Editor,—In his robust defence of the term asthma,¹ Dr Speight has failed to grasp the significance of the changed definition of this term. The original definition of asthma was purely functional: “airway obstruction which varies over the course of time and with treatment”.² In small infants in whom lung function measurements are not usually available, this was modified to “cough and/or wheeze in a setting where asthma is likely, and other rarer conditions have been excluded”.³ By this definition, few would quarrel with Dr Speight’s wish¹ to retain the term for infant wheezing.

Unfortunately, to use Asher’s words,⁴ “an abominable semantic crime has been committed, a single term has knowingly been applied to two completely different things without making the slightest effort to determine if the one is the equal to the other, or even related to the other. A pathological process and a collection of symptoms have been given the same name”. Asthma is now defined as “a chronic inflammatory disorder of the airways in which many cells play a role, including mast cells and eosinophils”⁵ or “a common and chronic inflammatory condition of the airways whose cause is not completely understood”,⁶ and by these definitions many of the infants whom Dr Speight labels as asthmatic have no such condition. This is not merely of theoretical importance, because there is abundant evidence that earlier treatment of T lymphocyte driven, eosinophil mediated airway inflammation with inhaled corticosteroids is beneficial both in terms of immediate symptomatic benefit and long term preservation of lung function.^{7 8}Confusedly labelling infants who wheeze with colds as asthmatic, with the implication of airway inflammation, will result in exactly the same treatment policy being advocated for them, despite evidence that there is no benefit either on acute symptoms⁹ or long term lung function.¹⁰ The safety record of inhaled steroids is impressive, but even in the short term, there is evidence that overtreatment causes harm which is not reversed on stopping therapy.¹¹ Furthermore, the fiscal cost of the medications is not small and the long term effects are sufficiently imponderable as to make this not a subject for complacency.

The issues may be different if the sole concern is the laudable one of ensuring acutely ill children get ambulances quickly. Speed is of the essence, and accuracy less relevant. In this setting, the use of the term is justified, and has in the past been absolutely invaluable. In 1997, between consenting adults in the cold light of day, the use of the unqualified term asthma is indefensible, unless the clock be turned back and the old definition restored.