Friday, November 18, 2016

1860: Dr. Salter's Varieties of Asthma

According to Dr. Henry Hyde Saler, or preeminent 19th century expert on asthma, all cases of asthma are the same in that they all present bronchial stricture that results in tightness of breathing and other symptoms of asthma.  That said, there are different varieties of asthma, with the features of each variety unique to that type.

The following are the basic forms of asthma: (1, page 63

1.  Pure Asthma:  Asthma uncomplicated with bronchitis, heart disease or other "organic complication of the heart or lungs."  With a few exceptions, asthma is almost always a nervous disorder, and that the symptomatic nature of the disease is due to "spasmotic contraction of the fibre-cells of organic and unstriped muscle which anatomy has demonstrated to exist in the bronchial tubes."  Also called idiopathic, uncomplicated, or spasmotic asthma.
  • Classification: 1.  Exciting Cause Manifests
    • Group 1.  Intrinsic Asthma: The lungs alone are concerned; the irritant applied to the lungs themselves, and in most cases is inhaled. (group
      • Variety 1.  Asthma from fog, smoke, fumes of various kinds: the lungs spasm to keep the offending material out of the lungs; thus, they are doing what they are supposed to do
      • Variety 2.  Ipecacuan Asthma:  Rare; attack occurs only when this powder is inhaled (1, page 63)
      • Variety 3.  Hay Asthma: People with it experience sneezing, intolerance to light, irritation of conjunctiva, nasal passages, and fauces; dyspnea from asthma. (see summer asthma below) (1, page 64)
      • Variety 4.  Asthma from animal emanations:  Similar to hay fever; inflamed conjunctiva, watery eyes, inflammation of tear ducts, nasal passages and throat; dyspnea from asthma; results after touching a cat, or after touching a cat and then the eyes. 
      • Variety 5.  Asthma from certain airs:  Asthma caused by air of certain localities, such as a person going to the country would have syptoms he normaly didn't have in London. Person can breathe perfectly well in one place and not in another 
      • Variety 6.  Toxaemic Asthma: Asthma produced by blood poisoning, thus circulates in the blood and is not inhaled. Caused by things taken into the blood by absorption: i.e. beer, wine, and sweets; cause asthma as soon as reach pulmonary circulation; usually asthma that takes place after a meal (dyspepsia, loaded rectum)
    • Group 2.  Excito-motory, or Reflex Asthma: Source of irritation has a distant seat, far removed from the lungs, and reaches and affects the lungs by a reflex action. (classification)
      • Variety 1.  Peptic Asthma:  Bloated stomach; eating too much; upset stomach; dyspepsia; bowel irritation; uterine cause; asthma follows an error in diet; always supervenes on a full meal.  Bronchospasm is caused by irritation of the gastric filiments of the pneumogastric nerve. (1, page 65)
      • Variety 2.  Asthma from organic nervous irritation: asthma from a loaded rectum or uterine irritation that results in asthma by means of the sympathetic nervous system.
      • Variety 3.  Asthma from peripheral cerebral-spinal irritation:  Cerebral Spinal system receives the first irritation; i.e. exciting cause is some particular condition unto which the external surface is thrown (as in sudden application of cold to the instep). Those cases which asthma is broght on by sudden emotion (1, page 65-66)
      • Variety 4.  Cardiac Asthma:  The heart and lungs are connected by intimate nervous connections, and through these a disease heart may cause spasm by reflex nervous irritation. (Cardiac Asthma can also cause spasm by impeding circulation through the lungs, see below)
      • Variety 5.  Nocturnal Asthma: Lethargy and seep induces reflex nervous action.  While sleeping, or being very sleepy, the asthma comes on, but upon waking and sitting up, all is fine.  Remedy is wakefulness or coffee.  (1, page 105)
    • Group 3.  Central Asthma:  In the brain itself
      • Variety 1.  Epileptic:
      • Variety 2.  Emotional: 
      • Variety 3.  Etc.
  • Classifican 2.  No apparent exciting cause of attacks
    • Group 1.  Periodic Asthma:  Asthma that occurs only appears at a certain time of year, such as only in the summer, fall, winter or spring.  The asthmatic learns to expect it and plan for it, and he learns what will remedy it.  It also could be asthma that occurs at a certain time of day, or during a certain day of the week.  No amount of care will prevent the attack. Exciting causes (exertion, laughter, heavy supper, etc.) will only bother him at time, and not bother him at other times. The attack is like epilepsy: some loophole comes around to cause it, and when the loophole is gone the patinet has no symptoms whatsoever. (1, page 66)
      • Variety 1.  Diurnal Asthma:  A patient has an attack at about the same hour (such as 4 a.m.) every day.  Such morning asthma symptoms are very commonly associated with bronchitis, heart disease, or otherwise not pure asthma.  When a person complains of morning asthma, you should look at some other "heart or lung mischief."  However, pure asthma may also be involved due to some daily exciting cause, such as eating too much at dinner and having a full stomach, such as daily after dinner.  In some cases the daily symptoms are at random times, and the exciting cause is undecipherable, and "another explanation must be sought." (1, page 48-49)
      • Variety 2.  Winter Asthma:  Symptoms that occur once a year usually occur in winter, and are associated with bronchitis (muscular spasm engrafted on inflammation of the mucus membrane of the air passages).  These cases are not primary asthma, but asthma secondary to bronchitis.
      • Variety 3.  Summer Asthma (Hay Asthma):  Also called hay-fever.  It's usually only appears and ends with the hay season, or as long as the grass is in flower.  It usually lasts 4-6 weeks in early summer. The asthma is not consistent, but comes on when other exciting causes are present, such as: hay, full meal, laughter, or bright, hot, dusty sunshine.  The symptoms may be worse at night, such as what occurs in diurnal asthma. The attacks are usually very severe.  There are no symptoms of asthma between hay fever seasons. (1, page 50)
      • Variety 4.  Autumnal Asthma:  Symptoms usually occur in the late summer or early autumn.  The exciting cause appears to be hot weather.  Symptoms may be worse when the air is thundery and hot.  For those patients with pure asthma, symptoms seem to get worse during this time of year.  The intervals of these attacks are arbitrary, lasting ten days, two weeks, one month, or even up to two months.
      • Asthma complicating bronchitis.  (1, page 50)
2.  Complicated Asthma: Also called symptomatic or organic asthma.   Asthma is complicated by some form of organic disorder, such as heart failure, kidney failure, or chronic bronchitis.
  • Group 1.  Organic cause vascular: Organic lesion itself is the exciting cause of the asthma.  The paroxysms will be more frequent compared to idiopathic asthma (pure asthma).  Patient may be mild dyspneic all day long as compared to very dyspneic during random fits. The patient will be permanently marked by signs of organic disease (i.e. see varieties 1-2 below). Note that airway spasm that occurs with bronchitis is more "considerable" than spasm that occurs with cardiac disease.
    • Variety 1.  Asthma complicating bronchitis: Active congestion of the air passages. Causes derangement of bronchial tubes through inflammation. (also called common hymid asthma or senile asthma. Causes active hyperaemia of the lungs. Accute bronchitis causes inflammation, narrowing of the tubes, and this results in contraction.  Chronic bronchitis is difficult to determine whether it's bornchitis with asthma, or asthma with bronchitis. However, severe bronchitis never exists without asthma complications. This is generally triggered by irritant to the airway. (1, page 67-8)
    • Variety 2.  Cardiac Asthma: Passive congestion of the air passages. Derangement of the bronchial tubes through congestion in the lungs; caused by a failing heart, thus interfering with the transit of blood through or or from the lungs, such as aneurism or heart disease. (fluid in lungs) Causes passive hyperemia of the lungs.  Most varieties of cardiac asthma are not asthma at all; "it is dyspnea of the true cardiac type, and in no way dependent on bronchial contraction."(1, page 62)
  • Group 2.  Organic cause nervous:  
    • Herberden's Case: Asthma due to exostosis (production of new bone on surface of a bone) of the upper dorsal vertebrae. This results in "frequent difficult respiration."
    • Etc.: Such as tumor pressing on the pneumogastric nerves
Long-Continued Asthma:  Asthma that is constant and results in permanant scarring in the lungs that results in lungs that are so sensitive that even slight exposure to exciting causes may cause a paroxysm of asthma.  Examples may include excitement, laughing, coughing, sneezing, etc.  A modern term for this may be hardluck asthma, or chronic uncontrolled asthma.  (1, page 83)

Emphysema Asthma: Emphysema is not named by Salter as a variety of asthma, and he states this is because "I think that a great majority of the cases in which emphysema and asthma are combined, the emphysema is... either a consequence of the asthma, or of some common cause both of the asthma and of itself."  He notes that for those who develop emphysema "generally the asthma exists uncomplicated for some months or years, with perfect freedom from dyspnea between the paroxysms, before the permanent dyspnea, and the configuration of the chest, and other signs of emphysema, develop themselves." He notes that "emphysema is a consequence, not a cause of asthma." Severe asthma may ultimately "have emphysema engrafted upon it." (1, page 68)

So there you have it: Types of Asthma per Dr. Salter.  Each doctor had his own opinion, yet Dr. Salter's opinion was highly sought out.

  • Salter, Henry Hyde, "On Asthma: It's Pathology and Treatment," 1882, New York, William Wood and Company, (chapter V) pages 62-69, (chapter VI) 70-81.  (original publication of chapters in magazines during the 1850s. The articles were compiled and published as a book, the first edition of which was in 1860in London)

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