1860: Dr. Salter's asthma signs and symptoms

Generally speaking, an attack of asthma rarely suddenly strikes without warning. Usually, a person with asthma will become adept at recognizing the signs and symptoms that asthma is coming on.  In this way, this allows an asthmatic to take immediate action to stave off an impending attack.

It should also be noted that these early signs and symptoms could be indicative of the effect of asthma, but they may also be indicative of the underlying cause.  That said, here are the signs and symptoms of asthma as recorded by Dr. Henry Hyde Salter, the preeminent asthma expert of the 18th century. (1, page 32-33, 37)

1. Drowsiness and sleepiness: unable to keep head up or eyes open without doing anything that would account for the fatigue.  This is the most common precursory symptom of asthma
2. Unusual mental acuity or buoyancy
3. Opthalmia, or inflammation of the eyes; inflammation of conjunctiva; the exciting cause will also ultimately cause spasm of the air tubes. 
4. Loss of appetite
5. Flatulence
6. Costiveness (a change in normal bowel habits)
7. Uneasy sensation of the epigastrum
8. Horizontal position of the body (which may explain nocturnal asthma)
9. Itching under the chin (others can see it by his constantly itching under his chin)
10. Headache
11. Excitability
12. Extremities get cold (during the heart of the attack)
13. Temperature drops
14. Sweats
15. Wheezes
16. Cyanosis
17. The appearance of a dying man
18. Sonorous (coarse wheezes or rhonchi) and sibilant (musical wheezes) and rhonchi are heard on inhalation and exhalation
19. Accessory muscle use; all muscles that increase the capacity of the chest are strained

It was also observed early on in history that an episode of asthma most commonly strikes in the night while the patient is sleeping.  He had a theory to explain why asthma was so often nocturnal.  (1, page 33)

When a person lies down and goes to sleep, the recumbent position favors the afflux of blood to the right side of the heart, and therefore to the lungs; in addition to this, the position of the body places the muscles of respiration at a disadvantage, especially the diaphragm, against the under surface of which the recumbent position brings the contents of the abdomen to bear; to this may be added the diminished rate at which the vital changes go on during sleep; and lastly, the lowered sensibility of sleep which prevents the arrears into which the respiration may be getting from being at once appreciated.

The patient goes to bed feeling just fine, and wakes up in a full fledged asthma attack. Salters continued: (1, page 34)

I know one asthmatic who often sits up half the night after taking a supper (breathing perfectly freely), because he knows that if he goes to sleep his asthmawill come on immediately ; but by thus sitting up till his supper is fairly digested, his stomach empty, and the source of irritation thus removed, he may go to sleep fearlessly and have a good night's rest.

In a sense, Salter said, this was very similar to cardiac disease, where the patient is prone to orthopnea, which means the patient must sit in order to prevent dyspnea; in order to breathe.

The following are signs of an attack, which generally occur after going to sleep: (1, pages 36-43)

1. Profuse diuresis: hysterical urinne, which is an indicator of nervous cause of asthma
2. Neuralgic pains: deep seated pains in nerves and joints
3. He becomes distressed in his breathing
4. He dreams of being in a circumstance that makes breathing difficult
5. Wheezing commences while sleeping, perhaps without disturbing him
6. The wheezing wakes those in adjoining rooms
7. He may wake and change positions
8. Increasing difficulty breathing eventually awakens him
9. He sits up in bed in a distressing, half conscious condition
10. He gets temporary abatement
11. Sleep overpowers him
12. He falls asleep
13. This cycle continues (the miserable fight between asthma and sleep)
14. Breathing gets progressively worse to the point sleep is no longer possible
15. Increasing dyspnea no longer allows the patient to forget himself for a moment
16. He becomes wide awake
17. He sits up in bed
18. Throws himself forward
19. Plants his elbows on his knees; sits up on the edge of the bed with his fingers dug into the mattress; sits in a chair with his elbows on his lab, or sits in a chair and leans on a table, perhaps with the aid of a pillow on the table.
20. His shoulders are raised to his ears
21. With fixed head and elevated shoulders labors for his breath like a dying man
22. If he moves at all it is with great difficulty, creeping by stages from one piece of furniture to another
23. His back is rounded
24. His gait stooping
25. He grabs onto anything that aides his walk, and allows him to keep his shoulders high; this also helps to spare muscular effort in doing so
26. His chest, back and shoulders are fixed; he peers around the room without moving his neck; only moving his eyes
27. At every breath his chest is thrown back, his shoulders still more raised, and his mouth a little opened with a gasping movement
28. His expression is anxious and distressed
29. The eyes are wide open; sometimes strained, turgid and suffused. 
30. His face is pallid
31. He may be slightly cyanotic (blue tinge to his lips and fingers)
32. Beads of perspiration stand on his forehead, or may run in drops down his face, which is attendant has to wipe
33. He is so engrossed in his suffering that he is unconscious of what is going on around him
34. He becomes impatient
35. He becomes intolerant of those who are trying in vane to help him
36. He may have the appearance of a dying man
37. The pulse becomes small, and yet smaller as the intensity of dyspnea increases, and may become excessively feeble and very difficult to feel
38. The patient will present also with severe itching under the chin, which may be so bad he can't stop himself from itching at his chin.  Yet the scratching does not relieve it.  (I have done this to myself once, leaving scars under my skin as evidence for my friends to notice and tease me about)
39. His breathing excessively tight
40. His exhalations prolonged (with exhalation maybe 4-5 times longer than inspiration, and sometimes the air may not be completely expelled prior to the next inhalation.  This may contribute to the enlarged chest, or emphysema, that often results from this)
41. Exhalation is a violent, muscular effort (instead of being natural)
42. His inhalations excessively difficult
43. Thus, the respiratory rate is slow (perhaps only 9 in a minute, and this is a sign to the doctor that spasm of the air passages is evident, as if it were any other cause respirations would go up)
44. In his strenuous efforts to fill his chest with air, his chest becomes permanently filled with it, or emphysemitic
45. There is no rest after exhalation; inhalation starts immediately
46. His chest becomes enlarged in every way (emphysema, barrel chest)
47. The attack slowly comes to an end
48. The chest comes down to its normal size
49. The patient has a memory he'd rather forget, but never will
50. Such an attack will last from a few minutes to several days.  
51. In some the attack passes as soon as the patient grabs onto and leans on a piece of furniture, in some it ends when breakfasts is over, in some with one or more of the various asthma remedies, and in some it lasts all day until evening.  In some it gets gradually worse as evening comes on, and the second night is worse than the first.
52. It usually ends coincidentally with a cough and the release of some sputum (which made Dr. Bree think this was the cause of asthma, as opposed to the effect). 

The worse part was entire sequence of events was there was very little in the line of effective remedies.  Dr. Salter himself said that most remedies were merely meant to allay symptoms, more so than to cure the patient.

Lacking such a cure, the patient suffering so might any effort possible to allay the agony, such as trudging to an open window, placing his elbows on the sill, and poking his head out to inhale the cool night air with his shoulders extended high.

In the case of a child, whose dad wants to help in whatever way he can, he may become the passenger in a horse carriage ride into the distant trails.  His dad may concoct  some remedy that he learned from is past or from a doctor.  The remedy might be something that worked for the boy in the past, such as inhaling burned powders of strammonium, smoking asthma cigarettes, drinking coffee or whiskey, drinking a solution of emetic, or perhaps a simple massage of his shoulders.

Eventually, either the remedy tried, or nature itself, would allay the paroxysm, thus returning breathing to its normal state.  A brief or prolonged period would ensue where the asthmatic would feel as though he has not asthma until some unknown circumstance brings back the signs and symptoms of asthma, followed by another full fledged attack.

The cycle continues as such for the rest of the asthmatic's life, which, since asthma rarely killed, was usually a long time.  In this way, most asthmatics became rather adept at knowing the signs and symptoms of their disease, how to prevent them, and what remedies worked.

References:

1. Salter, Henry Hyde, "On Asthma: It's Pathology and Treatment," 1882, New York, William Wood and Company

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1860: Dr. Salter's asthma causes and triggers

Dr. Henry Hyde Salter must have spent many sleepless nights thinking about what might have caused the disease that often took his breath away, and also inspired his professional expertise, and likewise inspired him to write a book.

Based on his own experience, and by questioning his patients, he concluded that the following are the general causes of the affection called asthma.

1.  Intrinsic Causes: Affecting the air tubes primarily and directly, or applied to the air tubes themselves.  Things that affect the lungs primarily. (1, page 71-74)

• Things Inhaled:
• Particular kinds of air: , i.e. country air, city air, thundery weather, fog, cold air, change of weather, change of wind, close air (crowded room, enclosed room, church, railway, carriage)
• Chemical and mechanical irritants:   These are things that naturally offend the air passages and produce irritation of the bronchial mucus membrane as secures their immediate expulsion by cough   These tend to throw the air passages into a violent motion and vibration, thus causing a spasm.  Examples include coughing and sneezing.  Irritants that may cause this are dust, smoke, pungent fumes, mephitic (foul smelling) vapors, cold air, hay season, grass season, bright hot dusty sunshine.  The most likely to cause a spasm is smoke and dust. Cats and rabbits seem to trigger asthma in many, so they'll have to avoid cats and rabbits.  
• Animal and vegetable emanations: Irritants here would include hay, ipecacuan, grass, certain animals, etc. The best remedy for this type is removal of the asthmatic from the exciting cause, or removing the exciting cause from the asthmatic.  For example, a hay fever sufferer may benefit from a sea voyage, or a person with ipececuan asthma not opening a can of ipecacuan powder.  Do not pet cats, or sleep with a feathered pillow. 
• Inflammation of air passages (morbidly irritable condition of the bronchial mucous membrane):
• Chronic Bronchitis:  Caused by permanent organic change of lung 
• Acute Bronchitis:  Cold air can cause bronchitis if it causes first a cold
• Offending Condition of Blood (presence of a blood in the pulmonary system and acts as a source of irritation, such as the blood after a meal.) This is not necessarily morbid, although can be. Often called peptic, or peptic asthma, and is caused by digestion or improper digestion. 
• Alimentary (nourishment) irritants:
• Being of the wrong quality:  Unwholesome and indigestible food (see chapter XII: Dietetic treatment of asthma)
• Being excessive in quality:  Bloated stomach after eating too much
• Being taken too late in the day:  May cause nocturnal asthma due to dyspepsia 
• After all food (full meal*, any particular food, undigested meal)
• After certain ingesta: wine, beer, peanuts, cheese (especially if old), 
• Preserved food (due to ingredients require, such as antiseptics because they prevent "putrefaction" out of the body, and opposes digestion): sausage, potted meats, dried tongue, stuffing and seasoning, 
• Preserved fruits: (due to ingredients required) ginger, candied orange peel, dried figs, raisins)
• Meat pies, Beef stake, Kidney pudding, Coffee (if taken strong and with sugar can be very indigestible and trigger asthma), Heavy Malt Liquors
• Drinks containing carbolic acid (Bottled Scout, Scotch ale, etc.)
• From dyspepsia (upset stomach, indigestion)

2.  Extrinsic Causes: Applied to some remote part. Things that affect the lungs secondarily, and reach the bronchial tubes by the nervous circuit -- ganglionic or cerebral spinal.

• Reflex nervous irritation:
• Through the organic nervous system:
• Organic disease of the brain
• Hysterical Asthma: uterine or full rectum effect organic nervous system
• Through the cerebral spinal nervous system:
• Cold air (it acts as a stimulant)
• Cold feet
• Central Nervous System
• Irritant psychical (involving the mind):
• Smells
• Stress
• Mental excitement
• Smells (like smell of lucifer match)
• Irritant physical (involving the body): 
• Laughter (Anything that excites that nervous system can cause congestion of the face and chest by excito-motory action)
• Physical Excitement: Excitement, fear, violent emotions
• Over exertion (taxing respiratory organs, pulmonary congestion and producing nervous excitement and exhaustion)

Dr. Salter wanted to make certain that he made an adequate definition of cause, which he divided into two categories: (1, page 70)

1. Things that cause the disease: The original and essential cause of the asthmatic tendency
2. Things that cause the paroxysm: The immediate provocative of the attack. These are called your immediate and exciting causes of an asthma attack or paroxysm. 

He said that "sometimes the cause of the two are the same -- that which has laid the foundation of the disease will produce the subsequent attacks. Thus asthma often takes its origin in bronchitis, and whenever bronchitis subsequently occurs it brings an attack of asthma with it."

"But," he continued, "more often the cause of the disease and the cause of the paroxysm have nothing to do with one another -- are quite distinct; that which produces the disease not producing the paroxysms, and that which produces the paroxysms not producing the disease.  Thus measles may have laid the foundation for the disease; but it never occurs again to produce the paroxysms; on the other hand, the presence of ipacacuanha powder in the inspired air may produce the paroxysm, but it could not produce the asthmatic tendency."

While the cause of the disease may forever go unknown, most asthmatics will eventually learn what the exciting causes are that trigger their disease.  They will learn to avoid them, and learn the remedies that will allay the symptoms of being exposed to them, or at least give some relief as to take the edge off until the symptoms pass, or the exciting cause goes away.

So, the immediate causes, or exciting causes, or provocative causes of the asthma attack are as follow:

• Monthly period (1, chapter IV)
• Laughter (causes extreme expiration witch excites the asthma)
• Prolonged expiration (forcing air out of your lungs, as in laughing, or forced wheeze)
• Excitability
• Headache
• Bodily exertion (1, page 43)
• Yielding to sleep
• Cardiac Asthma (organic lesion is cause of spasm)
• Chronic Bronchitis (organic lesion is cause of spasm)  
• Particular kinds of air I (i.e. country air, city air)
• Chemical and mechanical irritants
• Animal emanations
• Hay season
• Grass season
• Bright, hot, dusty sunshine
• Dust (1, page 44)
• Smoke
• Certain food
• Certain drinks (wine, beer)
• Full meal
• Undigested meal
• Dyspepsia (upset stomach)
• Mental excitement
• Peanuts
• Fog
• Thundery weather
• Heat (heat and thundery weather make nervous system more irritable or sensitive)
• The smell of Lucifer match
• Coughing
• Sneezing (same as coughing)
• Cold air
• Change of weather
• Change of wind
• Type of wind (east wind, west wind, north wind, south wind)
• Close air (stuffy room, closed room, carriage, crowded room, church, railway)
• Pungent fumes
• Rabbits
• Cats (Cat-Asthma)
• Horses
• Beasts
• Guinea pigs 
• Dogs
• Cattle (1, page 76)
• Sheep
• Manageries 
• Eating too late in day
• Eating the wrong foods
• Eating too much (undigestible)
• 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 stake
• Kidney pudding
• Coffee (if taken strong and with sugar can be very indigestible and trigger asthma)
• Heavy Malt Liquors
• Bottled Scout (has carbolic acid)
• Scotch ale (has carbolic acid)
• Other drinks containing carbolic acid)

These exciting causes are things that may cause irritation of the bronchial mucus membrane. Many of these belong in more than one of the above categories.

It's also interesting to note that a single patient may have more than one exciting cause, and may even have more than one exciting cause from various categories: such as thundery weather, beer and wine, smell of Lucifer (one mental, one bronchial, one peptic)

The following are the theories as to why people develop asthma:

• Organic injury of the lung:  It results from some disease that caused organic damage to the lungs. This is probably the cause of about 80 percent of youth asthma.  In this case, one will show no signs of asthma until one of the following diseases takes place (be it close to birth or at the age of ten or later).  These are conditions that cause damage to the bronchial mucous membrane, and then some changes occur in the air passages making them sensitive to asthma when exposed to exciting causes.  Examples would include:
• Whooping cough
• Bronchitis
• Measles
• Etc. 
• Non-organic injury to the lung:  The asthma occurs even when there is no history of any disease to form organic lung changes.  In these cases the asthma is congenital, heriditary, and acquired.  Examples include: (1, page 80-81)
• Ipecacuan Asthma:  The asthma is caused and aggravated by Ipecacuan
• Hay Asthma: The asthma is caused and aggravated by Hay or Grass

So these are the things that Dr. Salter suspected were the causes of asthma, the things that might cause one to develop asthma, and the exciting causes, or what we would refer to as asthma triggers.

*Salter said that many physicians believe a full meal causes asthma because a full stomach presses up against the diaphragm, thus creating less room for the lungs. He said this was a fallacy, that the reason a full stomach caused asthma was because the food inside it is indigestible, thus irritating the nerves..

References:

1. Salter, Henry Hyde, "On Asthma: It's Pathology and Treatment," 1882, New York, William Wood and Company, pages 70-81 (or as otherwise stated)

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1860: Dr. Salter's Asthma Features

What makes one case of asthma similar to another?  This was a subject Henry Hyde Salter took up in writing his infamous book about asthma in 1869 called "On Asthma: It's Pathology and Treatment."  So what follows are the general features, or principles, of asthma.

1. Periodicity: "The paroxysms occur at regular and definite intervals or periods.  Such periods can be a day, a week, a month, or a year.

• Random:  In some cases the periods vary a great deal, in some it is lost entirely.  It is impossible to predict when they will occur
• Regular:   When the attack will occur can be "predicted with the greatest certainty and never fails to occur at the right time. They occur regularly under:
• Certain cycles (as in at a certain time of year, such as summer, winter, and fall asthma)
• Recurrence of certain conditions either external or inside the body (monthly period, eating full meal every Sunday, hay fever season)

2.  Tendency to habitude: "A disposition to maintain and constantly repeat any peculiarity it may have acquired." This means the same external conditions, and removal of the external condition remedies the asthma. This means that every time it occurs, the patient can predict what will happen to him and what remedy will fix him.   The benefit of this "is the asthmatic becomes 'up' in his own case; every symptom is an old acquaintance to him; her recognizes the slightest indications; and can predict every event of his disease exactly as it will happen; he knows when an attack is coming on long before others can see any sign of it; he knows when it will go off; he soon comes to learn, too, by this exact repeated experience, what he may do and what he may not; what will do him harm and what good; and thus often becomes his own best physician."  He learns whether the attack will come on during the night or day, the time, the length of time, and the remedy.  A physician can actually get some reliable hints from his patient as to what to do. The best remedy may be breaking the chain of repetition, such as relocation to London for example.

3. Change of Type: Slow gradual changes occur in the characteristic of the disease over time, "brought on by slight and almost imperceptible variations in these recurrent phenomena.  You may see a change in type, periodicity, and habitude.  The attacks may become more severe or less severe.  Their character may change, time of day they occur may change, length of time they last may change, the symptoms may change and remedies also may change.

4.  Capriciousness:  "It is always puzzling its victim and his friends by the exhibition of some unexpected vagary; giving him pleasant and unpleasant surprises, raising his hopes and then disappointing them, and altogether confounding his calculations." Each case of asthma is capricious, and every case of asthma is capricious in itself (no two cases of asthma are the same).  One case may get better in humidity, another worse.  One case may get worse with ipacec, another better. One is worse in winter, another summer, another all year.  "One flies from the place another seeks." In one nitre-pater is the cure, in another it does nothing. Strammonium works for some, and not for others. (There is no better example of the caprice of asthma than the exciting causes of asthma, as what may excite one person's asthma, may not excite another's asthma. 1, page 77)

5.  Time of life of first access: "There appears to be no time of life at which asthma may not make its appearance -- from the earliest infancy to old age." These cases have a tendency to be pure asthma.  However, most cases of asthma have a tendency to form in the early stages of life. Those with the lowest risk of developing asthma are between 40 and 60 years of age. The time asthma develops has a direct correlation with the causative agent, as the person may never have been exposed to hay until he is, say 39.  At which point the disease makes its appearance.

• Early life: The cases that come on earlier in life are usually due to "bronchiolar disorders of childhood... that causes a sensitive bronchial mucous membrane, some pulmonary collapse, and emphysema." 
• Infantile bronchitis
• Measles
• Whooping Cough
• Etc.
• Later life: Asthma that comes on later in life has a tendency to be caused due to some organic changes in the lungs or body, such as cardiac asthma, kidney asthma, or chronic bronchitis. Many cases of elderly asthma are actually chronic bronchitis (an old man coughs, wheezes and spits). 

6.  Influence of Sex:  While both sexes are prone to develop asthma, you are twice as likely to get it if you are a male.  One theory is that men have a "greater proclivity to asthma on the part of the male nervous system than the female." However, Salter does not believe this.  He has a tendency to believe another theory, that  men are more likely to be exposed to the hardships of life:

• Inclemencies of the weather (cold and wet weather)
• The wear and tear of hardships of life (stressful jobs, night working)
• The stress of violent and sustained respiratory efforts (heavy labor, intemperance)

7.  Hereditariness: Salter notes that "I think there is no doubt that it is."  He states that " In all diseases a certain number of cases will be found in which, on the mere doctrine of chances, the parents, or other members of the family, have been similarly affected." Based on his studies, it is hereditary on the "proportion of two to three."  There are a variety of members of the family who may have had asthma in the past, such as:

• Inherited from the father
• Father a confirmed asthmatic
• Father a confirmed asthmatic, brother suffers from hay asthma.
• Grandfather a confirmed asthmatic.
• Brother and paternal grandmother asthmatic.
• Father, two paternal uncles, and paternal grandfather.
• Paternal sister died of it.
• Father died asthmatic at forty-seven.
• Several indirect branches of the family asthmatic, but neither parent.
• Mother slightly asthmatic, maternal grandmother severely.
• Grandfather now suffers from asthma.
• Grandfather and uncle both asthmatic.
• Sister and paternal grandmother asthmatic, brother with hay asthma.
• Inherited from the mother:
• Mother asthmatic
• Two brothers, and uncle, and a nephew.
• Mother, grandfather, two sisters, nephew, and grandchild asthmatic.
• Grandfather, great-grandfather, two great aunts, two of his

And such are the features of asthma s recorded by Dr. Salter.

References:

• Salter, Henry Hyde, "On Asthma: It's Pathology and Treatment," 1882, New York, William Wood and Company, pages 47-60

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1860: Salter disproves ancient asthma theories

Dr. Henry Hyde Salter was among the first physicians to believe that diseases ought to be defined based on personal experiences with the diseases, observing patients, and studying autopsies, as opposed to speculation.  Later physicians said it was this technique that made him the most famous asthma doctor of his era.  

In the opening chapter of his 1960 book "Asthma: Its Pathology and Treatment" he put to rest any theories about asthma that didn't support modern evidence. While he shunned the humoral ideas of ancient writers, he also shunned the bronchitic theories of the famous Dr. Robert Bree  who's believed asthma was caused by some peccant matter entering the lungs

Salter said that Bree was so convincing, and had obtained such a large following, that he had to dedicate almost an entire chapter to disproving his theories.

However, in the end, Dr. Salter said Dr. Bree's theory was disproved simply by the invention of the stethoscope.  He said if Bree had access to a stethoscope he would have easily heard the wheezes caused by narrowed air passages due to neurosis, and would have heard that the wheezes persist even after mucus is expectorated, as opposed to before.

One of the reasons Dr. Bree's ideas were so well accepted was because they were more in line with the Hippocratic doctrine, which was still well accepted by many prominent physicians when Bree first wrote his 1798 book "A Practical Inquiry into Disordered Respiration."

Since Hippocrates, many asthma experts believed asthma was caused by an imbalance of the four humors. Salter doesn't deny...

..."that in some cases the exciting cause of the attack is humoral; but what I would deny is, that the humoral derangement has any higher place than that of an exciting cause; and what I would insist upon is, that the heart and core of the disease is nervous; that the essential peculiarity of the asthmatic is a vice in his nervous system, a peculiar morbid irritability of it, whereby a certain portion of it is thrown into a state of excitement from the application of stimuli which another person would produce no effect at all, or a very different effect." (1, page 25)

Salter disproved the idea that congestion, or phlegm, or mucus, was the cause of asthma, because the attack usually ends with the expectoration of phlegm. He wrote:

"We admit the fact to be true, but doubt very much the correctness of the inference; at least it is certain that, in ordinary bronchitis, enormously greater accumulations of mucus take place with comparatively few signs of general obstruction. We think this position must be admitted by any unbiased observer; and it is, in our opinion, fatal to this theory. (1, page 25)

Given the tools available to Salter, wasn't hard for him to disprove old asthma theories in favor of science. He went on to prove that asthma was nervous and spasmotic, and was so convincing that his ideas were referenced by nearly every author on asthma for the next 50 plus years.

References:

1. Salter, Henry Hyde, "Asthma: It's Pathology and Treatment," 1864, Philadelphia, Blanchard and Lea

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1860: Salter proved nervous theory of asthma

Dr. Salter believed asthma was a nervous disease. He believed the evidence asthma was nervous was so abounding that it could not be denied.

While the idea asthma was nervous was postulated back in the ancient era, and even postulated by physicians such as Jan Baptiste van Helmont and Thomas Willis in the 17th century, and William Cullen in the 18th century, it really didn't engulf the medical community until it was re-introduced by Salter's mentor, Dr. Robert Bentley Todd. 

While Dr. Salter didn't accept all Dr. Todd's ideas about asthma, he did accept his notion that asthma was nervous.  By writing his famous articles on asthma that were ultimately published in the 1960 book "On Asthma: Its Pathology and Treatment," Salter brought the idea to the mainstream of physicians, many of whom accepted it as fact, even treating it as a nervous disorder.  Even 20th cen

Even the famous 20th century asthma expert Frances M. Rackemann was a supporter of Salter's nervous theory of asthma.  Even while disproved during the 1950s once the immune system was learned of, his ideas continued to be accepted, even into the 1970s and 1980s.

He even went as far as to offer to the  medical community evidence that asthma was nervous.

• Fatigue and mental emotion bring about an attack
• Remedies that appeal to the nervous system allay an attack, such as stramonium, antimony and chloriform. 
• The periodicity of asthma. It goes away and comes back without warning by recurrence of hay fever, indigestion after dinner, expectoration after a good nights sleep, etc. 
• Symptoms of asthma, such as clear urine (nervous urine), nervous headache, drowsiness, and an attack after laughter or animation. These are similar to hysteria and epilepsy.
• No organic change in the lungs during or following an attack. Post mortem exam of asthmatics shows no organic changes, or damage, to the lungs. They are essentially normal.
• Asthma is muscular in that it is caused by muscular fibre that spasm and squeeze the air passages of the lungs. Muscular disorders like this are always nervous as the nerves are connected with the mind (4 page 13-16)

Salter didn't deny asthma was a spasmodic disease of the lungs, yet he believed this was the result of a nervous condition of the patient.   He said:

The inflammation or congestion of the mucous surface appears to be the stimulus that, through the nerves of the air tubes, excites the muscular wall to contract. (6, page 92)

It was also for this reason he recommended remedies that would soothe the mind of the patient, such as alcohol, cigarettes, morphine, formaldehyde, strammonium, antimony, antispasmotics, and direct nervous depressants. (6, page 33)

His favorite remedy was chloroform because "just a few whiffs, and the asthma is gone; a dyspnea that a few seconds before seemed to threaten life is replaced by a breathing calm and tranquil." (4, page 33)

Thus, he wrote, remembering that the action of these remedies on the nervous system, "it is impossible to help seeing in this the most conclusive proof that the symptoms are due to a nervous cause."  (4, page 33 & 34)

He described one symptoms of asthma as itching of the skin under the chin.  I personally have experienced this when my asthma has been bad, and I think to this day there is yet no scientific explanation for it.  Yet Dr. Salter was convinced the cause was an "irritation at the roots of these nerves.  (5)

So he believed nervous asthma resulted in spasmotic asthma.  Actually, he believed nervous asthma was spasmotic asthma, and in this way he was a supporter of both the nervous and spasmotic theories of asthma.

He defined nervous, or spasmotic, asthma as "paroxysmal dyspnea of a peculiar character, generally periodic, with intervals of healthy respiration between the atatcks."

He said asthma was more common than believed, yet pure asthma, or "asthma without the slightest organic complications," was rare. (4)

However, if the nervous disposition lead to asthma attacks that were frequent, this may result in "permanent injury on the lungs, and even the heart."

He said:

"Asthma is not the less asthma because it has produced certain organic changes which complicate it; and many cases are primarily and essentially asthma that ultimately become, and are called, emphysema and heart disease." (4, page 17)

He was also a realist, and did not claim to offer a cure for the disease.  He believed that since the disease was nervous in origin, there really was not truly effective treatment.  He said:

"...the treatment is regarded as palliative. It must be admitted that the remedies for asthma are of very irregular and uncertain operation: that probably there is no single remedy that is not inoperative in a large number of cases; that that which is useful in one is valueless in another; while there are many cases that resist all remedies. If this intractability of asthma were doubtfull, the large number of remedies that have been suggested would be a sufficient proof of it."

 Further reading:

• 1823-1871:  Dr. Salter offers proof asthma is nervous
• 1850s: Dr. Salter's Asthma Features (2/14/14)
• 1850s: Dr. Salter's Varieties of Asthma (2/20/14)
• 1850s  Dr. Salter's asthma triggers (2/27/14)
• 1850s: Dr. Salter's asthma signs and symptoms (3/6/14)
• 1850s: Dr. Salter's Consequences of asthma (3/13/14)
• 1850s: Dr. Salter's Asthma Remedies (3/27/14)
• 1850s: Dr. Salter's prognosis for asthmatics (4/10/14)

Click here for more asthma history.

References:

1. "The Late Henry Hyde Salter," Medical Times and Gazette, Sept. 13, 1871. 
2. McCulough, David, "Mornings on Horseback," 1981, New York
3. Sakula, Alex, "Henry Hyde Salter (1823-71) a biographical sketch," Thorax, 1985; 40; pages 887-888.
4. Salter, Henry Hyde, "On Asthma:  Its Pathology and Treatment," 1861, London, Philadelphia
5. Kidd, G.H. Dr., "On the pathology of Asthma," Dublin Quarterly Journal of Med. Science," 1861, May,
6. Salter, Henry Hyde, "Asthma: It's Pathology and Treatment," 1864, Philadelphia, Blanchard and Lea

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1860: Salter: Why do young people outgrow asthma?

For many centuries it was believed that most cases of asthma were present in children, and that as one ages the asthma has a high tendency of disappearing.  The first person, to my knowledge anyway, to come up with a theory as to why this was believed, was Dr. Henry Hyde Salter. 

Dr. Salter believed that asthma was a nervous disorder, and that some exciting cause excited the nervous system and this ultimately caused spasms of the bronchial muscles that constricts the air passages.  When this occurs blood in the pulmonary vessels is unable to move through the blocked portions of the lungs, and becomes congested. 

When asthma is pure (free from any organic changes), it is intermittent, meaning that the attacks come upon the patient and then go away for a long period of time prior to occurring again.  The period of time between the attacks is random or periodic and cannot be predicted. 

Salter believed asthma was more likely to be of the pure form the younger people were when they acquired it.  So asthmatics under the age of 15 had a greatest chance of outgrowing it, those between 20 and 40 a fair chance, and over 40 a rare chance. 

"Now, why is this?" Salter asked.  "Why, caeterus paribus, (everything else being equal) should age have such a determining influence on the tendency of asthma?

He answered his own question:

1.  The young are more capable of repair:  "Partly for the reasons that I have mentioned—that in the young the powers of repair are great, in those advanced in life feeble; that in the young the pulmonary congestion that always accompanies asthma completely vanishes in the intervals of the attacks, the capillaries recover their tone, and the nutritional balance of the lungs is regained; whereas in the old the engorged capillaries are slower in recovering themselves, and the pulmonary congestion hangs about the patient some time after the asthmatic spasm has disappeared, manifesting itself by a profuse mucous exudation, and a certain thickness of breathing and incapacity for exertion. If the attacks are frequent this pulmonary congestion never entirely vanishes, and thus is produced a kind of spurious chronic bronchitis, with a tendency to aggravation by each attack, which is one of the worst and commonest complications of the asthma of the old."

2.  The young are less likely to develop chronic bronchitis:  "Another complication of asthma—dilated right heart —is much more apt to occur in the old than in the young, and for the very reason that the dyspnoea in the old is so apt, by the generation of this spurious bronchitis of which I have been speaking, to pass from the occasional and intermittent form characteristic of pure asthma, and become continuous and permanent . As far as I have seen, the right side of the heart never becomes dilated by asthma, however severe the dyspnoea may be during the attacks, if the intervals between them are considerable, and the recovery in those intervals complete. It is a continued and not an occasional and transient arrest of the pulmonary circulation that dilates the right side of the heart. It is from this fact that we see dilatation of the right side of the heart, venous stasis, and general dropsy so much more common as a result of chronic bronchitis than of asthma."

3.  The young have more room for hope:  "But this greater disposition in asthma to produce organic change in the old than in the young is not the only circumstance which imparts to age its determining influence on the tendency of the disease. In asthma, as in all other constitutional disorders, we have in the young much more room for hope from those changes in the type and build of the constitution which in them are so marked and striking; whereas in the old the constitution is set and fixed, and we have but little to hope on this score. Indeed, the existence of a constitutional peculiarity in a child is of itself almost a presumption that he will one day lose it; while in an old person it furnishes a presumption equally strong that it is fixed and indelible.

4.  Young lungs have more time to recover between fits:  "Again, in an old person the probability is that the asthma has existed longer than in a young one, and, as I shall show presently, the chances of recovery from asthma (as is the case in almost all diseases) are in inverse proportion to the length of time that the disease has existed."

5.  The young are more likely to have pure nervous asthma:  "But there is a special reason, depending on the nervous nature of asthma, that makes us sanguine of recovery in the case of the young, and which explains at the same time the greater frequency of pure nervous examples of the disease in the young than in the old. What, for want of a better name, we must call "nervous irritability" is much more marked in the young than in the old. It appears continuously to diminish from birth forward. Sources of irritation that in the young are adequate to the production of the most violent nervous phenomena, in mature life are powerless to produce such effects. The cutting of a tooth, for example, will send an infant into epileptic convulsions: one never hears of a fit from the second dentition. A young child will grind its teeth, or even be violently convulsed, from the presence of ascarides in its rectum; but one never sees such results from worms in the adult. And thus the diminution of nervous irritability, as childhood passes into youth and manhood, may make an attack of asthma less and less prone to occur on the supervention of its exciting causes, and less intensely spasmodic when it does occur. I believe, indeed, that this diminution of nervous irritability is the true explanation of that gradual recovery of young asthmatics which is so common, so almost universal."

6.  Youth asthma is not causes by organic changes:  Lastly, age influences unfavorably the tendency of asthma, not only because it is more apt in advanced life to engender organic disease, but because it is also more apt to have organic disease as its cause. The causation of asthma in youth and age is indeed very different. In age there is commonly some appreciable organic basis for it; in youth much more rarely.

So there you have it: six reasons why the youth are more likely to outgrow their asthma. 

References:

• Salter, Henry Hyde, "On Asthma: It's Pathology and Treatment," 1882, New York, William Wood and Company, pages 135-142  (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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1860: Dr. Salter, the famous asthma doctor

Figure 1 -- Dr. Henry Hyde Salter.

As a kid he suffered mightily from asthma, and when he grew up he made his disease the focus of his life.  He wrote a book that became the most famous asthma book of his era. His name was Dr. Henry Hyde Salter, the famous asthma doctor.

He was born on November 2, 1823. Within only a few weeks of his birth he suffered a bout of whooping cough that ultimately lead him to a lifetime of suffering from asthma. (1)

His dad was a prominent surgeon.  His grandpa, uncle and several members of his family were also physicians.  So it wasn't surprising that, after graduating from the University of London, he entered King's college to study medicine. (1)

He earned his medical degree in 1851 and soon opened a medical practice.  It probably didn't take him long to realize he had a special sort of empathy towards his asthmatic patients, particularly asthmatic children.

In 1851 he became assistant physician at King's College Charing Cross Hospital, and in 1852 he became assistant physician to Robert Bentley Todd (1816-92) in New York.  He sat in on Todd's lectures and took copious notes "almost verbatim," which were published in the Medical Gazette and ultimately this "added much to Dr. Todd's reputation. (1)

Likewise, in 1851, he became assistant-editor of the "Encyclopedia of Anatomy and Physiology."  He wrote articles on the tongue and pancreas, and he read and edited the entire collection.  (1)

In 1854 he returned to King's College where he lectured in physiology, physiological anatomy and medicine for the next 12 years.  His efforts as a writer, lecturer and physician earned him a spot as the youngest member of the Royal College of Chest Physicians in 1856 at the age of 33.  He gave a lecture to this group on dyspnea in 1866. (1)

From a photograph of an asthmatic, whose disease

dated from whooping-cough at three months old.

(One might wonder if this is a photo of a young

Dr. Salter.) (6, page 115)

Yet it was asthma that was his "special interest" in many of his research and study projects. (2) He gave many lectures, most about diseases of the thorax -- and asthma.  (5)

Dr. Salter's special interest in asthma gave him a unique inside take on what it was like to have asthma. This, coupled with his exemplary skill at writing, made him the ideal person to write on the subject.

In his book he provided some of the best and most vivid descriptions of asthma up to that time, as shown here:

"But not only is asthma not an uncommon disease, but it is one of the direst suffering; the horrors of the asthmatic paraxysm far exceed any acute bodily pain; the sense of impending suffocation, the agonizing struggle for the breath of life, are so terrible, that they cannot even be whitnessed without sharing in the sufferers distress." (6, page 17)

His description of the suffering was likewise vivid.  He wrote:

 "With a face expressive of the intensist anxiety, unable to move, speak, the head thrown back between elevated shoulders, the muscles of respiration rigid and tightened like cords, and tugging and straining for every breath that is drawn, the surface pallid or livid, cold and sweating -- such are the signs by which this dreadful suffering manifests itself." (6, page 18) 

As well as was his overall description of the asthma paroxysm.  He wrote:

But the dyspnoea of asthma tells a plainer tale than this; it tells us not only what it is not, but what it is. It gives the most positive evidence of narrowing of the air-passages. The asthmatic's breathing is what our forefathers called "strait," what we call " tight;" he feels as if a weight were on his sternum, as if his chest were compressed, as if a cord bound him, as if it would be the greatest relief to him if some one would cut his breast open and allow it to expand; he rushes to the window to get air, he cannot tolerate people or curtains about him, his clothes are loosened, and all the muscles of respiration tug and strain their utmost to fill his chest. But he can neither get air in nor out, he can neither inspire nor expire—his respiration is almost at a dead lock; he cannot blow his nose, ean hardly cough or sneeze, cannot smoke a pipe, and if his fire is failing, cannot blow it up; he has hardly air enough to produce the laryngeal vibrations of speech. (6, pages 37-38)

He even went as far to describe what life was like for an asthmatic between attacks.  He wrote:

"And even in the intervals of health, the asthmatics sufferings do not cease; he seems well, he goes about like his fellows and among them, but he knows he is altogether different; he bears about his disease within him wherever he goes; he knows he is struck... he is conscious that he is not sound... he only knows that a certain percentage of his future life must be dedicated to suffering; he cannot make engagements except with a proviso; and from many of the occupations of life he is cut off; the recreations, the enjoyments, the indulgences of others he dare not take; his usefulness is crippled, his life is marred; and if he knows anything of the nature of is complaint, he knows that his suffering may terminatein a closing scene worse only than the present." (4, page 17, 18)

Any person who ever suffered from an attack of asthma, or ever witnessed one, could easily relate to what Salter described.  It was such exemplary asthma prose that proved to his readers that he knew what he was writing about.  It was such that made him to be the famous asthma doctor.

After years spent suffering, and years spent studying his patients, and performing interviews and autopsies, he put his best asthma knowledge together during the 1950s in a series of articles that were published in medical journals throughout the decade.  Each article was ultimately turned into a chapter in his 1864 book "On Asthma:  It's Pathology and Treatment."

During the last four years of his life his asthma took a turn for the worse.  During the night he'd spend time leaning against the bed post with his shouders hunched while smoking datura leaves. During the day he ate lightly, and continued to work as a physician and to give lectures.

In 1871 he became thinner and weaker and was diagnosed with typphoid fever.  Yet ultimately it was discovered he developed a lung abcess and passed away on August 30, 1871, at the young age of 48.

Dr. Salter's book is referenced in nearly every article, every chapter, and every book on asthma for the rest of the decade.  Even the great Dr. William Henry Osler referenced Dr. Salter when he wrote his textbook for medical students.

Further reading:

• 1864:  Dr. Salter offers proof asthma is nervous
• 1864: Dr. Salter proves nervous theory of asthma (1/5/16)
• 1864: Dr. Salter disproves ancient asthma theories (12/30/14)
• 1864: Dr. Salter's Asthma Features (2/14/14)
• 1864: Dr. Salter's Varieties of Asthma (2/20/14)
• 1864  Dr. Salter's asthma triggers (2/27/14)
• 1864: Dr. Salter's asthma signs and symptoms (3/6/14)
• 1864: Dr. Salter's Consequences of asthma (3/13/14)
• 1864: Dr. Salter's Asthma Remedies (3/27/14)
• 1864: Dr. Salter's prognosis for asthmatics (4/10/14)

Click here for more asthma history.

References:

1. "The Late Henry Hyde Salter," Medical Times and Gazette, Sept. 13, 1871. 
2. McCulough, David, "Mornings on Horseback," 1981, New York
3. Sakula, Alex, "Henry Hyde Salter (1823-71) a biographical sketch," Thorax, 1985; 40; pages 887-888.
4. Salter, Henry Hyde, "On Asthma:  Its Pathology and Treatment," 1861, London, Philadelphia
5. Kidd, G.H. Dr., "On the pathology of Asthma," Dublin Quarterly Journal of Med. Science," 1861, May,
6. Salter, Henry Hyde, "Asthma: It's Pathology and Treatment," 1864, Philadelphia, Blanchard and Lea

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