Asthma: a new conception.

Of the relatively few emergency calls made upon you in practice, the call for treatment of the acute attack of asthma will be by far the most common. In fact with some patients the calls become so frequent and at such inconvenient moment that both the doctor and his patient begin to meet with ill grace. The late Wilfred Trotter in an address on emergencies said this: "In a certain sense of the term the feeling of emergency can never be far from the mind of the active doctor. However disturbing that experience may be, and however much at times he may be inclined to envy the calm and prestige of more secure professions, if he is a person who prefers having a man's job to having one of the other kind, he will remember that his deficiency and his exposure are the price to be paid for that dignity." He continued, "When we turn to consider the emergencies in the strict sense of the term with which the doctor has to deal, we find we are still in a region where personality at least holds its own in comparison with technical equipment. For the more urgent the call for decision and action, the more important are character, the slowly matured power of judgment and a grasp of fundamental principle, and the less trustworthy are mere detailed knowledge and executive skill." Although Wilfred Trotter was discussing emergency from the surgical angle, these words have a very important bearing upon the doctor and the asthmatic patient. I am going to-day to talk about the treatment of asthma and to discuss with you the aetiological factors concerned, certain of which are new, being based upon recent clinical research and which, in my view, are of considerable importance in the treatment of this so-called disease. Unfortunately there has grown up in the profession a scepticism about asthma. So many doctors have thought of it as either purely psychological or are concerned with it only because of its nuisance value in practice. Sanderson (I945) in a recent lecture said: "One tends to think that the world might be divided into those who have asthma, and those who do not; but the truth may well be that everyone has an asthmna threshold, a certain greater or lesser inborn susceptibility to the condition-much in the same way that everyone might be said to have a sea-sickness threshold. The individual in whom this constitutional tendency is high is the patient with clinical asthma; when this tendency is low, as it is in the majority, it is unlikely that the condition will ever occur, although such powerful irritants as phosgene suggest that nearly all are potential asthmatics. This attitude of mind has an important therapeutic implication-namely that we should regard the asthmatic, and teach him to regard himself, not as an abnormal person, but as an essentially normal person with a functional disability, within the limits of which he must learn to live his life. "Even Sir Arthur Hurst, at the end of a lifetime of subjective and objective experience of asthma summed up his creed as follows: 'I am no believer in asthma cures ... and regard most of the popular treatment of to-day like that of ten, twenty or thirty years ago as nothing more than gross suggestion; yet I know that every asthmatic derives much benefit from good advice. He can be taught a way of life and among other things how to avoid the exciting causes of his particular brand of asthma. How to control attacks which he is unable to prevent and how to be happy in spite of bad luck of having been born with the asthma diathesis.'" With such conceptions I disagree. From the purely economic view alone it is a morbid process which is of farreaching importance and one demanding our further investigation.