxysms of difficult breathing (dyspnoea) usually followed by a period of complete relief, with recurrence of the attacks at more or less frequent intervals. The term is often loosely employed in reference to states of embarrassed respiration, which are plainly due to permanent organic disease of the respiratory organs (see Respiratory System: Pathology).

The attacks occur quite suddenly, and in some patients at regular, in others at irregular intervals. They are characterized by extreme difficulty both in inspiration and expiration, but especially in the latter, the chest becoming distended and the diaphragm immobile. In the case of “pure,” “idiopathic” or “nervous” asthma, there is no fever or other sign of inflammation. But where the asthma is secondary to disease of some organ of the body, the symptoms will depend largely on that organ and the disease present. Such secondary forms may be bronchitic, cardiac, renal, peptic or thymic.

The mode of onset differs very markedly in different cases. In some the attack begins quite suddenly and without warning, but in others various sensations well known to the patient announce that an attack is imminent. According to the late Dr Hyde Salter the commonest warning is that of an intense desire for sleep, so overpowering that though the patient knows his only chance of warding off the attack is to keep awake, he is yet utterly unable to fight against his drowsiness. Among other patients, however, a condition of unwonted mental excitement presages the attack. Again the secondary forms of the disease may be ushered in by flatulence, constipation and loss of appetite, and a symptom which often attends the onset, though it is not strictly premonitory, is a profuse diuresis, the urine being watery and nearly colourless, as in the condition of hysterical diuresis. In the majority of instances the attack begins during the night, sometimes abruptly but often by degrees. The patient may or may not be aware that his asthma is threatening. A few hours after midnight he is aroused from sleep by a sense of difficult breathing. In some cases this is a slowly increasing condition, not becoming acute for some hour or more. But in others the attack is so sudden, so severe, that the patient springs from his bed and makes his way at once to an open window, apparently struggling for breath. Most asthmatics have some favourite attitude which best enables them to use all the auxiliary muscles of respiration in their struggle for breath, and this attitude they immediately assume, and guard fixedly until the attack begins to subside. The picture is characteristic and a very painful one to watch. The face is pale, anxious, and it may be livid. The veins of the forehead stand out, the eyes bulge, and perspiration bedews the face. The head is fixed in position, and likewise the powerful muscles of the back to aid the attempt at respiration. The breath is whistling and wheezing, and if it becomes necessary for the patient to speak, the words are uttered with great difficulty. If the chest be watched it is seen to be almost motionless, and the respirations may become extraordinarily slowed. Inspiration is difficult as the chest is already over-distended, but expiration is an even far greater struggle. The attack may last any time from an hour to several days, and between the attacks the patient is usually quite at ease. But notwithstanding the intensely distressing character of the attacks, asthma is not one of the diseases that shorten life.

In the child, asthma is usually periodic in its recurrence, but as he ages it tends to become more erratic in both its manifestations and time of appearance. Also, though at first it may be strictly “pure” asthma, later in life it becomes attended by chronic bronchitis, which in its turn gives rise to emphysema.

As to the underlying cause of the disease, one has only to read the many utterly different theories put forward to account for it, to see how little is really known. But it has now been clearly shown that in the asthmatic state the respiratory centre is in an unstable and excitable condition, and that there is a morbid connexion between this and some part of the nasal apparatus. Dr Alexander Francis has shown, however, that the disease is not directly due to any mechanical obstruction of the nasal passages, and that the nose comparatively rarely supplies the immediate exciting cause of the asthmatic attack. Paroxysmal sneezing is another form in which asthma may show itself, and, curiously enough, this form occurs more frequently in women, asthma of the more recognized type in men. In infants and young children paroxysmal bronchitis is another form of the same disease. Dr James Goodhart notes the connexion between asthma and certain skin troubles, giving cases of the alternation of asthma and psoriasis, and also of asthma and eczema. The disease occurs in families with a well-marked neurotic inheritance, and twice as frequently in men as in women. The immediate cause of an attack may be anything or nothing. Dr Hyde Salter notes that 80% of cases in the young date from an attack of whooping cough, bronchitis or measles.

In the general treatment of asthma there are two methods of dealing with the patient, either that of hardening the individual, widening his range of accommodation, and thus making him less susceptible, or that of modifying and adapting the environment to the patient. These two methods correspond to the two methods of drug treatment, tonic or sedative. During the last few years the method of treatment first used by Dr Alexander Francis has come into prominence. His plan is to restore the stability of the respiratory centre, by cauterizing the septal mucous membrane, and combining with this general hygienic measures. In his own words the operation, which is entirely painless and insignificant, is performed as follows:—“After painting one side of the septum nasi with a few drops of cocaine and resorcin, I draw a line with a galvano-cautery point from a spot opposite the middle turbinated body, forwards and slightly downwards for a distance of rather less than half an inch. In about one week’s time I repeat the operation on the other side.” In his monograph on the subject, he classifies a large number of cases treated in this manner, most of which resulted in complete relief, some in very great improvement, and a very few in slight or no relief.

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