1851-1913: The history of asthma sputum

Ernst Victor von Leyden (1832-1910 discovered
crystals in asthmatic sputum and suspected these
to be the cause of asthma. During his era, he was
the closest supporter of Dr. Robert Bree's
bronchitic theory of asthma. (9, pages 14-15)
He believed these crystals somehow irritated the
"vagus in the mucous membrane of the bronchials,
and hereby caused by reflex action a spasm
of the muscles of the small bronchial tubes."
(10, page 8)

Most people find sputum disgusting, and so will have nothing to do with it. But as far back as 400 B.C., the medical significance of it was observed by ancient Greek physicians, and probably even earlier than that.
If you mention it at the dinner table your mother might smack your hand. But for the sake of gaining a complete grasp on the history of asthma and respiratory disease, we must delve into the topic of sputum.  Sorry, but we must.

It must have been observed at an early date in history that people with breathing issues produce sputum, sometimes consisting of a putrid smell, often consisting of many varied colors such as red, yellow, brown and white.

Yet rather than being petrified by the grossness of the substance, Greek philosophers became fascinated by it. They even gave it its own classification as one of the four humors that, along with determining one's personality, also determined whether was healthy or sick.

Prior to the philosophical medicine of the ancient Greeks, other ancient societies, and the primitive clans and families that roamed the lands before them, believed sputum was the production of some evil spirit, demon or god. When a person expectorated the substance, they were, in essence, expectorating an evil substance that caused the symptoms they were suffering from.

From the ancient world to the scientific revolution there were few changes in the way physicians viewed diseases and treated their patients.  In 1799 Dr. Robert Bree speculated that sputum contained a poison that it was trying to get out of the body, and asthma was the result.  This theory wasn't much different than any idea Hippocrates might have postulated.

Since the sputum preceded the asthmatic fit, Bree essentially speculated that asthma was essentially bronchitis, and thus created the bronchitic theory of asthma.  Others, without much more evidence, speculated sputum was the effect of asthma rather than the cause.

Such speculation gradually tapered off, but never really came to an end, during the scientific revolution, and mainly due to the inventions of the microscope, which allowed physicians to see that the human body was made up of substances too small to be seen by the unassisted eye, and the stethoscope, which allowed physicians to hear changes that occurred inside the chest and to diagnose diseases with accuracy prior to autopsy.

The microscope allowed physicians to learn that air passages were surrounded by smooth muscle and that it was capable of spasming when stimulated.  The stethoscope allowed them to hear when sputum accumulated in the chest, and learn that it was the effect and not the cause of asthma.

So, pretty much, prior to the 1850s asthma was basically considered to be a disease of excess sputum, mainly because this was all physicians could observe with the unaided eye and ear.

Yet by the 1850s, it was looking pretty clear that asthma was also a disease associated with spasms of the air passages, particularly by the wheezes heard by air flowing through narrowed air passages, and rhonchi heard as air flowed through sputum lined air passages.  (1, pages 592-595)

In 1851, Dr. Beau, along with his assistant Cozart, observed that fits of asthma usually ended with a wad of sputum being coughed up. Beau used this observation as evidence to support his theory that asthma was a disease of chronic catarrh, and that asthma was caused by increased sputum in the air passages.  (3, page 31)

When this sputum dried out mucus plugs formed that were capable of blocking the air passages, thus resulting in dyspnea and other symptoms of asthma, including the "sonorous and sibilant rhonchi -- their 'rales vibrants' heard upon auscultation with a stethoscope."  (3, page 31)

The fit, therefore, was resolved when mucus plugs were broken up with a fit of coughing.  (3, page 31)

Then, in 1878, at a time when most physicians had accepted the nervous and spasmotic theories,  J.B. Berkart used Beau's research as evidence of the bronchitic theory of asthma.

Berkart said:

With the displacement of the mucous plug into the larger bronchus, or on its expulsion by means of a fit of coughing, the dyspnea ceases, and with it also the rales disappear.  This form of bronchitis is, in their (Beau and Crozant's) opinion, due partly to an idiosyncrasy of the patient, partly to exciting causes, which greatly vary in different individuals."

Tiny crystals were first observed in sputum in 1851 by Jean-Martin Charcot, but it wasn't until 1872 that these crystals were linked to asthma by Ernst Victor von Leyden. So history has given credit for this discovery to both men by calling the crystals Charcot-Leyden crystals.

Leyden, whose asthma theories were similar to Dr. Bree's bronchitic theory, believed Charcot-Leyden crystals caused asthma by irritating...

...the peripheral extremities of the vagus nerve, and produce reflex spasm of the bronchial muscle."  

The asthma attack, as Bree and Beau observed, ended when a wad of sputum was coughed up during a fit of coughing. (4, page 14-15

However, it was the discovery of these Charcot-Leyden crystals that would ultimately put an end to the bronchitis theory of asthma.  This was noted by Dr. John Charles Thorowgood in 1878.  He said that these crystals were found in sputum obtained from patients with "ordinary catarrh and croupus bronchitis."  (4, page 15)

Thorowgood said:

The asthmatic patient while in a fit presents abundance of symptoms distressing enough to endure or to witness; and yet, when things seem to be at their worse, and the patient well-nigh at his last gasp, a remission comes on, the spasm yields, air enters the lungs, and the attack subsides, coincidentally often with access of cough and mucous expectoration." (4, page 16)(9, page 1,2)

In 1879, bacteriologist Paul Erlich discovered the eosinophil, and it was soon discovered that elevated levels of eosinophils (eosinophilia) was commonly found in asthmatics. (5)

In 1882 Heinrich Crushmann observed other spirals in asthma sputum and believed they were associated with causing asthma. He believed since Leyden's crystals didn't cause asthma, perhaps his crystals did. (5)

Later Curshmann's crystals were determined to be fragments of mucus plugs associated with asthma, and Leyden crystals were determined to be fragments of eosinophils. Eosinophils were later learned to be a type of white blood cell that, along with mast cells, are involved in the allergic reaction.

In 1911 Hermann Sahli described eosinophils in asthmatic sputum. Yet Sahli noted another author from 1891 who described eosinophils in the asthmatic blood, and he concluded that these must be pathological with asthma. Yet he also noted that neither the cause of the eosinophils nor their origin was known. (7)

Sahli could isolate the area where the sputum came from based on epithelial cells in it, yet he did not understand the mechanisms of its production as we do today. (7)

Dr. James Adams describes asthma sputum in 1913: (8)

"Asthmatic sputum varies. Often there is none till the end of the attack; then it is in the typical form of small, tough pellets expelled by laborious coughing. The attack may then cease, or it may go on till a more free and profuse expectoration occurs."

He also wrote:  (8)

"The sputum does not readily decompose, and is said to be wonderfully free from microbes; but this is not always so, as I have occasionally found it teeming with them."

The true purpose of sputum is to ball up microbes inside the lungs and haul them out, and in this way, the lungs stay sterile.  Surely asthma can be caused by inhaling a microbe, such as a bacteria, but it's also caused by asthma triggers (dust mites, smoke, fumes, chemicals, pollution, animal dander) that are non-infecting agents.

So this might explain why Adams most often found asthmatic sputum without an infecting agent, and sometimes "teeming with them."

Backing up a moment to 1906, Australian pediatrician Clemons van Pirquet coined the term allergy when he observed that some of his patients were hypersensitive to substances that did not bother other people (what we now refer to as allergens, or asthma triggers).  This was the first time asthma was linked with allergies.

By 1910 Histamine was discovered and found to be a major component in the allergic response.  So some went on to speculate that finding a way to block histamine would cure both allergies and asthma.
In 1937, the first antihistamine was synthesized in a lab, and in 1946 antihistamines hit the market. Within a decade they were among the most commonly prescribed medicines.

Yet as time went by, it was learned that there was more to asthma and allergies than just histamine.  It was learned that asthmatic and allergic immune systems respond irrationally to allergens and asthma triggers by increasing production of eosinophils and this spearheads inflammation of the bronchial muscles.

Another weapon of the immune system is mast cells that line the respiratory tract and eyes, and these were discovered in 1953.  .

In 1967 Immunoglobulin E antibodies (IgE) were discovered.  It was later learned IgE has a significant role in the asthmatic and the allergic response.  The first time asthmatics are exposed to asthma triggers (allergens), say dust mites, their immune systems develop dust mite IgE antibodies that attach to mast cells that line the epithelial layer of the skin or respiratory tract.

The second time that person is exposed to that allergen (dust mites in this case), a mast cell that has a dust mite IgE antibody attached to it explodes and releases its contents:  the mediators of inflammation.  A mediator of inflammation called histamine was discovered in 1910, and others called cytokines and leukotrienes were discovered in the 1970s.

These mediators, when released into the blood stream, cause inflammation of the respiratory tract, thus causing the allergic and asthmatic responses.

In the allergic person, they can also cause inflammation of the upper respiratory tract, which includes the back of the throat and nose.  The offending substance (dust in our case) is recognized by the immune system, trapped in the mucus layer, absorbed by the mucus, balled up by the mucus, and sent on it's way up the respiratory track to be coughed up.

So this would explain what Dr. Bree, Beau, and Berkart observed. While hacking up a wad of sputum may have been related to the fit of asthma, it was not the cause, and had nothing to do with the cure.

Later it was learned that asthmatic lungs tended to produce an abnormal number of goblet cells, this results in an abnormal increase in mucus production during an asthma attack.  While some of this sputum may be coughed up, some becomes trapped in obstructed air passages, dries out to form mucus plugs, and this further blocks the air passages, thus compounding the asthma response.

When the fit ends, when the air passages relax and dilate, which may be a result of time or medications, the asthmatic will probably expectorate this sputum, which will usually be, if no bacteria or virus is balled up within it, white and sterile.  It will also have IgE and eosinophils in it, hence your Charcot-Leyden and Curshmann crystals.

So it's easy to understand how this production of sputum at the end of an attack could easily be misinterpreted as the cause, rather than the effect, of asthma.

References:

1. Lotval, J., "Contractility of Lungs and air tubes: experiments performed in 1840 by Charles J.B. Williams, European Respiratory Journal, 1994, (7) pages 592-595
2. Bree, Robert, "A Practical Inquiry into Disordered Respiration Distinguishing the Species of Convulsive Asthma, their Causes and Indication for a Cure," 4th ed, 1810, London, page pages 117-118
3. Berkart, J.B., "On Asthma: Its Pathology and Treatment," 1878
4. Thorowgood, John C., "Asthma and Chronic Bronchitis: A New Edition of Notes on Asthma and Bronchial Asthma," 1894, London, Bailliere, Tyndall, & Cox
5. Lipkowitz, Myron, Tova Navarra, "Encyclopedia of Allergies," 2001
6. Brenner, Barry E, "Emergency Medicine, 1998, page 10
7. Sahli, Hermann, "A treatise on diagnostic methods of examination," 1911
8. Adams, James, Asthma and it's Radical Treatment, 1913
9. Thorowgood, John C., "Notes on Asthma," 1878, 3rd edition, London, J & A Churchill
10. Shmiegelow, Ernst, "Asthma, considered specially in relation to nasal disease," 1890, London, H.K. Lewis

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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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1835: Ramadge questions that Dr. Bree had asthma?

So we know that Dr. Robert Bree published a book called "A Practical Inquiry into Disordered Respiration" that became the principle authority on asthma during the first half of the 19th century. Yet his book did not come without criticism.  

George Lipscomb, a fellow British physician, had the nerve to criticize Dr. Bree's ideas regarding asthma even as the book was first published.

Then, in 1935, Dr. Francis Hopkins Ramadge, in his 1835 book "Asthma, its species and complications," went almost as far as to suggest that Dr. Bree did not have asthma at all, and, therefore, was probably describing some other disease.  

He said: 

Dr. Bree delineated the early stages of his disorder, as distinctly as the latter, I have no doubt it would be found, that his asthma supervened upon latent consumption. Thus he gives no account of the symptoms preceding dyspepsia, which would have indicated, at once, the origin of his complaint. But, it is evident that some ailment of the chest was early at work, from his alluding to pain of the intercostal muscles, which could hardly have existed without; or, the reverse might have happened, and the dyspepsia impairing his health, have thus indirectly originated the pulmonary affection. (1, pages 135-136)

Some remarks of Laennec coincide wonderfully with this view of the case. He observes, "that nervous symptoms may mask phthisis for a long period; and that he has known it concealed for years by habitual dyspepsia, and other symptoms of hypochondria." (1, page 136)

This, in fact, is giving in other words the commencement of Dr. Bree's case, as stated by himself. So strongly, indeed, am I convinced that one or other of these explanations will apply to the learned Doctor's case, and elucidate what has been omitted by him, that, could he be induced to summon up his recollections, and retrace minutely the precursory symptoms of his disease, it would, I have little doubt, appear that either before, or during his dyspeptic condition, he had had attacks, slight ones perhaps, of haemoptysis. However, for an author to retrace his steps, crossexamine himself, and confess his views to be erroneous, would be an effort of candour above the powers of poor humanity! (1, pages 136-137)

I would not be supposed to insinuate, that any thing was purposely omitted by him. On the contrary, I believe he has detailed, and fully too, every symptom he conceived to be of importance; and that, supposing he had laboured under slight spitting of blood, he would have deemed it too irrelevant for notice. The course, therefore, of his complaint, on the supposition of the correctness of the views above taken, would be that on the appearance of the dry form of asthma, which did not exhibit itself for several years after the first manifestation of dyspnoea, his lungs became emphysematous, and the cavity, which I conjecture to have previously existed, was gradually healed up. The care he appears subsequently to have taken of himself put a stop to the bronchial affection, and with it of the asthma,which at one period seems to have been habitual with him. (1, pages 137-138)

Dr. Ramadge, along with other physicians who came to the same conclusion about Dr. Brees ideas regarding asthma, said that Dr. Bree was a smart man who, if he had had access to the stethoscope of Dr. Rene Laennec, would have easily seen his mistake.  

About twenty years later Dr. Henry Hyde Salter, who we will come to know as the author of the most famous asthma book of the second half of the 19th century, also criticized Dr. Brees ideas regarding asthma. 

Dr. Bree argued in favor of the bronchitic theory of asthma.  He believed the spasms or convulsions associated with a fit of asthma are all a part of the bodies effort to get rid of some irritating or peccant matter that was inhaled into the air tubes.  

I know I quote Dr. Salter's criticism of Dr .Bree in another post, yet I think it's worth repeating here.  Dr. Salter said: 

Dr. Bree maintains his argument with a great deal of ingenuity, and presses many facts into the service of his theory; but the most superficial reflection would suffice nowadays to show that it is utterly untenable ; and had Dr. Bree enjoyed the light that now shines on us from those two important points, the stethoscope and our acquaintance with excito-motory action, he would never have broached the doctrine he did: the one would have shown him the fallacy of his views, the other would have opened to him a solution of his difficulty—the stethoscope would have shown him that the conditions of an extraordinary discharging power are not present in an asthmatic attack ; indeed, that the power of getting rid of anything in the lungs is very much diminished by it; and the knowledge of reflex nervous action would, in connection with anatomy, have displayed the true nature of the disease, and made all its discrepant and scattered phenomena conspire to the production of its true and simple theory. (2, page 5)

With all due respect to Dr. Bree, the same argument about "if he had access to the stethoscope" could have been made regarding any of the physicians who studied lung diseases during their careers.  

Still, the argument that Dr. Bree never had asthma at all, and that his book did not describe convulsive asthma but some other disorder of the lungs, was quite impelling.  

References: 

1. Ramadge, Francis Hopkins, "Asthma, its species and complications, or researches into pathology or disordered respiration; with remarks on the remedial treatment applicable to each variety; being a practical and theoretical review of this malady, considered in its simple form, and in connection with disease of the heart, catarrh, indigestion, etc." 1835, London,  Longman, Rees, Orme, Brown, Green, and Longman
2. Salter, Henry Hyde, "On Asthma: It's Pathology and Treatment," 1882, New York, William Wood & Company; Dr. Salter's book was originally published in 1860, and was previously released as a series of articles during the course of the 1850s

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1800: Lipscomb tries to discredit Bree's asthma theories

While Dr. George Lipscomb may have had nothing against fellow physician, Dr. Robert Bree,  personally, he strongly opposed his ideas regarding asthma in his 1800 book  "Observations on the history and Cause of Asthma."

I have yet to be able to obtain a copy of Lipscomb's asthma book, nor a picture of it, nor a picture of the doctor himself.  I have, however, been able to learn a bit about him and his thoughts on asthma through the writings of other authors.

According to his obituary, he was born in Quainton (Queen's Estate) in England, on January 4, 1773, which, ironically, is the same birthday as my own, only 197 years earlier.  His grandfather was Thomas Lipscomb, who was a surgeon in Hampshire County, and died in 1791 at the age of 92. (5, pages 88-89)

The eldest son of Thomas was James, and he was a surgeon in the Royal Navy, and resided in Quainton from 1764 until his death in 1794.  James was the father of George.  So you can see that he was born into a family of surgeons, and so there was a high likelihood that this was going to be his trade.  (5, page 89)

George received his elementary instruction at Quainton School and transferred to Aylesbury in 1783, and then was educated at home for his "hereditary vocation." He then studied under James Earle in London in 1791, started his own business, and in 1792 became house surgeon of St. Bartholomew's Hospital (5, page 89)

In 1799 he wrote "An Essay on the Nature and Treatment of Putrid Fevers." He also wrote various other essays. In 1800 he published his book containing all his wisdom regarding asthma, which included a history of asthma and criticism of Dr. Bree. (5, page 89)

George Lipscomb would die in 1846.

Asthma historian Mark Jackson, in his book "Asthma: The Biography," said Dr. Lipscomb, while born London, practiced, like Bree, in Birmingham.  While he admitted to not knowing Bree and having nothing personally against him, his book was an ardent attack on Bree's ideas regarding asthma.

Jackson quotes Lipscomb as saying the intent of his book was to "elucidate the history of a very prevalent and distressing disease, which has been hitherto but ill explained, and very unsuccessfully treated (1, pages 86)

Jackson said Lipscomb argued against many of the ideas of Bree, "criticizing his vague terminology, denouncing his over-reliance on ancient authorities, disputing his speculations about the irritating qualities of serum or the morbid state of the pulmonary vessels, and dismissing his classification of asthma into four species." (1, page 87)

William Cullen, our asthma expert from the 18th century, said asthma was a disease of constriction of the lungs. Bree, however, believed this theory was disproved as soon as the lungs were inspected, as no signs of constriction were found in asthmatic airways, and copious amounts of sputum were found in these airways. This was proof, he said, that asthma was bronchitic and not spasmotic.

Jackson said Lipscomb believed that Bree could no more prove Cullen's theories were wrong than Cullen could prove them right, mainly because, upon death, the lungs automatically relax (1, pages 86-87)

In this way, because the lungs automatically relax, even if asthmatic air passages were constricted, they would no longer be constricted upon death.  So Lipscomb argued that, while Bree's argument is flawed, Cullens

While Lipscomb argued against Brees theories, he postulated some flawed theories of his own.  Jackson said:

Lipscomb replaced the theories of Cullen and Bee with speculations of his own. Accepting the primary role of mucus obstructing the air passages, Lipscomb argued that any bronchial effusion must have originated in the arteries of the lungs. However, in asthmatics, the accumulation of serum in the bronchi was not the result of weakened capillaries, as Bree had assumed, but the product of some irritating, acidic, 'acrid matter' in the blood, which induced the rapid pulse and dyspepsia characteristic of early asthma as well as the paradigmatic shortness of breath. Although Lipscomb admitted that the mechanism by which acids produced irritation remained to be elucidated, he nevertheless insisted that the formation of acid in the blood constituted 'the real cause of asthma': 'If, then, a definition of Asthma be required, I have no objection to call it, an excessive contraction of the respiratory muscles, excited by the irritation of acid serum effused from the pulmonary vessels into the vesiculae and bronchia.' 1, pages 87-88) (2, page 86) 

In the year 1800 a review of Dr. Lipscomb's book appeared in the Monthly Review or Literary Journal:  (17, page 310)

This publication, notwithstanding its promise, contains merely an attack on Dr. Bree's Enquiry. Some of the observations may be just, but they are so minute as to assume a captious appearance; and the strictures on Dr. Bree's language are certainly conveyed with an unnecessary degree of severity. After our large account of the Doctor's work in the Review for May last, it is needless to repeat our opinion concerning the style and arrangement of it: but we, should not have expressed ourselves in the manner of Mr. Lipscomb. In p. 89, Mr. L. sneers at Dr. Bree's account of acid perspiration; but, if he will consult Dr. Wilson's book on febrile diseases on the subject of sediment in the urine, he will find ample proof of the fact. It is not indeed peculiar to asthma, nor to any morbid state of the body.  We are sorry to learn, from Mr. Lipscomb's preface, that he has enemies, who have succeeded in lessening his professional engagements. Lest we should be deemed desirous of adding to his uneasiness, we shall decline any farther examination of his criticisms. (17, page 310)

Another similar criticism occurred in the British Critic:

In his Preface, this author complains heavily of a combination of' persons or circumstances, which has occasioned him much uneasiness, and obliged him, as he seems to say, to quit his profession; hence leisure has been afforded him to examine Dr. Bree's book on Asthma, which he criticizes with a considerable degree of acuteness, and, we will add, of asperity too; although he positively disclaims bearing any ill will to the author, or even knowing him, he says, either as a gentleman or as a physician. The points however on which he disagrees with Dr. Bree, are principally speculative, and relate rather to the supposed cause, than to the mode of treating Asthma; and as it will never be demonstrably proved, whether the asthmatic paroxysm is occasioned by the'mere weight or bulk of the serum effused into the cellular termination of the bronchial vessels, as Dr. Bree seems to think; or by the acrid, or rather acid, quality of the aforesaid serum, as Mr. L. believes, the public will not think itself much interested in the dispute; we shall therefore dismiss this article, earnestly hoping, for the fake of Dr.Bree, as well as the author, that the cause of his present chagrin may cease, although we much doubt whether the production before us will at all contribute to that desirable end. (4, page 559-560) 

So you can see that Dr. Bree's arguments were rather strongly accepted by the medical community, and this was mainly because it was easier for the medical community to hang on to antiquated theories than science.  In fact, Dr. Bree was so well respected, little Lipscomb had to say would hold much sway.

However, this would change in 1819 when the stethoscope was invented, allowing physicians to hear constricted airways by a procedure called mediate auscultation.
References:

1. Jackson, Mark, "Asthma: A Biography," 
2. Griffiths, Ralph, editor, "The Monthly Review or Literary Journal, Enlarged: from May to August, inclusive, M,DCCC," 1800, Volume XXXII, London, Printed by A. Strahan for R. Griffiths, and sold by T. Becket, "Article 25: Observations on the history and cause of asthma; and a brief review of 'A practical enquiry on disordered respiration:' in a letter to Robert Bree, M.D., the author of that work. By George Lipscomb, surgeon, at Birmingham."
3. Lipscomb, George, "Observations on the History and Cause of Asthma," 1800, Birmingham
4. "The British Critic, for July, August, September, October, November, and December, MDCCC," Volume XVII, 1800, London, Printed by J. Rickaby, "Art. 26:  "Observation on the History and Cause of Asthma, and a Review of a Practical Enquiry on disordered Respiration, in a Letter to Robert Bree, M.D., the Author of that Work, By George Lipscomb, Surgeon at Birmingham
5. Urban Sylvanus, "The Gentleman's Magazine," January to June inclusive, volume XXVII, 1847, London, John Bowyer Nichol's and Son, "Obituary: George Lipscomb"

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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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1798: Bree's Symptoms of Asthma

The following are the symptoms of asthma as described by Robert Bree in his book "A Practical Inquiry into Disordered Respiration Distinguishing the Species of Convulsive Asthma, their Causes and Indication for a Cure."  It was written in 1810.

Note:  You must understand that Bree's undestanding of asthma was very puerile compared to our modern definition.  Much of his descriptions and theories on asthma are based on observation and personal experience with the disease as opposed to scientific facts.  However, some facts were available at this time and he used this information to support his opinions.  This was not uncommon for his day and age.

Anxiety:  Owing to the difficulty attending the efforts of nature to removing an irritating offense.

Itching of the skin of breast and neck:  This sometimes precedes the violence of the fit and declines as agony of the fit decreases. This may be an effect of sympathy with the lungs and first passages. Irritating matter in the stomach is the probable cause of this symptoms.  Another cause may be the difficulty to which venous blood is returned to the heart

Perception of heat:  You feel like you have a fever, but you don't.

Great desire of cool air:  Probably occassioned by a desire for oxygen, as you feel the means of obtaining it is increased by fresh air.

Closeness:  Areteaus wrote:  "The patient loves walking in the open air, with his mouth open, and is dissatisfied with the largest house, which seems to small to breathe in."

Dyspepsia:  (Upset stomach)  Always precedes periodic asthma.  This causes flatulence of the stomach and bowels and pain over the head and eyes and sleepiness.

The attack of the paraxysm in the night:  By concentrating, and by sacrificing sleep by staining up late and sitting in a recliner instead of the bed, this can often be avoided.

Diabetes:  By this I think he's referring to the need to pee a lot during an asthma attack. He says this is common, although it provides little relief to the asthmatic.  He gives a few reasons, none of which make any sense.  Such as in the case of hysteric asthma, he says the kidneys may be relaxed due to sudden passions of the mind.  He says the kidneys receive nerves from the intercostals, and there is likewise a strong association between the lungs, kidneys, and stomach.  May also be linked to edema, swelling of the ankles and legs.

The straightness of the breast:  He supposes that this makes it easier for the exchange of air when the air sacs are filled with secretions, which is often the case in asthma.  The rest of his several paragraphs describing this are simply meaningless poppycock.

Intermitting pulse:  John Floyer attriutes this to constriction of the arteries, by circumvolving nerves, may more probably proceed from this condition of the heart.  It may also be cauesd by dyspepsia because of the strong relationship between the stomach and the heart.

Spitting of black mucus:  He believes the coloring agent in the sputum to be carbon in the blood, which in the healthy person was exhaled

The pulse is generally feeble:

Urine is pale and copious:

Sleepiness:

Belly seldom regular:  Constiation may alternate with diarrhea, and may be attributed to dyspepsia (upset stomach). There is remarkable action of the abdominal muscles and all the muscles  used to discharge faeces.  And he flatters himself that evacuation of such will provide breathing relief.

The habit of the asthmatic is generally cold:  The temperature will be lower than normal.

The mind is impatient:  Not only does Bree write this as a symptom, he adds, "...and he suffers much from opposition to his method of management in his own case."  After several episodes of asthma he learns methods of comforting and satisfying himself, but help from others is often received with anxiety.  He becomes irritable during the fits, "and, with difficulty refrains his disposition to petulence."

Generosity:  Bree notes the following interesting fact:  "It may be observed generally as a fact, that the mind of an asthmatics is more susceptible of generous and grateful feelings than that of any other invalid, subject to a chronical disease equally obstinate."  Emphasis added by me.

Respirations more numerous during asthma attack:  They never exceed 30 without a considerable increase in pulse.  Bree recognized this is in general opposition to Floyer

References:

• Bree, Robert, "A Practical Inquiry into Disordered Respiration Distinguishing the Species of Convulsive Asthma, their Causes and Indication for a Cure," 1810, London, pages 117-140, Section IX

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1798: Bree's asthma remedies

Dr. Robert Bree was recognized as a predominant expert on asthma during the first half of the 19th century, as I wrote here.  In 1910 he wrote a book titled, "A Practical Inquiry into Disordered Respiration Distinguishing the Species of Convulsive Asthma, their Causes and Indication for a Cure."  The following are the remedies he recommends for asthma:

1.  Cathartics:  These are medicines or herbs that cause evacuation of the bowels, or purging.  Purging is the use of vomiting or laxitives to clear the stomach, according to dictionary.com.  For example, one patinet noted taking "10 grains of powder of jalap, and three grains of colomel when the fit commenced, which completely removed the fit, on many occasions by evacuating a load of bile."  Yet Bree wasn't a big fan of cathertics, and suggested that if this relieved the asthma the cause was something other thanas asthma.  However, he admits that cathertics to work for some asthmatics.

2.  Emetics:  These are medicines that induce vomiting, according to Dictionary.com.  Tartarized Antimony and Antimonial Wine or small doses of Ipecacohan can incuce vomiting.  Amid other things, they promote exhalation from the lungs and are therefore "powerful expectorants."

3.  Diaphoretics:  These are medicines that promote sweating, according to dictionary.com  He recommended "gentle diaphoresis, but not sweating."

4.  Bleeding:  This is where you cut a vein and allow blood to flow in an attempt to balance the humors.  He believes this has "doubtful effects" on asthmatics.  However, he does recommend it for most species of asthma.

5.  Diuretics: These are medicines that make you pee.  "Natron taken every night, in doses of eight grains, has been found to be very beneficial" for certain types of asthma.

6.  Issues:  These are medicines to treat mental or emotional problems, according to dictionary.com.  "In very old asthmatics, issues are sometimes necessary.  In younger subjects, when the disease is not yet inveterate, they may occasionally be useful, by diverting acqueous humour from the lungs, and giving a better opportunity for the operation of tonic remedies...  When the disease is complicated by dropsy (an old term for edema, according to dictionary.com), I have seen great advantage to the breathing, from from their application in the thighs."

7.  Antispasmotics:  These are medicines that relax smooth muscles, such as the muscles that wrap around the air passages in the lungs or that line the respiratory tract.  One common medicine is opium and it is enhance by the use of ether.  Calcined zinc has proven beneficial for epilepsy, although is not useful for asthma.  "Velerian, cardamine, camphor, musk, castor, belladonna, tobacco infusion, extract of  henbane, fetid gums, cuprum ammoniacle in various doses, more or less joined with the other antispasmotics, or tonic medicines, and combined with opium in large and small portions" helps sometimes but most often prolongs the paraoxym.

8.  Expectorants:  These are medicines that induce sputum production.  Ammoniac is a very valueable expectorant, although it should be given with opium to prevent purging (unless you want purging).  Squills are sometimes useful.  Squills also work when given with vinegar, similar to what John Floyer prescribed.  This is often called vinegar of squills.  A side effect is nausea and purging.  Tincture of squills combined with extract of henbane and the nitric acid is a good combination of expectorant and sedative.  Oxymell is efficatious if combined with vinegar or squill.  Honey and sugar are good for cough, but not so much for asthma.  Decoction of seneca can be useful in older persons, but is too irritating for younger people.  If asthma takes on the character of peripneumonia, decoction of seneca should be given with amonia during the febrile state, and when the fever goes away squill and camphorated tincture of opium will promote expectoration, perspiration, and urine.  All expectorants may cause nausea and vomiting, and this may be good in that it may remove the irritaing matter.  However, they also help relieve phlegm from the chest.

9.  Inhaling vapours:  "Hippocrates introduced the inhalation of vapours from various herbs and gums.  He used herbs and nitre boiled with vinegar and oil, and directed the vapour of such boiling compositions to be drawn into the lungs through a proper pipe."  Fumes can also be used to dry secretions that are known to cause asthma.  Frankincense, myrth, and many other gums, and these are occasionally mixed with arsenic.
Modern physicians recommended inhaling vapour of aether "raised in the steam of warm water."  However, aether can make asthma worse.  Vapour of hemlock leaves can be useful for some forms of asthma, and especially for it's narcotic qualities.

10.  Smoking tobacco:  Bree actually recommends asthmatics stop smoking "with great advantage to their health."

11.  Oxygen:  May benefit asthma when the color of the skin turns blue.  May help cease labored respirations.  It works expecially well for convulsive asthma.

12.  Hydrogen:  This has been proven to be beneficial to asthmatics, particularly spasmotic asthma.

13.  Stomachics:  "These remedies are absolutely necessary in asthma to correct dyspepsia (upset stomach), in whatever species of the disease it may appear.  Bitter tinctures are not to be used in the paroxysm, but bitter infusions and testaceous powders are generally beneficial.  Acetous acid is also grateful to the stomach when any bilious acrimony is present.  In this case "

14.  Diet:  Any food that is an exciting cause of asthma should be avoided.  Barley water and all weak liquors that are likely to ferment or relax the stomach should be avoided.  Infusion of coffee is good for any type of asthma except the second. "Pure cool water has frequently removed the bad effect of an imprudent meal.  If the asthmatic perceive his stomach to be disordered or uneasy, he may next expect more certain symptoms of a paroxysm.  In these circumstances I have experienced, very frequently, the advantage of repeated draughts of water, so that two or three pints have been taken in the whole, from the commencement of the uneasiness; and this has given perfect relief when coffee had failed."  It is wise not to eat more than the stomach can handle."  (page 204)

Note:  According to Bree, the above remedies vary in accordance to the species of asthma diagnosed by the doctor.  However, in order to simplify Bree's work I have left out which species of asthma the above remedies are for.  In either case, all of the above remedies were recommended for one or another species of asthma.  I did find Bree's writings to be quite complicated to understand, and I apologize if my interpretations of Bree's work isn't exactly as he understood.

References:

• Bree, Robert, "A Practical Inquiry into Disordered Respiration Distinguishing the Species of Convulsive Asthma, their Causes and Indication for a Cure," 1810, London, 4th ed., items 1-13 are obtained from pages 237-278, item 14 from page 292-294

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1790: Defending old asthma theories

Dr. Robert Bree (1790-1859), an English physician who had asthma, wrote a book about asthma in 1797 called "A Practical Inquiry into Disordered Respiration, distinguishing the Species of Convulsive Asthma, their Causes, and Indications of Cure." It would go on to become the most read asthma book of the first half of the 19th century.

Dr. Bree was an ardent proponent of the bronchitic theory of asthma, a theory that states asthma is caused by an increase of phlegm in the lungs. The theory is similar to those postulated by ancient physicians, such as Hippocrates and Galen.  In this way, he is one of the last known physicians to defend old asthma theories.

He believed that the treatment of asthma was relative to the cause. He said asthma was caused by inhaling a peccant matter, and was cured when the peccant matter was expectorated.  This explained why asthma always ended after a fit of coughing that produced a wad of phlegm.

In this way, he believed modern theories regarding diseases like asthma were often the subject of quackery.  By autopsies and experiments he performed, he attempted to prove men like William Cullen, who postulated that science was a wiser approach to medicine than ancient theories. He was also one of the first physicians to describe asthma as spasmotic and nervous. (3)

Proving Cullen wrong about asthma was the essence of Bree's 1797 book.  He said Cullen is wrong because no science proves the nervous or spasmotic theory of asthma, especially considering those two conditions cannot be seen on autopsy.

On the other hand, phlegm can be seen on autopsy. So, if anything, science supports the bronchitic theory of asthma and the theories of the ancients, more so than the ideas of Cullen.

However, Bree did not completely reject the spaspotic theory of asthma, he simply considered it as secondary to some other cause.  In reviewing the opinions of Dr. Bree in 1890, Ernest Schmiegelow said:

Bree does not actually deny the possibility of bronchial spasms taking some part in the cause of asthma, but it is only secondary; the primary cause is an exudation in the bronchial tubes, by which the lungs (specially the muscles of respiration) are stimulated to contraction, in order to expel the mucus which they contain. (4, pages 8-9)

In other words, Bree believed mucus was the cause of most diseases, including asthma.  He believed the contraction of the lungs was a defense mechanism to expel mucus from the lungs.

About 30 years after Bree published his book the stethoscope was invented, and as soon as it was used to listen to asthmatic lungs Dr. Bree's theory was disproved, said Schmiegelow.  He said that once the stethoscope gained favor, it was easy to prove that an attack of bronchitis does not precede an attack of asthma, and that rhales (a lung sound Laennec used to describe the sound of secretions in the lungs) are heard later during the attack.

While Bree waswell respected in his day, his ideas about asthma, and even most of his remedies, slowly gave way to science.  In this way, Despite Bree's noble efforts, his bronchitic theory of asthma eventually took a back seat to Cullen's nervous and spasmotic theories.

Regardless, all three theories would be debated over the course of the 19th century.

Continue the journey by clicking here.

References:

1. Pepper, William,  Louis Star, "A System of Practical Medicine," Volume 3, page 184
2. Berkart, J.B., "On Asthma: It's pathology and treatment," 1878, London,  Chapter II, "History of Asthma," page 12
3. Bree, Robert, "A Practical Inquiry into Disordered Respiration, distinguishing the Species of Convulsive Asthma, their Causes, and Indications of Cure, London, 1810.  I could not find the 1790 edition online, yet this one serves our purpose.
4. Schmiegelow, Ernest, "Asthma, considered specially in relation to nasal disease," 1890, London, page 4 
5. Jackson, Mark, "Asthma: The biography," 2009, London, pages 86-88 (If you're interested in a good asthma history book, this is it.)

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1698: Floyer's asthma symptoms, triggers, treatment

Floyer's A Treaties on Asthma (1698)

John Floyer's A Treaties on Asthma provides a neat description of asthma, which probably comes from his own experiences with the the disease.   (4, page 374)

He described himself as having periodic asthma, which is probably more in line with our modern definition of the disease.

About a century after the first edition of his book was published a fellow asthmatic and asthma physician by the name of Robert Bree would quote Floyer's description of an asthma attack as such:

"I have found, that by late sitting up I have put by the fit for a night or two; and I have found it commonly necessary to rise out of bed, especially in the summer time, and to sleep in a chair the first night of the fit.  Two nights before the fit asthmatics want sleep frequently." (2, pages 123-124)

Perhaps it's from his own experience that Floyer decided asthma into four parts, which are basically broken down as: (1)

1.  Symptoms:  A history of the fits or the asthmatic attack. It's generally based on his scientific description of bronchospasm: (1)

• The attack usually begins at one or two of the Clock in the Night
• The breath if very slow (early sign)
• Fullness of stomach (early sign)
• A slight headache (early sign)
• Sleepiness (early sign)
• Feeling rigid
• Feeling stiff
• Feeling inflated (head seems to be filled with Fumes or Serous Humour)
• Began to suck in breath
• Straitness of breath, seems to be for want of an easie Inspiration
• Urge to sit in an erect Posture, that the weight of the viscera may pull down the diaphragm
• Enlarging of the breast during inspiration
• Muscles of inspiration strive and labour more vehemtly
• Muscles of expiration cannot easily perform the Contraction of the Thorax, being hindered by the Stiffness or Inflation of the Membranes in the Thorax
• Expriation is easier than inspiration
• Expriation is very slow, and leisurely (and wheezing)
• The patient can not cough, sneeze, spit or speak freely
• The diaphragm cannot contract itself to move downward
• Bronchi and trachea has its membranes and nervous fibres contracted which results in wheezing (mainly expiratory)
• Muscular Fibres of the Bronchia and Vesiculae of the Lungs are contracted adn that produces the Wheezing noise, which is most observable on expiration
• Convulsive cough before fit (inconsiderable)
• Phlegm is spit up (inconsiderable) 

2. The nature of asthma as he saw it: Basically based on Galanic principles: (1)

• A flatulent slimy Caccochymia which is bred in the stomach, and creates inflation there, and gives an effervescence in the blood and an inflation in the membranes in the lungs
• At 2 a.m. the Chyle is more plentiful in the blood.. and the viscid Chyle and Lymph will not easily circulate through the lungs of the asthmatics
• The Asthma is a High, Slow, Rare and Laborious Respiration, which depends immediately on the inflation of the Membranes of the Lungs by Windy Spirits, rarefied or propelled through the Glands of the Brain, either by external Accidents or periodic Febrile Effervescence (bubbling) of the Blood. 

3.  Triggers: (Accidental causes) or lifestyle causes or factors that precipitate an asthma attack: (1)

• Great heats or cold
• violent motions of the body or mind
• Excess in eating and drinking
• Venereal Pleasures
• Heat of the bed
• Changes of the weather to rain
• Snow
• Change in weather from frost to thaw
• Alteration of clothes
• Changes of the air at spring and fall (change in barometric pressure)
• Moist air (dry air is good for the asthmatic)
• Heat and smoke of from fires
• Fumes
• Perfumes
• dust
• Strong liquors and food
• Exercise
• Anger (makes humours more viscid)
• Fear
• Shouting
• Excessive study (upset the spirits)
• Any strong smells (candles put out, Smoak of tobacco, winie fermenting, soap making, burnign metals, etc.)
• Sadness makes humours more viscid 

4.  Treatment: (The cure of the fit) and preventative measures.  These are probably things he tried out on himself: (1)

• Light diet (fasting on day of attack with a light diet thereafter)
• Gentle Exercise
• Bleeding (performed in small quantities, but only in extreme cases)
• Blisters (Applied to limbs and shoulders)
• Narcotics/ opiates (if induced by sleep 'when nerves are filled with windy spirits'/ induce sleep)
• Abstinance of anger or shouting
• Emetics (to induce vomiting/  if excessive may bring on asthma/ monthly vomiting recommended)
• Feather in throat (another option to promote expectoration of viscid sputum
• Oxymel of squills (to induce expectoration)
• Clysters (laxitives) or Purges (violent purging should be avoided, but regular purges are recommended)
• Late sitting up (staying up late)
• Avoid extreme climate changes
• Febrifuges and Sudorifics to help fevers that accompany the asthma
• Diuretics such as millipedes and woodlice
• Cold water bathing (4, page 110)
• Apple water (4, page 110)

References:

1. Floyers, John, "A Treaties on Asthma," 1698, London
2. Bree, Robert, "A Practical Inquiry into Disordered Respiration Distinguishing the Species of Convulsive Asthma, their Causes and Indication for a Cure," 1810, London, pages 123-124
3. Floyer, John, "History of cold water bathing," 1722, 5th edition, London, Printod form William and John, Innys, at West-end of St. Paul's Church-yard
4. Gill, M. H., "Review and Bibliographic Notices: "On the spasmotic asthma of adults," by Bergson, published Gill's book, "The Dublin Quarterly Journal of Medical Science," volume X, August and November, 1850, Dublin, Hodges and Smith, pages 373-388

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