Wednesday, November 30, 2016

1864: Alfred Newton's Dry Powdered Inhaler

People have probably inhaled powders of certain dried and crushed herbs for their perceived benefits since the beginning of time.  Yet the first device for assisting with this process was patented in 1864 by Alfred E. Newman.  His device was the first dry powdered inhaler.

The book "Controlled Pulmonary Drug Delivery" describes the inhaler this way:
In 1864 another step forward with dry powder inhalation took place. Alfred E. Newman applied for a patent in London after correspondence with Dr. James in New York.  The dry powder device resembled a mantle clock with an orifice at one side, inside was a mesh and a crank shaft with feathers to beat the powder creating a dust, which would pass through the mesh towards the mouth.  It was not especially portable, but Newton recognized that the powder needed to be pulverized into a fine dust and that it should be kept dry, two essentials of modern dry powder inhalers. The device was designed for the delivery of potassium chlorate which today is recognized as a lung irritant. (1, page 60)
The authors also note that while dry powder inhalation was "in vogue" during the 1860s, it was generally meant to treat diseases of the throat such as laryngitis.  Still, it was a revolutionary concept and a precursor -- albeit large, bulky, un-portable, and probably -- to modern dry powder inhalers.

The device may also have been used for tuberculosis.  (2).

Quality pictures of the device can be observed by checking out either of the links in the references below.

  1. Smyth, Hugh D.C., Anthony J. Hickey, editors, "Controlled Pulmonary Delivery," 2011, New York, Springer, page 60-61
  2. Sanders, Mark, "Pioneers of Inhalation: Vapour Trails and Powder Monkey," from Online Museum of inhaler technology, slide show presentation, accessed on 11/13/12
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Monday, November 28, 2016

1864: Seigle and Adams steam powered Inhaler

Figure 1 (1)
The first steam powered inhaler was described in a paper published in 1862 by Dr. H. Walenburg of Germany. (1, page 464)

It was described as "an instrument by means of which he could produce medicated spray in combination with steam and through the motive power of that principle." according to George Beatson in an 1880 article in the Glasgow Medical Journal. (1, page 464)

Regardless of his invention, he did not get credit as the inventor of the steam powered inhaler, and this may have been because he didn't obtain a patent for his product.  (1, page 464)

Two years later, in 1864, Dr. Emil Seigle of Stuttgart did take out a patent for a steam powered inhaler, thus giving him credit for the invention.  (1, page 464)

However, to his credit, it's possible that, because the design of the Seigle inhaler was "entirely different" from that of the Walenburg inhaler, Seigle was unaware of Walenburg's paper.  (1, page 464)

Seigle's Inhaler was a significant improvement in nebulizer design because it was the first nebulizer to create a mist completely on its own, without any manpower. (1, page 464)

Dr. Scutter said the Seigle Inhaler "was far preferable" to the other options of the day "for its simplicity and because it is automatic. The best reason for preferring it, however, is, that its price is such as to bring it within the means of any patient, as it is furnished through the druggists for $5.00, and its construction is so simple, that it is readily operated by any one." (3 page 32)

Like the Mathieu and Bergson inhalers, the Seigle design used the Bernoulli Principle to create a mist. Yet the older designs required a stream of air to create the mist. Without electricity, this required manpower. A flow had to be produced by blowing into a tube, by cranking a peddle, by squeezing a bulb syringe, or by depressing billows.

Dr. Seigle used steam instead of air. This eliminated the requirement of manual effort to create the stream. From figure 1 we can see that what he "did was connect Bergson's spray tube with a glass boiler, using steam for producing and conveying the spray instead of air." (1, page 464)

Figure 2 (1)
There apparently were other similar devices for using steam to produce a medicated spray, but these other devices were not as simple in design and ease of use as the Seigle Inhaler.  (1, page 464)

It was nice because the patient could simply sit it on a table and inhale the mist without much effort. It may have been this reason Seigle's inhaler was considered the first of its kind, even though it was probably not.

Yet the original Seigle inhaler (pictured in Figure 1) had its flaws, including the fragile glass boiler, which occasionally overflowed, and "the water flowing over through the stream escape is projected forcibly in the face of the patient... it required much persuasion on the part of the physician, and considerable nerve on the part of the patient, to face Seigle's Patent Inhaler after one or two experiences of this nature." (2, page 218)

The device was updated many times, and ultimately was accepted by the medical community and recommended to some patients who could afford it. (1, page 465)

Dr. Adams with "Face Protector"  (2)
One of the most significant improvements on the device was made by Dr. Adams in 1868, who improved the boiler system so that it was no longer made of glass. He introduced his new design in the Glasgow Medical Journal in 1879. (1, page 465)

He discussed his new design ten years later in his 1889 article "On an improved apparatus for spray inhalations," (2, page 317)

Future designs of the Seigle inhaler were based on the Adams design, mainly because...
...they gave off a steady, uniform stream of spray, warm in character and so fine as to cause little irritation, while being self-acting, they neither fatigued the patient nor required an assistant. In this way they became extensively used. (1, page 465)
Figure 2 is nice in that it allows you to visualize how the Seigle and Adams inhaler worked by means of the Bernoulli Principle. You can see how the steam rises, flows through the vertical tube rapidly, and a negative side stream pressure is created that draws medication up from the medicine reservoir. The example shown is actually the Adams Inhaler, although the same concept was used with the Seigle Inhaler and other similar designs.

The Seigle's inhaler was later improved and re-marketed, or as Dr. Adams wrote "pirated," by Dr. Seigle and re branded as "Dr. Seigle's Patent Steam Spray Inhaler, with Boiler as suggested by Dr. Adams." (1, page 465) (2, page 317)

The principle used to create the Seigle Inhaler was used "on an extensive scale" at the Hospital for Diseases of the Throat and Chest in the United Kingdom.  Here a room was designated for the purpose of inhalations, up to twelve patients were able to inhale different medications at the same time. (4, pages 85-86)

The steam was conveyed from a boiler in the basement of the hospital, and it traveled through pipes "fixed horizontally round three sides of the inhaling room, and from this horizontal pipe there project at regular intervals, and at right angles, secondary tubes which correspond with the horizontal tube of a Seigle Inhaler.  Bottles containing different solutions are connected with each terminal tube."  (4, pages 85-86)

This was a nice design, allowing the physicians at the hospital to treat up to twelve patients, each with a different inhaled medicine, simultaneously.  (4, pages 85-86)

The principle used by Seigle and Adams was a simple one that allowed many patients to inhale a medicated mist.  Most often the patient would receive this therapy at a physician's office or hospital, and the physician, a nurse, or an attendant would prepare the medicine.

However, for those who could afford it, the devices could be purchased for a nominal fee, and the medicinal recipes prepared and inhaled in the privacy of their own homes.

  1. Beatson, George, "Practical Papers on the Materials of the Antiseptic Method of Treatment," Vol. III, "On Spray Producers," Coats, Joseph, editor, "History of the Origin and Progress of Spray Producers ", Glasgow Medical Journal, edited for the West of Scotland Medical Association, July to December 1880, Vol. XIV, Alex and Macdougall, pages 461-484
  2. Adams, "On an improved apparatus for spray inhalations," The Retrospect of Medicine," W. Braithwaite, editor, Vol. LXXX, July-Dec., 1879, London, published by Simpkin, Marshall, and Co, pages 317-321 Inhaler
  3. Scudder, John M, "On the use of medicated inhalations, in the treatment of diseases of the respiratory organs," 2nd edition, 1867, Cincinnati, Moorz, Wilstach & Baldwin
  4. Mackenzie, Morell, editor, "The Pharmacopoeia of the Hospital for Diseases of the Throat and Chest," 4th edition, 1881, Philadelphia, Plesley Blakiston
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Wednesday, November 23, 2016

1862: Phoebus studies 'summer catarrh'

Christian Freidrich Schonbein (1799-1868)
While not the first to mention ozone,
he was the first to produce it in a lab.
He wrote about how to make it in 1832.
He also noted that air containing ozone
caused certain catarrhal conditions,
including asthma and hay fever.
Phoebus noted the link in 1862,
and usually gets credit for it
(5, page 80) (6, page 311)
Since Dr. John Bostock defined hay-fever for the medical community in 1819 and 1828, there was little mention of the ailment until Dr. Philip Phoebus published a book titled "On the Typical Catarrh of Early Summer, or the so called Hay-fever or Hay-asthma" in 1862.  (1)

Dr. Phoebus was professor of medicine at the University Giessen in Germany, and he was apparently one of the first physicians to study hay fever who did not have the condition.  He is said to have gained interest in it by the single case that he treated.  (4, page 17)

In 1869 he issued circulars and advertisements inviting medical men all over Europe and the United States to respond to seven questions phrased to gain particular information regarding their patients diagnosed with hay fever. The questions were well worded to gain particular information, and were related to the following: (2, page 14-15) (3, page 2) (4, page 17)
  1. Where they lived (city, country, lowlands, mountains, etc.?)
  2. What they did in their every day lives (lawyer, doctor, industrial worker, farmer, etc.?
  3. Their sex (male or female?)
  4. Social position (rich, middle class, poor?)
  5. Inheritance (was their disease hereditary? Do they have parents, grandparents, or siblings with the condition?)
  6. Constitutional peculiarities (does it affect their health and well being?)
  7. When do attacks of hay fever occur? (autumn, winter, spring, summer?) (2, page 14)
He received many replies, and used the information he received to put together a complete theory about this disease.  He then published the results of his research three years later, in 1862, in a thorough treaties. (2, page 14-15)

He learned that hay fever was most common in England than any other nation of Europe.  He learned people were predisposed to it, although he didn't understand why.  (2, page 15)

He believed the exciting cause was the first heat of summer, and that the longer days of summer exposed those predisposed to it to more light, and probably more ozone too.  In this way he was among the first to suspect a link between air pollution (ozone) and hay fever or hay asthma. (2, page 15)

He also believed that odors, dust, the blossom of rye, and hay were also exciting causes. (2, page 15)

In reviewing the ideas regarding of Dr. Phoebus on hay fever, Dr. William Abott Smith said Phoebus described six groups of symptoms, of which may vary from one case to another. (1, page 16)

1.  Nostrils.  Severe catarrh (common cold) leads to sneezing, and this may irritate the bronchi, causing spasm.  (1, page 17)

2.  Eyes.  Catarrh and increased secretions. The eye feels full, itchy and irritating.  The eye looks red and swollen.  Eyesight is weakened, and there is an intolerance to light. Both eyes are usually affected simultaneously. (1, pages 18-19)

3.  Throat. Pharynx is red, and swollen; there is intense itching of the back of the mouth behind the tongue.  This causes an unpleasant sensation that is aggravated by the patients efforts to relieve the itching. Sometimes there is difficulty swallowing. (1, pages 19-20)

4.  Head.  A headache might occur, that might be caused or worsened by sneezing.  The patient might also complain of a feeling of itching over the forehead, nose, chin and ears. (1, pages 20-21)

5.  Airway.  The mucus  membrane of larynx all the way to the bronchi may become irritated, causing asthma or dyspnea.  This may result in a cough, increased sputum production, irritation of the throat, a heavy feeling over the chest, and a muffled and coarse voice.  If the bronchi become affected, this may result in wheezing that results from bronchial catarrh or asthma or, more specifically, hay asthma or periodic asthma.  Dyspnea generally occurs in the evening and continues through the night. Hay fever that affects the lungs in this way tends to be more severe, with the patient waking up gasping and struggling to breathe. (1, pages 21-22)

6.  Nervous disturbance.  This is coupled with catarrhal fever that results in shivering and cold perspirations with sneezing and coughing. When this happens the patient becomes restless, weary, and unable to perform normal activities. The patient becomes irritable, with something as simple as a cool breeze being disturbing to the patient.  These patients generally develop a nervous and anxious disposition during the paroxysm. (1, page 22)

All in all, Dr. Phoebus went into more detail on hay fever, what causes it, and the symptoms that resulted, than any of his predecessors. Yet, and he knowingly admitted, he left many questions still unanswered for future investigators to answer. (2, page 15)

Dr. Blackley took the observations of Phoebus and Schonbein regarding their suspected link between hay fever and ozone, and set out to perform experiments with the substance.  He spent six hours in his office inhaling the substance and observed no effect. (11, page 35) (8, page 8, pages 79-91)

However, while he proved ozone had no effect on hay fever, he became the first to suggest that dust might cause hay-fever symptoms.

  1. Smith, William Abbotts, "On Hay-Fever, Hay-Asthma, or Summer Catarrh," 1867, London, Henry Renshaw, pages 17-24. 
  2. Beard, George Miller, "Hay Fever; Or, Summer Catarrh: Its Nature and Treatment," 1876, New York, Harper & Brothers, Publishers
  3. Wyman, Morril, "Autumnal Catarrh (Hay Fever)," 1872, New York, Published by Hurd and Houghton, The Riverside Press
  4. Mackenzie, Morell, "Hay fever and paroxysmal sneezing," 5th ed., 1889, London, J&A Churchill
  5. Blackely, Charles Harrison, "Hay-fever: its causes, treatment, and effective prevention," 1873, 1880 2nd edition, London, Bailliere
  6. Dickenson, Samuel Henry, "Elements of Medicine: a compendious view of pathology and therapeutics, or the history and treatment of diseases," 1855, Philadelphia,  Blanchard and Lea
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Monday, November 21, 2016

1861: Merkel supports nervous theory of asthma

Another physician who discussed his ideas regarding asthma was Dr. L. Merkel.
In his 1917 review of the history of asthma, Dr. Orville Henry Brown said the following of Merkel:
Merkel, after an exhaustive survey of the literature of asthma, comes to the following conclusions:
  1.  Asthma is an affection of the bronchi caused by a neurosis or by an over-stimulation of the nerves of the respiratory system.
  2. The cramps are sometimes useful for the purpose of preventing the entrance of foreign bodies into the respiratory tract.
  3. But from various causes this function may be exercised when it is of no benefit or use.
  4. The spasm involves the muscles of respiration.
  5. Bronchorrhea, bronchitis, dilation of the bronchi,and congestion commonly result.
  6. Asthma is usually complicated by catarrh, emphysema, and heart disease.
  7. Treatment is most efficacious if directed toward the nervous system.
  8. Inhalations are the most efficacious treatment. 
  9. The location of the neurosis cannot be stated but on that account cannot be denied. (1, page 35)
That's all I have for today.

  1. Brown, Orville Harry, "Asthma, presenting an exposition of nonpassive expiration theory," 1917, St. Louis, C.V. Mosby Company; reference used: "Merkel, L.: Schmidt's Jahrb., 1861, cix, p. 225.
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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)

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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Friday, November 11, 2016

1860: Salter's Asthma Remedies

If you suffered with asthma during the second half of the 19th century the chances were pretty good you tried, at one time or another, one or more remedy recommended by the famous asthma physician, Dr. Henry Hyde Salter. 

Salter divided asthma remedies into two different types:
  • Treatment of the paroxysm (treatment of the symptoms that occur during an attack of asthma)
  • Treatment of the intervals of the paroxysm (the real treatment of the disease; preventing asthma)
As you approached a physician for the first time with symptoms of asthma, he would, if he was following Salter's recommendations, follow a series of three steps:

1.  The very first thing he will do is question you to try to determine what was the exciting cause that set off your asthma.  Once the exciting cause was determined, he recommended removal of it.  For instance:
  • Is the cause a cat? Remove the cat.
  • Is the cause a new feather pillow? Remove the pillow.
  • Is there a hay field nearby? Remove the patient from the area
  • Is there dust in the room? Smoke? Remove it
  • Is the air new, such as a visit to the country? Remove patient to some place that is agreeable
  • Is there ipecacuanha powder in the room? Remove it.
  • Is the cause an undigested meal? Give an emetic.
  • Is the cause a full rectum? Give an enema.
2.  He would then position you into a "favorable position":
  • Get him out of bed
  • Bolster him up in an arm-chair
  • Place before him a table of convenient height, with a pillow on it, on which he may rest his elbows and throw himself forward.
Salter said:
"It is quite surprising, almost incredible, how much comfort this will give, and not only so, but how it will actually relieve the breathing and dispose the spasm to yield. Sometimes the patient's breath is so bad that he cannot sit; the same arrangements must then be made for him in a standing posture."
3.  If the above doesn't work, it is now time to try some "remedy by which we may hope to cut it short. In our choice of this we shall be very much influenced by our patient's former experience. Few asthmatics suffer long from their disease without having discovered what particular remedy is most efficacious in their case, and in this respect different cases of asthma vary so much, and display such a caprice, that I really know of no other guide except the patient's experience."

There were three classes of asthma remedies:
  • Depressants: Lower intervention, depressing nervous irritability, and enfeebling the contraction of the bronchial muscle, and weaken the hearts action (relax spasm of bronchial tube). The remedy should be given as soon as the attack occurs for best results:
    • Ipecacuanha: 20 grains of ipacacuanha powder.  Relief takes place before vomiting, so it's the depressent effects more so than the vomiting that relieved the asthmatic fit. This was the most manageable of the depresant remedies.  Ipecacuanha lauzenges also work well, especially for children.
    • Tobacco: For those not tolerant of it, faintness, nausea and vomiting often result.  It is this effect that can break a fit of asthma.  This is a good remedy for children (smoke until you puke). "It renders spasm impossible by knocking down nervous power. (doubtless by poisoning the nervous centers)." (1, page 115)  Usually 20 whiffs of a pipe or cigar will cause collapse.  Usually you will feel breathing relief before the vomiting, and you can stop at that time. Generally takes 20-30 minutes. Works well for hay asthma. To prevent asthma smoke a cigar during the hay fever season just before bed. However, for it to be a remedy it must not be a habit, because it's the poisonous effect that is the remedy.  This is the most speedy and effectual of the depressant remedies. For children, a couple puffs of a cigarette may do well. (1, page 99-104)
    • Tartar-emetic:  Another alternative to the above depressants.
  • Stimulants:  They dispel depressions in the mind and restore the will to a wonted activity.  It thus disfavors the of excito-motory action, and thereby relieves the fit of asthma.
    • Coffee: A most common and most reputed remedy. Most asthmatics have tried it as one time or another. It works because sleep favors asthma.  It causes "mental vivacity and activity, of acuteness of perception and energy of volition." This is a "reverse of the abayance of will and perception which, in drowsiness or sleep, so favors the development of asthma. In sleep will and sence are suspended; after taking strong coffee they are not only active, but exalted." Dose should be one cup of very strong, hot coffee, with no milk or sugar, on an empty stomach.   (1, page 106-107)
    • Strong tea:  Works similar to coffee
    • Ammonia:  Works similar to coffee
    • Indian Hemp:  Works similar to coffee
    • Alcohol: Curative influence of violent emotion.  It works by creating a "new nervous condition other than asthma; it gives a "shock or shakeup of the nervous system."  It should be recommended only when all else fails, and used judiciously.  Side effects can be worse than asthma, such as habit and tolerance. The alcohol must not be taken as part of a diet, or taken every day; Brandy, whisky and gin work best because they are the most concentrated form; 
    • Mental excitement:  Allows you to forget asthma; set your mind on a different course
  • Sedatives:  Since asthma is the result of some nervous stimuli that causes nervous irritability that results in spasm of the air passages, sedatives often work as a nice remedy by allaying this "nervous irritability; destroying for that time the morbid sensitiveness of the pulmonary nervous system that constitutes so essential part of the disease." They ease the mind and east the spasm at the same time.  They work as both a treatment and preventative.  (1, page 114)
    • Tobacco:  For tobacco to cure as a sedative it merely produces the composing and tranquilizing condition with which smokers are so familiar.  It allays spasm by "temporarily effacing a morbid sensitiveness to certain stimuli, and inducing a normal indifference to and tolerance of them." When recommending this effect to the delicate and young the dose must be carefully measured. Note:  "Any one may experience the sedative effects of tobacco, and all smokers do habitually; but the production of its full depressant action is almost impossible in those who have long accustomed themselves to its use; in others, however, as in women and children, it is so easy that the difficulty is to prevent sedation from running into depression. It is for this reason that it is necessary, in administering tobacco as a sedative only, to the uninitiated, the delicate, or the young, to give the very mildest form, in carefully measured quantities, and to insist on its slow and deliberate exhibition.  Asthmatics are very commonly smokers, and many of them find in the habit an almost unfailing antidote to their disease. But in almost all the cases that I have met with, it is rather as a prophylactic that it is used— to secure immunity when under dangerous circumstances, or to meet the first threatenings of an attack—than as a veritable curative to cut short spasm."(1, page 115)
    • Chloroform: "One of the most valuable remedies for asthma that we possess; the inhalation of its vapor putting a stop to the asthmatic paroxysm more speedily and more certainly than even tobacco."  For the safety of the patient, a presence of a second person is necessary.  The medicine "dissipates the asthmatic spasm by relaxing muscular contraction... and acts through the general nervous system." In some the relief is produced without any insensibility whatever; and in some a very small dose is sufficient to give relief, the patient immediately passing into a tranquil sleep, which may continue for hours, and from which he will wake with the asthma gone, although the original dose was far short of enough to produce the true chloroform sleep. This remedy should be given as soon as the attack commences for best results. The dose is usually 2 drops of chloroform on a handkerchief.*  Side effects include: insomnia, deafness, apathy, tremulous of hands, an increase of the asthmatic tendency.  (1, page 115-117)  
    • Opium:  One of the less worthy asthma remedies, or what Salter refered to as "positively worthless." (1, page 115) It induces sleep, and sleep favors asthma.  Therefore, opium has a tendency to make the asthma worse.  It may work to help with bronchitis, but not asthma. (1, page 122-123)
    • Stramonium: (Datura Stramonium, thorn-apple) The powder of stramonium will be rolled into cigarettes or cigars, stuffed into pipes, or simply ignited on a plate.  If you use a plate, you may roll up a magazine to act as a funnel to better direct the smoke to your airway.  It was introduced in 1802 by General Gent from India, and was initially tried by all asthmatics.  However, due to the capriciousness of asthma it does not work as well as it was once thought for every asthmatic the same, and for the same asthmatic over time.  So, as with many newer remedies, "It's original reputation greatly exaggerated its merits, but that it has undoubted, though very unequal value, and will probably always maintain its place among the real remedies of asthma." Some asthmatics smoke it only to allay the fit, and smoke it daily even when the breathing is normal to fend off an attack. However, in most cases, it "mitigated rather than cured the spasm," giving only temporary relief.  Although it works different for different asthmatics. Likewise, the inhaling of smoke from Datura seeds is much more potent than inhaling smoke from other parts of the plant. Salter recommended smoking a mixture of both the leaves and seeds "as to administer by smoking a reliable preparation of an uniform strength." A direct inhalation of the smoke will allow much of the medicine to be directly applied as a topical to the lungs, and some small amount to be absorbed by the mouth and by swallowing saliva to the system.  Salter said: "I may say, in conclusion, with regard to this drug, that its great value in some cases would, in spite of its too frequent impotence, always induce me to give it a trial in cases in which it had not been tried; that I do not believe it is attended with any danger except from the most egregious overdosing."  He also recommended smoking a nightly pipe as opposed to waiting for the asthmatic paroxysm to occur.  (1, pages 123-6)
    • Lobelia: If it doesn't work you may try "sufficiently" larger doses. The Americans recommend "two drachms every two or three hours till some decided effect is manifested," and "it's effect is almost identical to tobacco-poisoning -- giddiness, faintness, sickness, cold sweat and complete muscular relaxation." Dr. Elliotson prefered to prescribe "frequent and gradually increased doses... ten minums every quarter or half hour, increasing each dose a minum till the disease yields, or the drugs tend to disagree with the patient." Side effects are vomiting, faintness and headache.  If these occur, the next time you use it never exceed above that point in dosing.  He warned that one must be careful, because some preparations are stronger than others.  Dr. Salter recommended to "give it in repeated doses every half hour, increasing the dose five minums each time, till some result is obtained."  By "some result" he meant a side effect or cessation of the asthma.  The next time start with the dose that gave the desired effect.  (1, page 127)
    • Indian hemp:  (Cannabis Sativa) It is used by the natives in India as an anti-asthmatic and had a great reputation.  It is a stimulant and a sedative.  In small stimulant doses has the "same effects as coffee, only in a marked degree." Due to its "hypnotic tendency" when given in high doses, Salter had the same objections to is as he did with opium.  
    • Ether: A very common asthma remedy written about by nearly all writers of the disease.  Some speak well of it, although many others say it does more harm than good.  (1, page 128)
  • Other Options:  When the above medicines do not work, the following have worked for some and may be worthy of a trial.
    • Inhalation of fumes of burning Nitre Paper: "This remedy consists in the inhalation of the fumes of burning nitrepaper—bibulous paper which has been dipped in a saturated solution of nitre (nitrate of potass), and dried. How or by whom it was discovered, or exactly when, I know not; but I find from the references made to it by different authors that it must have been in use for nearly twenty years, and its great value and efficacy are now beyond question, although for some time past it seems to have hybernated, and never to have attained a general notoriety." (1, page 129)  According to one referenced doctor, "the room becomes "almost instantly filled with a dense smoke" that is "always mitigating and sometimes completely relieving the spasmotic contractions of the air-tubes."  Such paper only works to relieve dyspnea from pure asthma, and in cases where both bronchitis and asthma are causing dyspnea, relief may only be partial as only one of the maladies is remedied.  "The paper must be moderately thick and very porous and loose in its texture (red blotting paper of moderate of moderate substance works best), so as to imbibe a sufficiency of the solution." Strammonium may be added to the solution for increased effect.  The goal was to produce "light, clear, white fumes," as opposed to black smoke. The nitre paper should then be stored in a dry place.  The best recipe was as follows, and was provided by one of Salter's patients: "Dissolve four ounces of saltpetre in half a pint of boiling water; pour the liquor into a small waiter, just wide enough to take the paper; then draw it through the liquor and dry it by the fire; cut it into pieces about four inches square, and burn one piece in the bedroom on retiring to rest at bedtime." (1, page 130-133)
    • Iodide of Potassium: It's a very common remedy that many physicians think highly of and recommend often for asthma.  "But I must say, that according to my own experience, it does not deserve so high a place as has been given it... in those which its success is complete are comparatively few." Although it does work in one case out of five, and therefore "I should not think it right to omit its trial in any case in which it had not been fairly tried." (1, page 160) Dose should be "five grams of iodide of potassium and twenty minums of aromatic spirit of ammonium, in a wineglass of water, three times a day." How it works Salter did not know, but he suspected it might be most adventitious in asthma associated with gout.  
    • Inhalation of Powdered Alum:  Works better for chronic bronchitis than asthma.  (1, page 166)
    • Inhalation of nitre-hydrochloric acid vaporThe inhalation of nitrohydrochloric acid diluted with aqueous vapor.   Treatment:  "Nitro-hydrochloric acid, a teaspoonful in a quarter of a pint of water, to be raised to a temperature of 150°, and inhaled in an inhaler for a quarter of an hour three or four times a day." (1, page 166)
    • Inhalation of oxygen gas:  The theory here was that bronchospasm caused blocked air passages that stopped oxygenation, thus this oxygen "suspended" in the lungs, resulting in "pulmonary congestion and a condition of partial asphyxia."  Supplemental oxygen would allow for the "blood to be "oxygenated and freely pass on, the vessels would unload themselves, congestion, the distress, and the effort would cease." Of course the problem with this theory was that asthmatics would have trouble getting air in, an trouble getting carbolic acid out. Until the passages could be open and the carbolic air allowed to freely escape, the oxygen could be of little service. Salter believed that the main problem with asthma was not the want of oxygen, but the desire to exhale carbolic acid. Because of this, the inhalation of oxygen for the treatment of asthma did little good, or so he suspected. Other physicians of the era came to a similar conclusions. (1, page 166-7)
    • Compressed air:  Inhaling oxygen by sitting in a compressed air chamber was still in the experimental stages at the time Salter did most of his writings on asthma.  However, he believed some asthmatics received benefits from this by it making breathing slightly easier. He believed this would probably end an asthma attack.  Studies, however, were ongoing, and Salter said he preferred to wait until making further judgement on it.  (1, page 167)
    • Galvanism It's the passing galvanic shock through the chest. This was sort of an ongoing trend for various ailments during the mid 19th century. Salter warned against it for the treatment of asthma. He said: "What idea could have originally suggested it I am at a loss to imagine, unless it were the paralysis theory (emphysema theory) of the disease—that asthma depended on loss of power of the bronchial muscle, or the muscles of the thoracic parietes. I have known it do great harm; I have known it bring on an attack in a patient at the time free from asthma, and I have known it aggravate existing spasm; but I have never known it do any good." (1, page 167): 
  • Other important remedies:
    • Dietetic:  That of which is determined by intake of food.  Basically, a diet should consist of three qualities: it should be small in quantity, highly nourishing, and of easy digestion. 
      • Regiminal: Eating should be done only at certain times during the day, and meals should be small.  The food eaten should be regulated as to not eat any food that has in the past caused a fit of asthma, such as peanuts.  Very important:  food should not be taken too late in the day, as  sleep can play a major part in causing dyspepsia. Most important: let no food be taken after such a time in the day as will allow digestion being completed and the stomach empty before going to bed.(1, page 135-142)
      • Quality:  "Never eat foods that are generally indigestiblethe food should be plain, well cooked, and containing the proper proportion of animal and vegetable elements."
      • Variety:  Do not give the same food over and over again; foods should vary
      • Nutritious:  As much so as possible (important because some asthmatics eat as little as two meals in a day
      • Quantity:  Large meals cause a full stomach that makes it impossible for the body to digest it all, and this results in asthma (a myth is that it causes asthma because a full stomach presses up on the diaphragm.  It does press up on the diaphragm, but this does not contribute to asthma).
      • Avoid certain foods:  Mainly, avoid unwholesome foods as follows:
        • cheese (especially if old), 
        • Preserved food (sausage, potted meats, dried tongue, stuffing and seasoning)
        • Preserved fruits (ginger, candied orange peel, dried figs, raisins)
        • Meat pies, beef steak, kidney pudding 
        • Strong coffee with sugar (undigestible)
      • Breakfast:  Rarely does an asthmatic attack occur after breakfast, so if you are going to eat a large meal, this is the time to do it.  The asthmatic may eat all the food, at any quantity, that he craved for the days prior, during the morning hours. Although they should be of the "most nutritious materials."(1, page 141)
    • Locality: Locality may determine onset of asthma, so change in the type of air breathed may also be the remedy (getting away from offending air).    For some asthmatics the disease only shows itself in one location, in others it is only remedied in one location. It is not possible to predict what locality, or what air, will benefit one asthmatic as compared to another.  In fact, "the cure is often an inexplicable surprise." The asthma only stays at bay as long  as the person stays in said area, for as soon as he returns home the asthma will reappear.  The only rule Salter and his fellow physicians could think of was: "The air will probably cure which is the opposite of the air in which the patient is worse."
      • Urban Air:  Country asthmatics benefit by city air.  Any city air may benefit asthma, even that of which is densely populated, low lying, smoky, damp and dense.  This remedy is beneficial to the most asthmatics
      • Seaside:  City asthmatics benefit by visiting the seaside or country
      • Dry inland:  Moving away from damp, low lying areas with vegetable life, either seaside or dry inland
      • Dirty air:  The worse the air for the general health the better, as a rule, for asthma (such as smoky air of London)
    • Hygienic:  He recommended that an asthmatic must stay active. 
      • Exercise:  He said: "I have seen several cases in which prolonged bodily exertion has been of great benefit, indeed, some in which it has been the best remedy to which the asthmatic could resort. This, at any rate, proves one thing—the compatibility of asthma with perfect organic health of lung; for if there were any structural defect in the organ—emphysema, bronchitis —or any heart-disease, it would be impossible to meet such extraordinary respiratory demands without embarrassment. It does not indeed show that asthma has never such organic disease for its cause, but it shows that asthma may exist without any organic basis, because it shows that in these cases such organic disease must clearly be absent.  This treatment is, of course, rather prophylactic than curative—it must be taken in the intervals of the attacks: but when so taken it seems to have a marvellous efficacy in keeping them off, and in giving to the asthmatic a lightness and freedom of respiration to which at other times he is a stranger.... it may act by the vigor and activity that it gives to the function of the skin... it may well that exercise, by increasing the amount of work done by the skin, throws less on the lungs, and gives that ease and freedom and sense of surplus power of breathing." Also, after prolonged fasting and exercise, the blood may be free of the poisons of certain foods that may travel through the lungs and cause "irritation of the pulmonary nervous system, and cause the bronchial tubes to spasm." (1, page 163-164)
      • Shower bath: "I think it is a law without an exception that nervous affections are less prone to occur in proportion to the general bodily vigor, and what, for want of a more definite term, we must call the tone of the nervous system. Anything, therefore, that corroborates and invigorates renders asthmatics less prone to their attacks. In this way the shock of the cold shower-bath, or sponge-bath, or sea-bathing, is often of great service to asthmatics. By raising the standard of the general health they also tend to prevent those humoral derangements which are often the exciting cause of asthma."
      • Tonics: "Of all tonics in asthma I think quinine the best, and next to quinine, iron. Whether the especial value of quinine depends at all on its antiperiodic power I cannot say, or whether the periodicity of asthma is one which quinine would not be likely to control. The tonic that I commonly order, and from which I think I have seen the best effect, is a combination of quinine, iron, and a mineral acid."
      • Avoidance of cold "Exposure of the external surface to cold is apt to induce asthma in two ways—immediately and directly, or remotely, through the intervention of bronchitis. Some asthmatics are at once conscious of an asthmatic tightening of their breathing if they venture out of doors with their chests imperfectly covered, or if their feet get damp and cold... But the most frequent way in which asthmatics suffer from cold is by its producing catarrhal bronchitis. In these cases the asthma is not immediate; it is accompanied by all the signs and symptoms of bronchitis, find is proportionate to the intensity of the bronchitic affection, of which, indeed, it is but a complication, and without which cold never produces it..There is yet a third way in which cold generates asthma—by its direct application to the bronchial tubes by the inspiration of cold air. I have lately had under my care a lady of whose asthma this appears to be the one sole cause. Whenever she breathes cold air the wheezing immediately comes on, and no amount of warm clothing makes any difference. If a fire is kept up all night in her room she sleeps uninterruptedly till the morning, quite free from asthma, but if it goes out her dyspnoea shortly wakes her. A respirator (handkerchief or other covering over the mouth and nose to prevent the inhalation of fine particles, such as dust) is a perfect cure. I should mention that she has no symptoms of bronchitis...The practical rules that I draw from these facts are: That asthmatics should wear flannel next to their skins; that they should vary the amount of their clothing in proportion to the temperature ; that they should immediately change wet garments, avoid cold after perspiring, and take all other precautions for precluding catarrh."
      • Uniformity of life:  This is one of the best ways of controlling asthma. "It is, to establish a rigorous uniformity of life, to make one day the exact counterpart of another, and to avoid irregularities of every kind. Asthma often seems as if it were lying in ambush watching its opportunity, or on the lookout for some loophole through which to make its attack, and there is hardly any change of life or habit of which it will not, as it were, take advantage—change of air, change of sleeping apartment, alteration of meal hours."
      • Good nights rest:  Restores digesting power of the stomach.  
Dr. Salter listed many remedies for asthma. Finding which one worked best for which asthmatic was generally a matter of trial and error, much like it is today.

*Dr. Robert Bentley Todd (Salter's mentor) warned that chloroform should never be self administered.  An attendant should administer the remedy "gradually and cautiously, and not in a full dose -- not to produce insensibility. A person should never give it to himself."

  1. Salter, Henry Hyde, "On Asthma: It's Pathology and Treatment," 1882, New York, William Wood and Company, pages 97-168  (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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Wednesday, November 9, 2016

1860: Salter's Consequences of asthma

Back in the 1850s Dr. Henry Hyde Salter wrote that "Asthma never kills; at least I have never seen a case in which a paroxysm proved fatal."  Rather than death, the disease causes certain consequences, none the greater than suffering that results from not being able to breathe.

When asthma does kills it is usually not pure asthma that kills, but asthma complicated by organic damage, such as asthma complicated with bronchitis, heart failure or kidney failure.  He said:
If death did take place from asthma it would be by slow asphyxia—by the circulation of imperfectly decarbonized blood; and before this occurred I think the spasm would yield. When a case of asthma terminates fatally it does so by the production of certain organic changes in the heart and lungs; and it is on this tendency to the generation of organic disease that the gravity of asthma depends.
So while asthma rarely kills, it does result in some consequences that affect the life of the asthmatic. He said:
If we examine the chest of an asthmatic who has but recently been affected with his disease, or whose attacks have been infrequent, we shall very likely find evidence of perfect anatomical soundness of all its organs: but if we examine him again in ten years we shall to a certainty, if the patient has in the interval suffered constantly from attacks of his malady, find evidence of organic disease of the lungs, and very likely of the heart.
The reason for this is because the organs are united with such "perfect anatomical soundness" that a "functional disorder cannot exist without dragging in it's train organic change."

In other words, when asthma attacks are frequent, a sequence of events occur within the body that impact the asthmatic's life, and make him a recognizable asthmatic, as opposed to a pure asthmatic with no anatomical changes.

So, what are the complications of asthma and why do they occur?  First we'll tack the consequences of asthma.  These consequences of asthma can be divided into four parts:

1.   Bronchiolar changes:  The direct results on the bronchial tubes themselves of the inordinate action of their walls. When the muslces that wrap around the air passages (also called "circular fibres of the branchiae," or "bronchial muscles) are overworked, they become hypertrophied (just like any other muscle of the body). This results in "permanent thickening of their walls and consequent narrowing of their calibre."  Such hypertrophied muscles more easily takes on a state of contraction resulting in "dyspneoea."  In other words, the more frequently the asthma occurs, the more likely exposure to exciting causes are to trigger an attack.  This may also result in some permanent contraction and permanent dyspnea, or what Salter refers to as "long-continued asthma."

2.   Heart changes: All those results of obstructed circulation, first pulmonary, then systemic, which the inadequate supply of air to the lungs induces.  The lungs become so shut down that it's nearly impossible for the heart to pump blood through them.  This results in:
  • Pulmonary arterial congestion (congested heart failure)
  • Distended right heart (hypertrophy)
  • Large, bulging veins trying to carry blood to the lungs, but unable (edema)
  • Scanty supply of oxygenated blood getting to left side of the heart (hypoxemia)
Basically, if all the bronchioles were to contract at the same time death would result.  However, in asthma only some of the bronchioles contract, and this simply results in severe discomfort, and the person (usually) does not die.  Oxygenated blood is diminished, but never stops altogether.

When this occurs over a long period of time, or often enough, it results in permanent organic changes to the heart and the lungs, which may result in continued (chronic) asthma and constant dyspnea.

Generally, organic changes to the lungs result in organic changes to the heart over time, if asthma attacks are not completely resolved (especially if there is a bronchitic component to the asthma).

3.   Emphysema:  That special result of the unequal and partial distribution of air to the lungs—emphysema. This is the most commonest morbid changes asthma produces.

Salter defined emphysema as "compensitory dilation, and the neighborhood of non-expandable lung."

Basically, it's air that is trapped in the lungs due to areas of the lungs that are blocked by bronchiolar contraction and mucus.  Escape of this air and mucus is prevented so long as the asthmatic paroxysm lasts.

"In the meantime," he said, "whatever may have been the length of the attack (and we know that it often lasted for days), the inspirator muscles are making the most violent efforts to fill the chest, and are, in fact, keeping it in a state of extreme distention."

Over time this organic change can result in permanently "non-expandable lung" units, resulting in an expanded emphysemitic chest.

From a photograph of an asthmatic, whose disease
dated from whooping-cough at three months old.
Photograph here is from Salter's Asthma Book.
4.   Asthmatic Physique:  The general effect of the disease on the physiognomy (facial features or expression) and build of the patient—the production of what may be called the asthmatic physique (see figure).
  • Exceedingly thin (often emaciated)
  • High shoulders
  • Back rounded
  • Walks in a stooped gate
  • Head burried between elevated shoulders
  • Chest is fixed and rigid, like a box
  • Enlargement of the thoracic cavity, like barrel chest of emphysema
  • While breathing, the reverse movement of the ribs can be seen, called pigeon-breast
  • Arms hang and do not swing
  • Limbs attenuated and bony
  • Every rib can be counted
  • Clothes hang loosely on them
  • Hands are cold, blue, thin and veiny (due to feebleness of circulation and dyspnea (either permanent or due to the present asthmatic attack)
  • Cyanotic hands, feet and face (not if the attack is short, and the length of time between attacks is long, such as what may occur in asthmatic children)
  • Anxious expression on face
  • Face is dusky or pale, and thin
  • Cheeks are hollow
  • Lines on face deeply marked
  • Mouth open
  • Jaw hanging
  • Eyes are turgid, watery and prominent (if you see this, you should check for enlarged heart)
  • Voice is feeble and slightly harsh and rough
  • He speaks as though he's trying to get all his words out in one sentence, as though he were making his last breath. 
  • His sentences and short and frequently interrupted by a dry cough
Most of these are generally present in other diseases that produce chronic dyspnea, and in the healthy asthmatic many may not be present.  Of this, Salter said:
In the purest cases of spasmodic asthma, in which there is no trace of dyspnoea in the intervals, they are the least marked, and are the most conspicuous in those which are complicated with some chronic bronchitis or bronchial congestion, so that I look upon their absence as a good sign, as a sign that the lungs are sound and unscathed; and it is because asthma seldom exists long without producing such changes as permanently embarrass the breathing, that these changes in the physiognomy and configuration come to be signs of asthma; they are just as much a part of its clinical history as those internal changes in the lungs and heart, of which they are the sure sign and accompaniment. I have, however, seen the asthmatic physique very strongly marked in some cases where the lungs were organically sound; but these were always cases where the paroxysms were very long, lasting for days or weeks, so that the efficient cause was in continued operation for a long time; or else they were cases in which the asthma had been very severe in childhood, when the figure was forming, so that it got set in the asthmatic shape, and, although the disease afterward quite disappeared, the figure never recovered itself. Such cases carry a certain highness of shoulders and roundness of back with them to the end of their days, however completely the asthma may be in mature life recovered from. Sometimes, however, on the disappearance of the disease, a wonderful improvement may take place in the figure, especially if the patient is young. (1, page 91)
So this is what we know of Salter's perspective of the consequences of asthma.  In a day when there were few remedies to prevent and treat the disease, such must have been a common picture of your average asthmatic.

Many of the characteristics above may go away as the asthma improves and doesn't reappear for a long time.  However, Salter said:

"I am of opinion that the occurance of asthma once renders the subject of it more liable ever afterword to a recurrance of it. It is very rare to hear of a person having a single attack; so rare that I am not sure that I have ever heard of a case." (1, page 95-6)
So while asthma may not occur until one is older, once it occurs the person will have a predisposition to it, and will probably have an attack at least once a month.  And it is for this reason that a majority of asthmatics will have a tendency to develop the consequences of asthma.

  • 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), Pages 82-96
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