Gesret method : asthma general definition
Excerpts from : «ASTHMA», is Raoul KOURLISKY, Encyclopaedia Universalis. Edition 1990 (P 252/ 255).
Asthma is :
- a breathing impediment induced by a great difficulty to breath out occuring by outbursts.
It happens at any age, appears, disappears, or remains according to an unpredictable variability ; it is conditioned by an intermittent contracting of bronchus caused by a spasm of their unstriped muscles and an obstruction by bronchial secretions.
Several starting modes are now pointed :
- allergic hypersensitivity
- psychophysiological problems
The main characteristic of asthma is :
- a dyspnea on breathing out, generally evolving through paroxysmal attacks, interrupted by long periods of total calm.
The crisis outburst occurs in two steps :
- gradual choking due to impossible breathing out
- evacuation of bronchial secretions.
The clinical analysis of asthma outburst shows forth two processes :
- firstly a mechanical one
- secondly a secretary one.
The frequency and the amplitude of the outburts are :
- largely variable according to the patients, going as far as lethal issue by choking, in extreme cases.
Impediment on breathing out and secretary disorders may be moderate ; if the former dominates and block efforts, we may wrongly think about a cardiac or circulatory problem.
If the two disorders remain together for years on, the patient who coughs, spits and experiences dyspnea seems to have got chronic bronchitis.
This term is exclusively used for a well defined chronic bronchial irritation which may, after a number of years, be complicated by an extreme dilation of pulmonary canaliculus, that is to say emphysema.
The main difference with asthma is that emphysema is non-reversible because of bronchoalveolar damages, but if the former gets secondary infection, it may, later on, turn into this state.
Asthma may appear under its different forms, in both sexes, at any time in life :
- in the young adult - 3 out of 5 cases
- about 50 years old - 2 out of 5 cases
- but also in old age and childhood.
For the child, the development of the breathing apparatus being incomplete until 7, the general aspect of the attacks is different from the adult :
- fast breathing, not slow
- expiration impediment less violent
- hypersecretion less heavy.
Very often attacks are associated with infectious dermatosis.
It is difficult to classify an infection with such multiform and changeable characteristics. We therefore have always hesitated between a syndrome, i. e. a group of symptoms associated with a lot of different causes, or a disease.
For individualizing this disease we will have to discover the cause :
- according to Trousseau, it was a personal predisposition in some individuals (diathesis) to experiment, simultaneously or alternatively, different manifestations on different organs (for example : breathing problems/eczema
- on the contrary Brissaud, only retaining the anxiety and the nervosism of the patients, considered it was a nervous disorder, a "breathing neurosis".
Scientific methods of investigation
Laennec was the first to describe bronchus damages about the disease he called "bronchus dry catarrh" :
- There is a swelling with dark or purple redness of the internal membrane of the bronchus ... often noticeable in the small boughs which are sometimes obstructed. When they are not obstructed they are often occluded by a very viscous substance with a starch consistency or stronger. But it is more usual to find a more important clogging of the bronchial membrane in the small boughs than in the trunk from which they stem.
These observations have been widely confirmed when anatomical controls have been later performed in lethal asthma cases.
A violent inflammatory reaction has been discovered too, where capillaries are dilated, where mononuclear leukocytes, some of them named "eosinophilia", prevail over white polynuclear bood cells.
Bronchus physiological dysfunctions
The elective uneasiness of breathing out is due to a contracting of bronchioles by a spasm of unstriped muscles, which oppose the discharge of the alveolus. This problem is said to be obstruent and it is measurable with a spirograph. For the asthmatic the maximum expiration volume per second is less than the usual 1 000 millilitres and the ratio of this volume to the vital capacity, which is normally 75, is lessened in proportion.
Obstruction is variable, with a maximum during attacks, but does not totally disappears at other times.
The bronchial muscular spasm is started by a parasympathetic nervous excitement, coming from the pneumogastric nerve, leading to numerous small ganglions (80 to 100 per mm2) which line bronchioles walls.
Contraction is caused by the liberation at the tip of nervous fibers of a constrictive substance : acetylcholin.
In order to stop this contraction, the therapeutic method now used consists in giving two antagonistic substances : catecholamine and aminophylline.
Secretion comes from two apparatus :
- the first, cellular, constituted by calceiform cells, alternating with ciliated cells on the surface of bronchial mucosa
- the second, glandular, is similar to salivar glands and is situated deeply in the the bronchial sub-mucosa.
Bronchial secretion is also stimulated through the nervous process, through the two systems : sympathetic and parasympathetic.
Widal, Abrami, Pasteur Valléry-Radot, have shown that the inflammation of bronchial mucosa with all its consequences (muscular spasm and hypersecretion) may result from an immunological manifestation of hypersensitivity which is immediate. This manifestation is caused by vegetable or animal substances named "allergen" present in the inhaled air, with the same proprieties as the antigenic molecules which induce the formation of antagonistic substances : antibodies.
The complex formed by the combination antigen-antibody induce serious inflammatory and cytotoxic disorders in the tissues.
In man, the asthma attack is very similar to breathing accidents caused in the guinea-pig by anaphylactic hypersensitivity. The injection of very small quantities of antigens before the inoculation of the releasing quantity prevents the attack.
The principle of desensitization has been drawn from those findings.
The discovery, in the tissues, when attack occurs, of chemical substances (histamine, serotonin, bradykinin) able to locally cause all the physiological elements of asthma, lead to the synthesis of antihistamine substances able to highly alleviate symptoms.
Anyhow, allergic hypersensitivity is only provable in 25 to 65% of the cases according to the authors and the statistics.
Besides those asthmas from extrinsic origin, there are others from intrinsic origin in which not any etiology can be proved :
- the real mechanism of those asthmas is still unknown.
The discovery of substances extracted from the adrenal cortex (corticoids) has made possible to obtain an important alleviation of inflammatory bronchial symptoms without modifying the evolution ; but we cannot use those products very long without exposing the patient to serious risks.
Emotivity and anxiety in asthmatic patients have always been a puzzle for practionners.Epinger and Hess believed in the prevalence of a specific excitability of one or the other part of the internal organs innervation system called "autonomous". Others (Turiaf) had, without any success, looked for damages in the diencephalon, which controls the double visceromotor innervation.
As for the rivalry between psychiatrists and psychoanalists :
- the psychism of those patients is characterized by a very strong attachement to their mother which accounts for their hypersensitivity.
But this is true for other asthmatic patients too.
According to Kourilsky :
- the stimulus comes from a frustration conflict, known by the patient, but for which he ignores the relation it bears with the breathing problem
- the frustration dwelves on pulsions considered as essential and the patient can neither accept nor make this obstruction cease
- the anxious emotion is then invested in the visceral nervous system which regulates breathing
- the imperfect or total solution of the conflict will be conducive to a total or partial alleviation, excepot when personnality tests reveal in the patient abnormal dispositions, such as serious depression, immaturity, paranoid state
- the extreme variability of asthma is therefore due to the permanent psychophysiological modulation of symptoms by conflict anxiety.
His conclusion is :
- hypersensitivity is no doubt an intermediate link of utmost importance and psychophysiological modulation is one of the keys of intensity and evolution ; other external and internal influences are much less important
- asthma is more a state than a disease. It is rooetd in man itself, its personnality, its deeper affective regulations, its genetic inheritage of an allergic diathesis
- it will still harass man for a long time but, it is better and better understood and controlled.
What has another specialist to say ?
Breathing reduced by expiration impediment (c. f. Barth)
- "Here phenomena seem to be the opposite of the normal state : breathing in is short and silent, but breathing oiut is long, uneasy and noisy, it needs quite an effort.In the asthma crisis, phenomena are more intricate : there are simultaneously a spasm of inpiratory muscles, contracture of muscular rings of Reissessen and bronchial hypersecretion."
- "The attack starts with a dry cough accompanied by a discomfort sensation in the chest ; breathing in is comparatively easy but short and surface ; breathing out, long and whistling, is incomplete : lungs cannot empty the air contained ; soon the chest is dilated to the maximum, the secondary inspiratory muscles, scalenus and sternomastoid, are tightened like strings ; the face has got cyanosis."
Are there other forms of dyspnea ?
This last description is particularly interesting, it will help dealing with a problem which is generally left unexplored : inspiratory dyspnea, which is wrongly considered as asthma.
In this case the phenomenon runs contrary to those Barth exposed :
- breathing in is long and noisy, needing a considerable effort and causing a depression of the suprasternal area. There is seemingly a pharyngal constriction
- on the contrary, breathing out is short and silent.
Reading through my site will give you answers to many a questions which, in my opinion, have never been tackled with.
I totally disagree too with the psychophysiological theories as stated in this page ; you will understand my arguments when reading the page "psychosomatic ?".