1900: Asthma cigarettes (advertisement)

The asthma cigarette craze began in the 1880s and was full force by the year 1900. The following was a classified advertisement placed in a newspaper in 1900.

Asthma Cigarettes------

(W.B.C. Cleveland Ohio)  The following formula is one that the writer has used for several years occasionally, and has found effective and not unpleasant, provided that the cigarettes are used not to frequently, or to excess:

• Strammonium leaves.....................8 parts
• Green tea leaves............................8 parts
• Lobella Leaves..............................6 parts
• Plantain leaves.............................2 parts

Mince the leaves to a condition suitable to rolling in cigarette form, and moisten the mixture with cold saturated solution of potassium nitrate in water, dry thoroughly, and pack in air tight cans or jars.  Lavel "Asthma Cigarette" mixure.  Directions:  When an attack of asthma is imminent take sufficient of the mixture to make one or two cigarettes of the ordinary size, roll in cigarette paper, and smoke slowly, inhaling the smoke as deeply as possible.  If relief is not afforded by the first, a second cigarette should be used.

There were many advertisements like this in various newspapers and magazines around the United States and Europe.  So if you had asthma during this era you had many opportunities to learn about the benefits of such products, whether home made as this one was, or sold by various for profit companies.

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1879: Asthma cigarettes become a craze

Figure 7 -- Potter's Patient Inhaler (funnel device) (3)

By the mid 19th century the market for inhaling ingredients and powders grew steadily. Some pharmacists gathered the ingredients and sold them to individuals. Some tossed powders on plates and ignited it to inhale fumes. Some stuffed it into homemade pipes and others rolled it into cigarettes. 

Some pharmacists gathered the ingredients and further prepared them into powders to be further prepared by the patient.  Some pharmacists went a step further and rolled the powder into cigarettes that could be purchased in packs.  So there were a variety of options.

By 1879 an asthma cigarette craze struck America and Europe. (1)

More and more companies entered the market in an attempt to benefit off the plight of asthmatics.

Belladonna, stramonium, lobelia, henbane, atropine, and even cannabis were packaged in cans and placed on shelves in pharmacies.

The products were marketed for just about any respiratory condition, including asthma, chronic bronchitis, whooping cough, cholera, croup, catarrh, and hay fever.

By the 1880s technology progressed so some companies pre-rolled cigarettes, packaged them, and sold their product at pharmacies.

Asthma cigarettes from a variety of companies could be found on pharmacy shelves like the A.H. Lyman Company, a privately owned pharmacy on River Street in Manistee, Michigan.  When the business closed during the 1950s, the building and all its contents were donated to the Manistee Historical Society, and since turned into a museum.

Among the contents of the pharmacy, the shelves of which are still intact and filled with antique prescriptions, is a box of asthma cigarettes.

According the Mark Sanders at inhalatorium.com, the most famous brands were:

Figure 8 -- Potter's Asthma Cigarettes (3)

• Schiffmann’s 
• Asthmador
• Blosser’s
• Potter’s 
• Marshall’s
• Kinsman’ 
• Dr Guild’s green   Mountain
• Kellogg’s  
• Page’s
• Regesan’s

In my studies the brand I've come across most often was Potter's Asthma Cigarettes, which you can see in the picture to the right or by clicking over to inhalatorium.com.  This was among the most popular brands in Britain.

Figure 9 -- Potter's Asthma Pills (3)

The main ingredient in Potter's cigarettes were stramonium, belladonna and atropine.  Mark Sanders over at Inhalatorium.com notes that Potter's also had a variety of asthma remedies that included cigarettes, incense, pills and powders to be inhaled by Potter's funnel device (see figures 7, 8 and 9)

An asthmatic patient of mine who grew up in 1950s in Manistee, Michigan said she remembered her dad smoking cigarettes from a green package.  We later figured the produce was probalby Dr. Schiffmann's Asthmador Cigarettes.

References:

1. "The Scarcity of Cubebs," The Chemist and Druggist," 1887, Feb. 26, page 268 of  Chemist and Druggist: A Weekly Trade Journal, 1887, Vol. XXX, January to June 1887
2. Sanders, Mark, inhalatorium.com, http://inhalatorium.com/index.html, accessed on various dates
3. Picture used with permission from Inhalatorium.com
4. Jackson, Mark, "'Divine Stramonium': The Rise and Fall of Smoking for Asthma,"  Med Hist., 2010 April; 54(2): 171–194.

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1805: American Indians smoked asthma weed

American Indians smoked dried herbs stuffed into pipes too.  Now, did they get this wisdom from travelers from far off lands, or did they come up with the idea on their own?  No one knows for sure, and either theory is a possibility.

Figure 5 -- Kellog's Asthma Relief
contained both lobelia and strammonium (2)

Either way, American Indians had access to another member of the nightshade family called lobelia inflata.  Various people experimented and observed it's effects when ingested and inhaled, and soon it was learned of the hallucinogenic effect.

At first it must have been tossed into fires, later on heated bricks or in pots, and ultimately the herbs were stuffed into pipes and smoked, just as they were in ancient India, and probably Egypt and Mesopotamia before that.

While American Indians mostly smoked their pipes for the hallucinogenic effect, or to benefit other ailments, the medicine was, at some point, recommended for asthma-like symptoms too. It is for this reason that Indian Hemp is often referred to as Indian Tobacco or Asthma Weed.

American physicians were introduced to lobelia and used it for asthma releif, yet they also used it to make some patients vomit.  The idea here was that along with vomit, toxins would be removed from the body to balance the humors and cure the ailment.

For this reason it was often referred to as pukeweed and vomitwort.  (1)

References:

1.  University of Maryland Medical Center, "Lobelia,"  http://www.umm.edu/altmed/articles/lobelia-000264.ht
2. Picture used with permission from Inhalatorium.com
3. Jackson, Mark, "'Divine Stramonium': The Rise and Fall of Smoking for Asthma,"  Med Hist., 2010 April; 54(2): 171–194.

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1802: James Anderson discovers asthma cigarettes

figure 5 --Kellogg's Asthma Cigarettes (4)

A long time passed before British physician and asthmatic James Anderson visited India and enjoyed the mild breathing relief he obtained after smoking a cigarette containing datura strammonium.  The year was 1802.  (1)

Anderson returned to England and reported his find to his friend Dr. Sims in Edinbergh.  Sims trialed it, noted the benefits, and published a report in the Edinbrugh Medical and Surgican Journal. (2) (3, page 55)

After this report asthma cigarettes were entered into British and American pharmacopoeia, and ultimately became popular for the treatment of asthma in these western nations.  (2) (3 page 55)

Of course it also should be noted here that there were no standards or regulations regarding dosing in those days, and no recommendations as to how much of a medicine should be consumed, or in this case inhaled.  (3, page 55)

Perhaps for this reason, Dr Sims reportedly died a year after his report from an apparent overdosing of Belladonna.  (3, page 55)

References:

1. Sneader, Walter, "Drug discovery: a history, 2005, England,
2. Sneader, ibid
3. Smyth, Hugh D.C, Anthony J. Hickey, "Controlled Pulmonary Drug Delivery," 2100, Springer New York Dordrecht Heidelberg London
4. Picture used with permission from Inhalatorium.com
5. Jackson, Mark, "'Divine Stramonium': The Rise and Fall of Smoking for Asthma,"  Med Hist., 2010 April; 54(2): 171–194.

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100 A.D.: Pipes made inhaling herbal remedies easy

Figure 4 --Ad for Schiffmann's Asthma Cure (1899) (3)

Again, it's impossible to know who carved out, let alone smoked, the first pipes.  It's also impossible to know for whom the first pipe was carved for, nor what herbs were stuffed inside them.

It's possible the idea of using a sharp tool to hollow out a piece of wood for smoking herbs may have occurred to various inventors in various societies at different times.  The component smoked depended on what herbs were available.

For example, in India the incentive to carve out pipes was to smoke strammonium, belladonna, or Indian hemp for it's hallucinogenic effect. The fact the herb had other medicinal properties may have been learned later, or earlier.  Who knows?

Either way, inhaling smoke directly from a pipe would have allowed direct inhalation of the smoke, resulting in a greater effect. It would also have improved convenience, meaning that herbs could be smoked anywhere and anytime.

What we know for sure is the first medicinal use of pipes to smoke a medicine for asthma-like symptoms was recorded in ancient India around 100 A.D.  There were many herbs the Indians had access to, and one such was datura strammonium. (1)

The herb produces an unpleasant smell and grows to be about five feet tall with a pale green stem with spreading branches and puplish leaves coarsely sedated along the edges.  Its flowers are white or purple.  (1)

By empirical means its entertaining effect was learned, as well as its poisonous qualities when too much was inhaled or ingested, which mainly included hallucinogenic effects.  At times it must have been observed the medicine made you mad, which may explain the name.

Datura comes from the ancient Hindu word for plant, dhatura.  Stramonium is a New Latin word meaning thornapple.  Strammonium originally came from the Greek word strychnos which means nighshade and mankos meaning "mad."  (2)

Other than thornapple, common names I've found during my research that refer to strammonium are jimsonweed, Jamestown weed, drowny thornapple, Devil's trumpet, angel's trumpet, mad apple, stink weed and tolguacha.  It was obvious by these names the side effects of inhaling too much was well known

Like belladonna, the leaves, stems and roots were dried and crushed into a fine powder the Indians stuffed into their pipes and smoked it.  The benefits obtained must have been of higher quality than simply inhaling fumes from igniting the herbs on bricks.  Although either technique may have been used, depending on what the patient had access to.

Obviously the herb may have been used for entertainment, although medicine men and physicians ultimately learned of the medicinal benefits.  By 100 A.D. Indian physicians recommended smoking  strammonium for diseases of the lungs and throat, or simply for its hallucinogenic effect.  Again, the hallucinogenic effect may be desired when no other remedy was applicable

The famous Greek physician Hippocrates wrote about stramonium and belladonna, so we know Greek physicians had access to such wisdom.  With the fall of Cordova Greek medicine made its way to Rome, so we know the Romans had access to it too.   With the fall of Rome all such knowledge was lost for over a thousand years in Europe. 

Although, shortly thereafter, all medical wisdom made its way to the Arabia, where medicine, including including the inhalation of herbs, was saved for mankind. 

References:

1. "Plants poisonous to livestock," Cornell University's Department of Animal Science,  http://www.ansci.cornell.edu/plants/jimsonweed/jimsonweed.html
2. "Plants poisonous to livestock," ibid
3. Picture used with permission from Inhalatorium.comJackson, Mark, "'Divine Stramonium': The Rise and Fall of Smoking for Asthma,"  Med Hist., 2010 April; 54(2): 171–194.
4. Jackson, Mark, "'Divine Stramonium': The Rise and Fall of Smoking for Asthma," Med Hist., 2010 April; 54(2): 171–194.

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4000 B.C: Inhaling herbs was a great asthma remedy

Figure 1 -- Elliot's Asthma Cigarettes*

Growing up with hardluck asthma, I knew darn well the danger of tobacco smoke, or any other kind of smoke for that matter. So you can understand my amazement when I discovered asthmatics used to inhale smoke intentionally.

I made this discovery during a visit the Manistee County Historical Museum in Manistee, Michigan.  The museum is housed in the old A.H. Lyman Company building, which was a pharmacy until the mid 1950s when the building was donated.  In the back the old pharmacy shelves classic medicines.  On the box of one of these boxes was written: "Elliotts Asthma Cigarettes."  What I saw was similar to what you see figure 1.

Figure 2 -- Potter's Asthma Remedy
Photo by permission from inhalatorium.com (1)

My interest was piqued by this sight.  I thought:

If smoking was supposed to be so bad for asthma, why would any doctor recommend smoking for asthma?

I asked the museum curator if this was really a remedy for asthma, and he said that it was.  He said it was very common remedy during most of the 19th century.

It would be many years before I further investigated this, yet I never forgot about those asthma cigarettes.  My quest began in 2010, and it didn't take me long to find a ton of articles and advertisements in old newspapers and magazines and books about asthma cigarettes.

I learned that the cigarettes didn't contain tobacco, but crushed and dried herbs from the nightshade family of plants called solanaceae, which included datura strammonium, atropa belladonna, the hyoscyamus niger, Lobelia inflata and similar herbs such as Indian Hemp and Cannabis.

Such herbs contained an alkaloid called Atropine that caused mild bronchodilation, and in this way eased breathing.  The medicine also had a slight halucinogenic effect, and in this way took the edge off the feeling of air hunger by easing the mind.

So, while we think of cigarettes as hazardous, for most of history they were actually perceived as beneficial. This was, in fact, essentially the only way of inhaling medicine to obtain the greatest effect.

Figure 3 --
Kinsman's Asthma Cigarettes
(2)

It's difficult, if not impossible, to know exactly when mankind first discovered the benefits of smoking certain herbs. In fact, chances are pretty good that the first medicinal use of inhaled herbs had nothing to do with breathing and more to do with magic. 

The hallucinogenic effect allayed the mind of the medicine man so he could speak speak with the spirits or gods.  Yet other benefits must have been perceived, and at some point the quality of the medicine was shared with other members of the society. Yet even then it was probably prescribed for ailments other than asthma.

Still, at some point in the primitive world, or early on during the time civilizations were forming in Egypt and Mesopotamia, someone must have observed the medicine worked not just as a hallucinogenic but also as a mild bronchodilator, easing the mind and allowing for deeper inhalation.

In all likelihood, it occurred by chance as the herbs were tossed onto hot coals and incidental inhalation resulted in hallucinogenic effects.  Later on an asthmatic -- or someone suffering from dyspnea -- inhaled these fumes and felt relief.  This was an obvious gift from the medicine man, or more specifically, from the spirits or gods.

The first recordings of inhaling the herbs was around 4,000 B.C., which marked the dawn of the bronze age. Ancient city states of Sumeria and the empire of Egypt were in their infancy, and the discovery of papyrus and cuneiform soon allowed societies the ability to communicate from one generation to the next by writing, perhaps with a reed stick.

The Ancient Egyptians had plentiful access to atropa belladonna. It was a pungent smelling herb that grew to be about three feet high with oval shaped, pointed leaves that grew about three to six inches long with reddish or purplish flowers.   (1)

Folks experimented with this herb and discovered its poisonous effect. When too much was inhaled the person died. This gave the plant the reputation as the "deadly nightshade."

Egyptians soon learned the best recipe involved picking the leaves, stems and roots, drying them under the hot sun, crushing what was left, and using the byproduct in a variety of ways.

Egyptian women squirted drops in their eyes "for the allure given by large, black pupils: hence the name belladonna — ‘fine lady'." It made pretty eyes prettier and helped beautiful Egyptian women woo men. (1)

Medicine men, or early preist/physicians used it as a remedy for just about any respiratory ailment.

The dried and crushed herbs were tossed on bricks preheated on hot coals, and the smoke was inhaled to provide temporary breathing relief.  Over time a funnel was sometimes added to channel the smoke toward the patient's airway.

Inhaling the herb also provided a hallucinogenic effect, especially if enough was inhaled.  This may have been beneficial to the asthmatic as well, considering it helped take their minds of their trouble. Inhaling the smoke may have been beneficial to anyone suffering from a chronic illness, and was probably smoked regularly simply for recreational hallucinations.

However, there were risks, such as dry mouth, increased heart rate, dilated pupils, nausea and headache. If ingested or inhaled in high enough quantities, it may even cause death, hence the name deadly nightshade.

References:

1.  "Belladonna," Encyclopedia.com,  http://www.encyclopedia.com/topic/belladonna.aspx
2. Picture used with permission from Inhalatorium.com
3. Jackson, Mark, "'Divine Stramonium': The Rise and Fall of Smoking for Asthma," Med Hist., 2010 April; 54(2): 171–194.

References:

1. Picture used with permission from Inhalatorium.com

1890: Blodgett first to recommend continuous oxygen

Throughout most of the 19th century, when oxygen was prescribed by physicians, which wasn't very frequently, it was prescribed intermittently, which meant that it was only inhaled by the patient for 2-3 hours a day for a few days or weeks.  So when Dr. Albert Novatus Blodgett proposed the idea of inhaling oxygen continuously in 1890, it was a new idea. (2)

He described in the Boston Medical and Surgical Journal a woman who presented with all the symptoms of severe pneumonia, including cyanosis and air hunger.  His patient was a 46 year old woman suffering from pneumonia.

He said the recommended administration of oxygen that he was aware of was "two or three gallons at a time, several times daily." He decided this recommendation was the next proper course of action.  He said: (3, pages 482-483)

At this time I advised the use of oxygen gas, in the hope to increase the respiratory function by furnishing the limited lung-area with an augmented amount of oxygen, so that the condition of the circulation might be improved, and possibly the constant apprehension of asphyxia be relieved. I cannot say that I looked for any permanent good from it, but I hoped to at least gain for the patient the comfort of euthenasia. The gas employed was diluted with ten per cent, of nitrous oxide, and in this form caused no appreciable sensation of discomfort to the patient. The amount given was limited to a few gallons, the exact quantity not being ascertained, owing to a leak in the holder, but the effect was soon noticeable in the appearance of the patient, who became much more quiet, and was relieved to a great degree of the embarrassment in respiration. The face soon became less dusky, the con- junctival clearer ; the intelligence of the patient was much benefited, and she expressed herself as feeling better. The oxygen was now withdrawn, and the patient fell into a gentle sleep. (3, page 482)

However, by 3 a.m. the next morning the patient was in respiratory distress once again.  At this time Dr. Blodgett said he recommended oxygen again.  The patient benefited from this as before, and then the oxygen was withdrawn.

Yet the symptoms returned again by 8 a.m. later that morning.  This time, he decided to do administer the oxygen for a longer period of time. However, when he discussed this idea with the dealer of the oxygen, he was concerned about the risks of doing so.  Of this, Blodgett said:

The dealer who supplied the gas was astonished at the amount re- quired, and, thinking to do me a service, sent me a cautionary message, implying that no human being could possibly stand so great an amount of oxygen, on account of the dangerous degree of stimulation to the system and the increased combustion of tissue.

However, he decided to go forward with it anyway, noting that he did this...

...under the positive conviction that the patient was irrevocably doomed, and the best result that I looked for, was simply relief to the sensation of suffocation, and not any curative action. (3, page 483)

So, he said:

At this time I directed the continuous employment of oxygen, as the only means of prolonging life, and averting the paroxysms of distress which recurred at intervals. The gas was conveyed from the tank in which it is supplied through a wash-bottle directly to the mouth of the patient, and a constant stream of gas was flowing through the tube all
the time, so that with each of the rapid respirations the patient was obtaining a constant increased amount of oxygen. This method of administration, of which I have thus far found no account in the means of information at my command, seemed to afford considerable
relief in a short time, and after watching the case for an hour, I left, giving directions to continue the gas. (3, page 482)

The patient was kept on oxygen for a period of 106 hours, which amounted to about 200 gallons in 24 hours.  The modern equivalent to the amount of oxygen given by Blodgett would have been 6lpm, or about 44% oxygen. (2) (3, page 483)

This was the longest amount of time a patient had ever been on supplemental oxygen prior to this time.  Blodgett said that while "judicious employment" of oxygen in similar situations will not cure a patient, "I think that many cases will be found in which the period of greatest danger may be safely tided over,which would otherwise unquestionably be lost." (3, page 483)

While this experiment proved the usefulness of continuous oxygen, it would be another 30 years before it would be adapted by the medical profession as a recommended treatment for anoxia.

References:

1. Brainbridge, William Seaman, "Oxygen in Medicine and Surgery -- a contribution with report of cases," New York State Journal of Medicine, 1908, Vol. 8, June, No. 6, pages 281-295
2. Grainge, CP, "Breath of Life: the evolution of oxygen therapy," Journal of the Royal Society of Medicine, October, 2004, 97 (10), pages 489-493
3. Blodgett, Albert Novatus, "The continuous inhalation of oxygen in cases of pneumonia otherwise fatal, and in other diseases," Boston Medical and Surgical Journal, 1890, 123 (21), pages481-484

1800-1900: Thomsonian remedies for asthma

Samuel Thompson (1769-1843)

Samuel Thompson did not fashion himself as an Indian Physician, nor did he claim to get his inspiration from the Indians. He did, however, fashion himself as a botanic physician, an expert on herbal remedies. (1, page 131)

Despite his lack of formal education, and lack of knowledge regarding anything medical, he was able to convince many people that his medicine worked, and he earned himself quite a following.

This was contrary to licensed physicians, who endured several years of formal education to learn about the anatomy of the body, the diseases that plague it, and the remedies proven to work.

In fact, it was highly unlikely Thomson, nor any of his followers, knew any more about anatomy and diseases than the people he sold his products to.

Michael Flannery, in an article he wrote for Journal of the Medical Library, said:

In 1834, Thomsonians claimed one and a half million adherents; by the 1840s, optimistic estimates placed their number at between four and six million. (2) 

So Thomson became a very successful botanic physician.  Yet as he earned his success, he also earned the ire of the the medical profession.

In his 1970 book "American Indian Medicine," Virgil Vogel said Thomson...

...managed to become a bete noire to much of the medical profession of his time. (1, page 131)

But there was nothing any licensed physician could do to stop him, at least in most instances.  Not only did Thomson have many followers, there were also many copycats who pretended to be his followers.  Perhaps some had noble intentions, but many simply intended to make some money.

Vogel said:

In those days, no licensing laws or other legal impediments hindered them from plying their trade.  Some of them were fakers and charlatans, while some others were doubtless honest men who imagined themselves to be human benefactors."  (1, page 131)

In this way, Thomson helped create a profession of uneducated people who called themselves doctors and physicians, although licensed physicians called them nothing more than quacks or quack doctors.

The truth is, however, that while many of them were indeed quacks, some of their remedies worked just as well, if not better, than the remedies offered by licensed physicians.

While many botanic physicians, often claiming to be root and herb doctors, claimed to have obtained their remedies from the Indians, Thomson never made such claims.

Instead, Vogel said Thomson claimed to have spent time with...

...an elderly female 'root and herb' healer in his father's neighborhood.  When, to avoid the hard labor of scratching a living from a Vermont homestead, he took to doctoring, he promoted the idea that herbs and natural remedies were superior to mineral and exotic drugs, and was much devoted to 'steaming' or sweating patients in all kinds of ills" (1, page 131)

Thomson said he learned about his favorite remedy, lobelia, which many refer to as Indian tobacco, while "looking for the cows at the age of four."  (1, page 131)

These were obviously good stories, although no one will ever prove whether he was telling the truth, or just fibbing to increase the credibility of his products.

A 2002 article in  Journal of the Medical Library Association, Michael Flannery suggests Thomson was simply playing on the theme set forth amid the nation by the then President of the United States, Andrew Jackson. (2)

Flannery said that while Jackson preached that an uneducated man can run government, Thomson preached that an uneducated man could administer medicine. (2)

Thomson ultimately obtained a patent for his product "that Dr. William Thornton of the U.S. Patent Office termed a 'Fever Medicine,' said Flannery.  He continued:

The duly authorized patent was both a blessing and a curse. On the one hand, it gave Thomson some legal protection and remedy against those who deigned to usurp his system for their own, on the other hand, it became so jealously guarded by Thomson that it more often than not served merely as a source of contention and division within his growing circle of followers, divisions that turned friends into foes. Thomson quickly came to regard many agents not as allies but as enemies. He became convinced that duplicitous agents sailing under the Thomsonian banner were making unnecessary “improvements” to his system, were out to steal the profits for themselves, or were selling inferior, bootlegged products for quick profit. Thomson's fears were both real and imagined, but he tried to give added protection to his patent as well as create a vehicle for its expansion with the publication of his New Guide to Health, or Botanic Family Physician in 1822.  But even this became a source of difficulty as pirated editions began to dot the countryside." (1)

This provides me a segue into Thomson's asthma remedy.  It is listed on page 77 of volume II of the Botanic Family Physician . He notes in his book to have various correspondents around the United States who are always on the lookout for ideal Botanic Remedies.  Thus, his prescription for asthma is as follows:

THE ASTHMA. A correspondent remarks that, always wishing to do good and to be communicative to the great botanic community, and having been conversant with asthmatic affections, that he has found the following prescription uncommonly successful:

1. A thorough course of medicine several times repeated.
2. An emetic, either by the mouth or by injection, or both, daily, and always during a paroxysm.
3. Use a drink made of the white or silver-colored moss that grows on the limbs of sugar trees—The bark off of or near the roots of the beech tree, cleared of the outward surface—sarsafarilla roofs, spignard roots, wild valerian, of each equal parts—pour on boiling water and make a strong decoction— strain oft' the decoction and sweeten pleasantly with honey—scald and scum. Dose a tea-spoonful at a time every two hours, using a little occasionally if dry, at other times.— This method will seldom if ever fail of effecting a cure in asthma, which appears to be always attended with some obstructions of the bronchia and with some "spasmodic condition of the lungs and diaphragm.

We have no doubt of the efficacy of the prescription, having undo trials of a course very similar with remarkable success. It is a mode of treatment truely Thomsonian in principle, and with pleasure we give it a place in the Recorder.

The Paris Academy of Medicine lately reported the case of a man who died in July last, in that city, delirious, and in the right ventiele of whoso heart was found imbedded a needle, which extended into the cavity. No trace of a cicat rix, by which the needle might have entered, could be discovered on the exterior of the body. He had been sutfering for fomc months from pain in the side. (1, page 77-78)

There you go, there's your Botanic Remedy for asthma. If you want to believe it came from natives, so be it. Chances are, if you were desperate for something to remedy your asth ma, you'd give Mr. Thomson's asthma remedy a whirl.   

References: 

1. Vogel, Virgil, "American Indian Medicine," 1970, London, Oklahoma University Press
2. Flannery, Michael A., "The early botanical medical movement as a reflection of life, and literacy in Jacksonian America,"  Journal of the Medical Library Association, October, 2002, 90 (4), pages 442-454
3. Thomson, Samuel, "The Thomsonian Recorder or Impartial Advocate of Botonic Medicine: and the principles which govern the Thomsonian Practice," 1834, Volume II, Columbus (Ohio), Printed at the Thomsonian Botonic Office by Jonathon Phillips, page 77-78

1800-1900: Eleven asthma theories

The 19th century was an "age of enlightenment" where physicians and scientists started to question old theories of medicine and come up with new ones.  This was an important time in our history, because without it we might probably still be stuck with primitive medicine.

This era was particularly important to the evolution of asthma, as all the theories regarding it, old and new, were hotly debated.  Some physicians were dogmatic, holding on to one particular theory for dear life, while others were more open minded.  Either way, the fact that the disease was openly discussed in the arena of ideas allowed physicians to better understand this disease.

Think of it this way:

• Before 400 B.C. asthma was just another mysterious disease caused by evil spirits or gods.
• In 400 B.C. the Hippocratic writers defined asthma as dyspnea. 
• Around 1700 John Fuller defined asthma as a disease entity of its own, slightly more severe than dyspnea and less severe than orthopnea 
• During the 18th century asthma was basically believed to be a disease in some way associated with and caused by sputum.

During the course of the 19th century there were eleven theories regarding asthma that were hotly debated.  Some were ancient ideas, and some were new.  The most prevalent of these theories are listed here. 

1. Humoral theory of asthma:  This theory postulates that asthma was caused by an imbalance of the four humours: black bile, yellow bile, phlegm and blood. This was the prevailing theory from about 400 B.C. (and probably sooner) when Hippocrates defined it, and the 1st century when Galen reaffirmed it, to the 19th century when scientific theories disproved it. More specifically, Galen believed asthma was caused by an over abundance of phlegm.
2. Dyspnea theoery of asthma:  That asthma and dyspnea are the same thing was established by Hipporates.  Basicallly anything that causes you to be short of breath is asthma; asthma is a symptom, an entity, as opposed to a specific disease. This theory was on the way out the door by the turn of the 19th century, although was pretty much the prevailing thought until the 18th century when scientists and physicians realized there were various causes of dyspnea, and started treating asthma as a disease and not just a symptom.  
3. Symptomatic theory of asthma:  Many physicians believed asthma was nothing more than a symptom of some other malady, such as heart, lung or kidney disease.  Sometimes the cause remained mysterious.  
4. Bronchitic theory of asthma:   Wheezes and dyspnea depend on obstruction of the air tubes by the inflammatory products of bronchitis. This results in excessive mucus production. Dyspnea is less severe and more constant than a paroxysm of asthma. This was the prevailing theory during the 18th century, and it made its way into the 19th century through the writings of Dr. Robert Bree.  A variation of this theory held great sway at the end of the 19th century and was referred to as the Theory of vessel turgescence.  This is basically inflammation of the mucosal membranes that line the respiratory tract, and we might think of it today as bronchitis.  
5. Spasmotic/ convulsive theory of asthma:  Convulsions, Contractions or spasms of the muscles that line the bronchioles are a main component of asthma.  Celsus defined asthma as being caused by "the narrow passage by which the breath escapes, it comes out with a whistle."  The theory was introduced to the medial community by Thomas Willis in 1682, and William Cullen in the next century fine tuned it.  It was a hotly contested theory during the 19th century. 
6. Nervous theory of asthma:  The belief that asthma is nervous in origin, or caused by things that influence the mind -- such as strong emotions like laughter, crying, stress, excessive happiness, excessive sadness, a yearning for the mother, etc -- goes back to the ancient world. Physicians early on observed no organic lesions in asthmatic lungs, and therefore assumed it must be nervous in origin.  They observed asthma was intermittent, sometimes with long intermissions between paroxysms.  This theory the nerves caused spasms in the lungs was introduced to the medical community in the 16th century by Jan Baptiste van Helmont and Thomas Willis, and in the 18th century by William Cullen.  It was proven by the experiments of Francis Ramadge in 1835, Joseph Bergson and Amedee Lefevre win 1836, and Francis Romberg in 1841.  It was given true credibility by the writings of Henry Hyde Salter during the 1850s. 
7. Paralytic theory of asthma:  Asthma is caused by paralysis of the respiratory muscles and this results in dyspnea.  This idea was first established by Dr. Rene Laennec around around 1810 or 1820.  "Bronchial muscles," he said, "are paralyzed and dyspnea is expiratory, more more constant, and less spasmotic."  We might now refer to this as emphysema. (1, page 37)
8. Diaphragmatic spasm theory of asthma:  This theory postulates that tonic spasms of the diaphragm causes asthma.  This theory may have been devised by examining the way asthmatic people breath, and was probably proposed by Thomas Willis and Neumaun (?).  It was also later supported by (M. Alton) Wintrich in the mid 19th century, and later confirmed by Heinrich von Bamberger around 1870.
9. Cardiac theory of asthma:  This is the theory that asthma is caused by blood being sucked into the lungs causing congestion and dyspnea. During the 19th and early 20th centuries it was often referred to as a type of asthma.
10. Reflex theory of asthma:  This theory postulated that something other than the lungs causes it.  Eating too much or eating certain foods can effect a nerve and send a "reflex" signal to the lungs, which responds by causing the airways to contract.  For example, catarrh or inflammation of the nose can cause spasm of the muscles of the lungs by reflex action.  Most who support this theory believed some form of disturbance in the blood was the result.  Other causes of this might be a response from the urea, disturbance of metabolism, dyspepsia, etc. However, some who support this theory believed it was just an extehnsion of the nervous theory of asthma.
11. Hay fever theory of asthma:  Hay fever leads to asthma.  Some speculate inflammation (or catarrh) of the upper airway leads to inflammation of the lower airways of the lungs, leading to bronchitis or asthma. This is a theory that has recently gained momentum.
12. Other:  Yes, lots of other theories existed.  Some doctors just let their imaginations fly free. Dr. Breuer, for example, "believed there was an automatic control of breathing through the vagi and that the stretching of the alveolar walls stimulates expiration and hinders inspiration. An increasing of the total lung volume," he said, "would tend to stimulate expiration rather than inspiration." (1, page 37) Some theories may have been scientifically justified, and others, such as Breuer's, mere speculation. Other physicians noticed asthma improved after removal of polyps in the respiratory tract and sinuses.

Of all the theories regarding asthma during this era, Orville Brown said in 1917 in 1917:

The multitude of theories some ingenious and helpful and others far fetched and convincing evidence of a fruitless search, have failed to receive much attention."  (1, page 25)

For the most part, each physician had a favorite theory, found evidence to support it, and adjusted the definition slightly as evidence indicated.

So, what theory won the era? 

References:

1. Brown, Orville Harry, "Asthma, presenting an exposition of nonpassive expiration theory," 1917, St. Louis, C.V. Mosby Company.  The above mentioned theory of vessel turgescence comes from this reference also on page 25. 

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1802: Heberden first physician to recognize hay fever

For most of history people were clueless about colds and allergies.  The symptoms associated with them -- itchy and watery eyes, stuffy and runny nose, scratchy throat, coughing, sniffling and sneezing -- were probably brushed off as minor ailments.  Most people did not seek help, as doing so would be a sign of weakness. Instead, they went about their business the best they could.

While there were occasional vague and allusory descriptions of these common ailments, there were more serious diseases called plagues that earned the attention of most medical writers.

The term "plague" became a generic term used through most of history to describe diseases that were both lethal and destructive.  (1, page 17)

It was not until sometime during the 17th century that the term "fever" began to replace the term plague in describing diseases.  A good example of this came in the year 1666 when Thomas Sydenham published his book "The Method of Treating Fevers." He described diseases such as scarlet fever, perpetual fever, malaria fever, hospital fever, and typhoid fever. (1, page 17)

Still, it wasn't until the mid 18th century, and mainly during the 19th century, when the causative agents of specific symptoms were identified, that the term "fever" was used with increased frequency.  Examples would include rose fever and hay fever, with hay fever gaining the most recognition.  These terms crept into medical nomenclature as physicians linked sniffles and sneezes with rose and hay season. (1, page 17)

A generic terms that was more generally accepted by medical authorities was "catarrh."  This term comes from the Greek term katarrho, which means to flow. It generally referred to the flow of humors, or secretions, due to congestion of the vessels (swelling and inflammation) of certain parts of the body, such as the eyes, nose and throat.

Generally speaking, the symptoms that resulted were generally brushed off as the common cold.  For instance, William Heberden, in his 1802 book "Commentaries on the History and Cure of Disease," described catarrh this way:

If such a catarrh lasts only a few days, it is called a cold in the head; but in many it becomes a chronical disorder, and has lasted with no long intervals for several months, for four years, or every night for ten years; or has returned periodically twice a month for several years, or once in three weeks. (2, page 113)

The problem with the term catarrh, and the probably reason it was eventually phased out of the materia medica for the most part, was because nearly every disease causes some form of catarrh.  It was such a generic term that it lost its relevance. By Heberden's time the phase out had already begun, although the complete extrication of the term would take another 100 plus years.

Another term often used was Coryza, although it was not mentioned by Heberden.  It was a more specific term used to describe catarrh of the nose and throat, and was frequently used to describe the common cold. It was yet another generic term to describe a cold, although it was later used to describe a symptom of hay fever.  The word comes from the Greek term koruza which means "running of the nose."

As part of his chapter on catarrh, of which he also referred to as "defluxion," he described what may people think is the first description of hay fever by a medical writer.

I have known it (catarrh's) return in four or five persons annually in the months of April, May, June, or July, and last a month with great violence. In one a catarrh constantly visited him every summer; and in another this was the only part of the year in which it ceased to be troublesome. (2, page 113) (3, page 14) (4, page 14)

While he did not use the term hay fever, or hay asthma, or rose cold, or any of the other terms to describe the condition that had gained the fancy of the public, it's quite obvious this is was he was describing here.

References:

1. Ergonul, Onder, Chris A. Whitehouse, editors, "Crimeon-Congo Hemorrhagic Fever: A Global Perspective," 2007, Netherlands, Springer
2. Heberden, William, "Commentaries on the History and Cure of Disease," 4th edition, 1816, London, Printed for Payne and Foss - Pall Mall
3. Smith, William Abbotts, "On Hay-Fever, Hay-Asthma, or Summer Catarrh," 1867, London, Henry Renshaw
4. Mackenzie, Morell, "Hay fever and paroxysmal sneezing," 5th ed., 1889, London, J&A Churchill

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1600-1700: Some abhorent remedies for asthma

So you have asthma in 1618, and you approach your physician about your problem. You sit in a wooden chair opposite his voluminous desk, leaning on his desk to expand your chest, your chest heaving with each slow breath.

As you're explaining your dilemma, in a huffy fashion, he opens a book on his desk.  You observe the title: "Materia Medica."  You wait as he sifts through the pages, and says, "hmmmmm.  Let's see here."  His finger traces what he's reading.  He leans back in his chair.  

He says, "Now, according to this "Materia Medica" we have a few options here.  Do you have anyone who can hunt for you."

You say, "Well, I'd love to hunt for myself, yet the consequences of doing it put me here."  

"I see." He leans back in his chair, puckers his lips as if in deep thought.

"So what do I need to do?" You ask.

"Well, it says here," he picks up the book, turns it so you can see the page, and he points to the heading "Asthma."  You read the section he's pointing to:

• Worms
• Lozenges of dried vipers
• Foxes Lungs

You say, "Well, I think I can find someone to get me a fox, but I'm not sure about the viper.  I think getting one of those would be next to impossible." You look into the doctor's eyes.  "Don't tell me a viper bite will cure me, doctor."

Your comment induces a laugh from the doctor, and you join in briefly.  The laughter induces a cough, and you produce a large amount of sputum.  The doctor reaches into his desk and offers you a handkerchief.
-----------

For kicks and grins, here are some of the other remedies in 17th century pharmacopaeas:

• Powder's of precious stones
• Moss from the skull of the victum of violent death
• Human urine
• Blood
• Fat
• Bile
• Horns
• Crab's claws
• Crab's eyes
• Bones
• Bone marrow
• Sexual organs
• Eggs
• Excreta of animals of all sorts
• Spider-webs
• Fur
• Feathers
• Hair
• Scorpions

No wonder physicians struggled to gain respect.  To their credit, though these remedies offered hope to patients, and there were also many other remedies that had an actual benefit to the patient.  Considering the medical ignorance of the time, physicians who offered such remedies must have felt good about their efforts to help a sick person.

Such remedies were slowly phased out of the pharmacopoeia, mainly due to the works of men like William Heberden (1710-1801) who championed to put "diseases upon a scientific basis," and "who did a most important service to therapeutics by dispelling current superstitions and banishing them forever from the pharmacopoeia" in his 1745 book "Essays on Mithridatium Theriaca."*  (1, page 370)

Obviously most of these abhorrent remedies were slowly phased out of the pharmacopoeia, particularly as better remedies were introduced.  For example, stramonium was introduced to the London Pharmacopoeia in 1721 by Sir Hans Sloane.  A few decades later, the authors of the 5th London Pharmacopeia of 1746 condemned the old practice of astrology and folk medicine, dropping the following remedies: (1, page 408)

• Human fat
• Spider Webs
• Moss from human skulls
• Unicorn's horn
• Virgin's milk
• Bones from stag's heart (1, page 408)

Can you guess what was in your asthma medicine?

*Mithridatium = remedy that cures everything, particularly poisons; theriaca = a compound of 64 drugs believed to be a cure for all poisons)

References:  

1. Garrison, Fielding Hudson, "An introduction to the history of medicine," 1922, Philadelphia, W.B. Saunders Company, page 291

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1798: Robert Bree's 4 Species of Asthma

Robert Bree, our formost expert on asthma during the first half of the 19th century, described four species of asthma in his 1797 book, "A practical inquiry into disordered respiration: distinguishing the species of convulsive asthma, their causes and indications of cure."   

His "species" of asthma are based on his theory that asthma, and dyspnea, are caused by some irritating or peccant matter, and the asthma will continue until this peccant matter is removed.  The asthma attack, hence, is the effort of the body, or lungs, to expectorate this matter.  In this way, an asthma attack usually ends with the expectoration of sputum.

Now that we understand that, here are his species of convulsive asthma:

1.  The first species:  It's called Periodic or sometimes Convulsive Asthma (as described by John Cullen).  It's usually preceded by dyspepsia (irritated stomach).  It may show symptoms for years before it turns into a fit of asthma.  Dyspepsia is aggravated during the attack of asthma.  This usually effects the melancholic personality.  This is irritation of the serum within the lungs.  (1)

Symptoms include ("When an asthmatic feels these symptoms, he may be convinced that his enemy is at hand.":

• Flatulence
• Distended bowel
• Pain over forehead and eyes, which may become worse in the evenings
• Eructation of wind (burping)
• The evenings are attended with sleepiness
• Irritability that repels friends
• Tingling and heat in the ears, neck and breast (itching of the lungs)
• A motion to expel contents of the bowels
• Uneasiness of abdominal muscles
• After sleeping, he wakes with great difficulty of breathing
• Feels need to have an erect posture
• Inspiration performed with great effort of the muscles, but never performed deeply
• Diaphragm seems to descend with great difficulty against a force
• Speaking becomes distressing
• Irritibility of mind continues
• Wheezing sound on respiration
• There is a propensity to make water (pee, urinate), which is copious (lots) and pale
• After several hours cough birngs up phlegm
• Relief follows
• Tranquil state of feeling induces sleep with wheezes
• Remission on second day
• Expectoration of phlegm on 2nd or 3rd day ends the episode

2.  The second species:  Like the first it's caused by an irritating matter in the lungs.  It's accompanied by little or not expectoration of mucus.  For this reason it's commonly called Dry asthma. This is irritation from areal acrimony within the lungs.  (2)

Symptoms include:

• Little sputum, or none
• It comes on suddenly
• Succeeds sudden changes such as alterations in the wind, or a change of situation.
• The cause is of acrid or offensive quality, such as a strong smell, or subtle matter carried by the air. 
• The irritant is inhaled and attaches to the bronchial pipes or tracheal membrane. 
• The irritant usually atatcks by day more so than night
• No wheezes
• Action of intercostals and abdominal muscles are increased (as in other species of asthma)
• Dry cough
• Inflammation
• Hoarseness
• More prevalent in populous places or manufacturing places
• May come on suddenly when you come upon a town, and go away when you get back to the pure air of the country

3.  The third species: This is when the irritating matter that causes convulsive asthma is found in some organ other than the lungs. These causative organs are generally found below the thoracic cavity, such as the stomach or other viscera.    However, it cannot be proven the irritating matter was not present in the lungs at the same time. The irritating matter of another organ might be removed by an unobserved power of absorption, and the irritating matter of the lungs may be removed through expiration.

Many physicians doubt another organ causes asthma, and therefore inappropriately give blame to the lungs.  Many people think the lungs are the cause because of the respiratory distress.  For example, some physicians have found a link between spasm of the bladder or rectum and spasms of diaphragm and abdominal muscles, which are muscles "subservient to respiration."  In this way, Bree believed abdominal problems can cause respiratory problems.  (3)

4.  The fourth species:  This is convulsive asthma that is dependent on the habit of the person, and caused by sensation, after the irritation has been removed from the thoracic or abdominal viscera. I believe the idea here is that the asthma is caused due to the treatment of some other disease. Paroxysms return by minute causes in effect, such as mental association with the idea of being short of breath.  This usually is seen in those with frequent episodes of species 1-3.  For this type opium or other antispasmotics seem to work quite well. (4)

Further reading:

• To see other remedies for the above species see this link.
• To learn more about Dr. Robert Bree's definition of asthma click here
• To view the history of asthma click here

References:

1. Bree, Robert, "A practical inquiry into disordered respiration: distinguishing the species of convulsive asthma, their causes and indications of cure," 4th ed., 1810, London, page 43- 56
2. Bree, ibid, pages 182-193, 286-287
3. Bree, ibid, page 194-212, 287-290
4. Bree, ibid, pages 213-233, 290-292

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1800-2012: Evolution of back-door bronchodilator

One of the oldest and most popular asthma medicines historically are anticholinergic or muscarinic medicines. The exact mechanisms to how these medicines worked remained a mystery for most of history, so the terms anticholinergic and muscarinic are recent terms. What was known early in our history is that inhaling the medicine offered relief for asthma attacks.

Ancient Egyptian medical documents reported taking dried and crushed herbs, mainly belladonna, and placing them on heated bricks. Then the asthmatic, or the person suffering from asthma-like symptoms, inhaled the medicated smoke and was offered some relief. This was among the most common asthma remedies in Egypt.

At different times in our history, various other civilizations inhaled either belladonna, or other members of this family plants. The common name is the nightshade family, otherwise known as the Solanaceae family of plants. They include:

• Datura stramonium 
• Atropa belladonna 
• Hyoscyamus niger (henbane) 
• Lobelia inflata.

As the ancient physicians discovered, the best effect was obtained when the medicine was inhaled, and in this way, it was used as a topical applied directly to the lungs. Over time, different methods were used for inhaling the medicine, which included:

1.  Burning herbs: Leaves, roots and stems from the herbs Belladonna and stramonium were sun-dried and crushed by ancient Egyptians, placed on rocks heated on coals, and the asthmatic would roll up stalks of a reed, place one end up to the crushed herbs and inhale the smoke. Surely this sometimes made asthma worse, yet more often than not the herb offered some relief. This method was first recorded in 4000 BC, yet it was probably done long before this.

2.  Pipes:  The sun-dried products of the herbs were ground, and the powder stuffed into crude pipes, lit, and the medicinal smoke inhaled.  This technique was discovered for the modern world in 1803 for Europe and the U.S. and the asthma cigarette craze began.

3.  Cigarettes: The powder was rolled into small paper and smoked cigarettes and cigars.  This technique was commonly used in India and was discovered for the modern world in the early 19th century. An asthma cigarette craze began around 1879 and lasted until the middle of the 20th century.

4.  Pills:  During the 19th century the medicine was formed into pills that were taken by mouth.  A popular brand was Potter's Asthma Pills.  These were common from around 1880 to 1950s.

Ad for Ozone Paper
showing endorsement
by Dr. Thorowgood
(1891)

5.  Nitre/ Ozonepaper:  By the 1850s paper was impregnated with potassium nitrate, strammonium, or belladonna and ignited to produce fumes that were inhaled as a treatment for spasmodic asthma.  By 1973 this was a common mode of treatment and recommended by Dr. John Thorowgood in the British Medical Journal.  (1)  (2)  It may also be referred to as ozone paper.  One advertisement for the product even mentions Dr. Thorowgood's endorsement (see picture to right.

6.  Nebulizers/ Inhalers:  During the 19th century various nebulizers and inhalers were invented to help asthmatics inhale various solutions of the medicine.   Nebulizers, of course, were fine tuned in the 1930s, and modern inhalers were fine tuned during the 1950s.

As scientists and Pharmaceuticals worked with the plants, they learned, in 1833, that the active ingredient inside it was atropine.  From there they learned how to synthesize the medicine to create modern anticholinergics.

These include:

1.  Atropine:  It was derived from the belladonna plant in 1833, and by 1867 it was isolated and determined to be a component alkaloid of the various nightshade plants found in India, Egypt, South America and other rocky, warm climates.

It was first available for asthma cigarettes, but around the turn of the 20th century was available as a solution to be nebulized. It ultimately became a top line treatment for asthma during the 1950s.  The medicine was still prescribed for asthma during the 1980s, although by the 1990s was phased out due to a synthesized anticholinergic medicine with fewer side effects. I was prescribed this medicine in 1985 and took it up to four times per day until around 1990.

It was ultimately learned that the medicine worked by blocking the effects of the parasympathetic nervous system. This system releases a neurotransmitter called acetylcysteine which binds to muscarinic receptors that are randomly scattered along the bronchial smooth muscle. This causes bronchospasm, increased secretions, and asthma symptoms.

Prior to the 1990s, this parasympathetic pathway was thought to be the main cause of bronchospasm in asthma. Atropine and Atrovent worked by binding with muscarinic receptors, thereby preventing acetylcholine from attaching to them, thereby blocking acetylcholine. The medicine became known as anticholinergic or antimuscarinic medicine.

It was at this time, during the 1990s, that researchers learned that most cases of asthma involved some degree of underlying airway inflammation (10),  the severity of which determined how severe a person's asthma was. This inflammation worsened due to exposure to asthma triggers, resulting in bronchospasm, increased mucus production, and asthma symptoms.

It was learned that the best medicines for treating this bronchospasm and underlying airway inflammation were beta 2 adrenergic medicines and inhaled corticosteroids. At this time, anticholinergic medicine was relegated to second-line asthma medicine status, as opposed to front-line status. So, this was another reason most asthmatics are no longer prescribed anticholinergic medicine.

Atrovent Inhaler

2.  Ipratropium Bromide (Atrovent):  This is a synthesized anticholinergic, and it was first introduced in Germany in 1975, followed by the rest of Europe by the late 70s.  It was available both as a solution to be nebulized and as an inhaler, and it was prescribed four times per day.  An HFA inhaler was approved by the FDA in 2004.  I was prescribed this medicine in 1990 and took it up to four times a day until around 1995.  It was initially a top line asthma medicine, although better medicines have replaced it.  I believe the inhaler was phased out in favor of the new Ipatropium Respimat. (3) (4)

As a side note here, up until the mid-1990's, atropine, and later Atrovent, were top-line asthma medicines. Up until this time, the main pathway of bronchospasm was thought to be the parasympathetic nervous system. By this, researchers understood that atropine

3.  Oxitropium Bromide (Oxiven, Tersigen): This was another synthesized anticholinergic released along with ipratropium bromide.  It was marketed as both an inhaler and solution.  Because it was available in higher doses, the frequency was only three times per day.  This medicine was never approved by the FDA for sale in the U.S. (6)

10.  Combivent:  This is a combination of Albuterol and Ipratropium bromide in an inhaler form. It was approved by the FDA in 1996 for the convenience of COPD patients and some asthmatics who don't respond to other top line asthma medications. The medicine was set to be phased out by December 31, 2013, but due to a public outcry a new version of the medicine was introduced to the market as a replacement (see Combivent Respimat)

Combivent Inhaler

 11.  Duoneb:  This is a combination of albuterol and ipratropium bromide premixed in plastic amps with 0.3cc of normal saline. It was introduced in the early 1990s and approved by the FDA in 1996.  The medicine was nice because it made for a quicker breathing treatment, as compared to mixing separate amps of albuterol and ipratropium bromide, both with 3cc premixed.  It continues to be a top line treatment for COPD, although is an option for asthmatics.

Spiriva HandiHaler

12.  Tiotropium Bromide (Spiriva Handihaler): This dry powdered inhaler was introduced to the market in Europe in 2002 and the U.S. in 2003. It's the first long-acting back-door bronchodilator, meaning it only needs to be taken once a day.  Studies show it is more effective than ipratropium bromide in improving lung function. It is recommended as a top line treatment for COPD.   (7)

Combivent Respimat

13.  Combivent Respimat: This is the new version of Combivent approved by the FDA in 2012. The device has no propellant, is breath actuated, and delivers a dose that is supposed to provide greater lung distribution of the medicine than a metered dose inhaler. The medicine was in demand because a non CFC version of Combivent was needed.  (8)

Studies show this type of medicine may produce mild bronchodilation and mild breathing relief. Personally, I never noticed any difference with the medicine. However, modern evidence suggests the medicine, when used daily, may act as a preventative medicine, keeping lungs dilated long term.

Modern studies have found that anticholinergics that anticholinergics don't benefit asthmatics as once was suspected, and so, while they remain an option, they are no longer a top-line option.  Spiriva continues to be a top line option for COPD, as studies show it improves lung function. Atrovent and Combivent are slowly being phased out in favor of the newer medicines.

Duoneb continues to be an option for COPD patients, although even it has seen better days.  Some physicians are phasing this medicine out in favor of long acting medicines that only need to be taken once or twice a day, such as Spiriva, Brovana, and Pulmicort.

So what started out as a medicine that was sporadically recommended and inhaled as smoke around a primitive cooking fire, has evolved into a medicine that is taken in the form of simple inhalations that are conveniently and safely delivered as simple inhalations.

Anticholinergics (or muscarinics) are medicines that, once inhaled, sit on cholinergic (or muscarinic) receptor sites that sit along bronchial smooth muscles. It binds to and sits in these receptor sites, thereby preventing the neurotransmitter acetylcystine from binding to them.

of the neurotransmitter acetylcysteine to prevent it from causing bronchospasm. Because the medicine is blocking a natural response as opposed to actively causing bronchodilation, it is often referred to as a "back-door bronchodilator."

The first "back-door bronchodilators" used came from the nightshade family of plants called Solanaceae, and were often included in ancient recipes for asthma remedies.  Some common plants used were:



References:

1. "Nitre paper," Drugs.com, http://www.drugs.com/dict/niter-paper.html
2. Thorowgood, John, "On Bronchial Asthma," British Medical Journal, 1873, Nov. 22, page 600
3. Sittig, Marshal, "Pharmaceutical Manufacturing Encyclopedia," 1988, vol. 1, New Jersey, page 837
4. Barnes, Peter J., Jeffrey M. Drazen, Stephen I. Rennard, "Asthma and COPD: Basic Mechanisms and Clinical Management," 2008, page 616-17
5. Ipatropium Bromide, package insert, http://bidocs.boehringer-ingelheim.com/BIWebAccess/ViewServlet.serdocBase=renetnt&folderPath=/Prescribing+Information/PIs/Atrovent+HFA/10003001_US_1.pdfingelheim.com/BIWebAccess/ViewServlet.ser?docBase=renetnt&folderPath=/Prescribing+Information/PIs/Atrovent+HFA/10003001_US_1.pdf
6. Barnes, op cit
7. Barnes, op cit
8. "FDA Approves Combivent Respimat (ipatropium bromide and albuterol sulfate) Inhalation Spray," FDA.gov, http://www.fda.gov/Drugs/DrugSafety/InformationbyDrugClass/ucm274684.htm
9. *Picture with much appreciated permission from Inhalatorium.com
10. Wright, Rosalind J., Mario Rodriguez, Sheldon Cohen, “Review of psychosocial stress and asthma: an integrated biopsychosocial approach,” Thorax, 1998, December, http://thorax.bmj.com/content/53/12, accessed 7/18/17

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