Wednesday, November 16, 2016

1860: Salter's prognosis for asthmatics

What is the prognosis for your asthma? What are the chances you will outgrow your asthma?  With everything else being coeteris paribus (equal)the answer to this question may depend on the following:

1.  Age of the patient:  Patients who develop asthma under the age of 40 are more likely to outgrow their asthma than those over the age of 40.  Barring organic injury, asthmatics under the age of 15 are most likely to "gradually 'grow out'" of their asthma.  Those over 40 have a "fair chance" of outgrowing it.  (1, page 168-9)

2.  Absence of organic disease:  You are most likely to outgrow your asthma if you do not have any pulmonary or circulatory organic changes, such as chronic bronchitis or heart failure. "If the heart and lungs are completely free of organic disease, recovery is possible." If an organic disease exists that causes bronchospasm or is the cause of the asthma, "recovery is impossible" (which is more likely to be the case in asthmatics over the age of 40).  If the "cause is incurable," so to "is its consequence." (1, page 170)

3.  Length of attacks:  Repeated attacks cause damage to the lungs by causing "permanent pulmonary congestion. At each attack the shutting off of air by the narrowed bronchioles suspends the normal respiratory changes of the blood in the capillaries. This produces arrest in and ultimately engorgement of the whole pulmonary circulation, capillary and venous. Now this pulmonary congestion... becomes formidable and intractable in proportion to the length of time it has existed. If the attack is short, and the speedy relaxation of the bronchial tubes quickly readmits a free supply of air, the vessels are at once relieved, the blood passes on, and the transient congestion leaves no trace behind it." If the attacks last several days or weeks, "the capillaries and venules, long distended, never completely recover themselves, their tone is lost, and pulmonary congestion, manifested by chronic dyspnoea and expiration, is permanent." The chronic pulmonary congestion occludes the bronchial tubes with mucus and becomes a permanent source of bronchial irritation (it becomes a permanent exciting cause of asthma). (1, page 170)

4.  Frequency of attacks:  "If the intervals are so short that the lungs have not time completely to recover from one attack before the occurance of another, the omen is very bad, because the mischief of each attack being engrafted on some portion of that of its predicessor, the organic derangement is accumulative, and the case one of progressive disorganization."

5.  Completeness of recovery:  If the patient recovers completely between attacks, then you can rest assured there is no permanent permanent organic changes to the pulmonary circulation. If dyspnea persists between attacks, you can rest assured of the probably some organic changes have occurred (the terminology today would be airway changes or remodeling).

6.  Persistence of exporation:  If the patient is chronically coughing and spitting up secretions from the lungs, this is a bad sign.  It generally means the patient probably has humoral asthma, which, by all means, is probably chronic bronchitis more so than asthma (see bronchitic theory of asthma).  It is definitely chronic in nature and this type of asthma will not go away.

8.  Direction disease is taking:  Are attacks becoming less intense or more severe? Are they more frequent or less frequent? Are they severe and more frequent, or milder and more distant? Since the loss of asthma is generally gradual, less frequent and milder attacks is a good indicator the asthma may someday disappear.

9.  Ability to detect exciting cause:  Asthma is easier to treat and cure when the exciting cause is known.  If the exciting cause is living in the country, then the remedy may be simply moving to the city.  If the cause is eating a large meal, the remedy and cure will be eating light meals.  If the exciting cause cannot be detected, or if there are many exciting causes, the "omen is bad."

Salter concluded by noting the following:
"If, then, an asthmatic were to present himself to me and seek my opinion as to his prospects... (after) carefully scrutinized the condition of his chest, put to him the following questions:
  • What is your age? (if not already ascertained)
  • How long do your attacks last?
  • How often do they occur? 
  • Do you lose all traces of shortness or difficulty of breathing between the attacks; or is the breathing always a little difficult?
  • Do you habitually cough and spit?
  • Does the disease appear gaining on you, or the reverse?
  • Is the exciting cause of the attacks clear; and can you undertake that it shall not recur? (1, page 172)
Generally, if the answers provide help Dr. Salter draw the conclusion that you have pure asthma, then the prognosis given to you would be rather good.  He was one of many physicians who believed most asthmatics lived to a ripe old age.

  • Salter, Henry Hyde, "On Asthma: It's Pathology and Treatment," 1882, New York, William Wood and Company, pages 168-172  (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 1860 in London)
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