RECENTLY there came to the Massachusetts General Hospital a patient whose case illustrates so many of the problems concerned with asthma and emphysema that it will be helpful to use it as a text for the following review of the facts and theories of this disease.The patient was an active lawyer and business man of fifty-two who through most of his life had been well except for a troublesome nasal catarrh, which continued without change in different seasons and environments. There was no history of eczema or of seasonal hay fever, and there was no asthma until the age of forty-seven. At that age, the nasal catarrh became worse and sinusitis developed. The patient began to cough at night, and his appetite fell off. He began to lose weight. He was run down and was sent to Hot Springs, Arkansas, for rest and treatment. During that visit the asthma first appeared, in a sudden sharp attack. In the five years since then it has continued through all seasons and in all places, with ups and downs perhaps but with no real letup. During this time the patient has had all manner of treatments, as will be discussed.At the present time he has asthma and emphysema of a severe grade. The chest has a barrel shape, but there is no clubbing of the fingers. The air sacs are distended, and one can assume that many have coalesced to make larger air spaces, with consequent reduction in the surface area of the lungs. The diaphragm is low and under the fluoroscope it moves but little. The function of the lungs is greatly reduced. There are times, however, when the patient can lie back on his pillows comfortably and can walk to the toilet without trouble, but there are other times when mucus collects in the pharynx or bronchi or both and precipitates a violent attack of cough and wheezy dyspnea. This is relieved somewhat by an epinephrine spray and better by adrenalin given subcutaneously, but occasionally requires an intravenous injection of aminophyllin. It is evident that the disturbance of lung function is not constant in degree, and it is hard to believe that all these symptoms can be explained simply by the mechanical limitation of this function.The patient is generally miserable. He is evidently frightened by his disease and is obviously apprehensive about its future developments. He has lost much weight, is very thin, and has no appetite. He is unable to concentrate on anything and he does not care for reading.What causes this disease? The wheeze suggests allergy, but it is now recognized that "all is not allergy that wheezes," and in this case, as in many of similar nature, it is not possible to demonstrate any relation between the symptoms and changes in the environment or diet. The patient has lived in different places, but he could never see that houses, rooms, mattresses or pillows made any difference to him.One thinks of foods. Here in the hospital he was fed a diet high in calories and vitamins, with no limitation as to choice of foods, and seemed to thrive on it. Skin tests were made on three different occasions by three diff...
