1860: Salter proved nervous theory of asthma

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

He said:

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

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

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

 Further reading:

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

Click here for more asthma history.

References:

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

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1860: Salter: Why do young people outgrow asthma?

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

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

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

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

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

He answered his own question:

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

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

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

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

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

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

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

References:

• Salter, Henry Hyde, "On Asthma: It's Pathology and Treatment," 1882, New York, William Wood and Company, pages 135-142  (original publication of chapters in magazines during the 1850s. The articles were compiled and published as a book, the first edition of which was in 1860 in London)

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1860: Dr. Salter, the famous asthma doctor

Figure 1 -- Dr. Henry Hyde Salter.

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

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

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

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

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

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

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

From a photograph of an asthmatic, whose disease

dated from whooping-cough at three months old.

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

Dr. Salter.) (6, page 115)

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Further reading:

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

Click here for more asthma history.

References:

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

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1851: Reid and Bergson verify spasmotic theory of asthma

Figure 1 --

While Reid and Bergson argued that asthma was spasmotic,

Dr. Carl (Karl) Friedrich Canstatt (1807-1850), pictured here, 

was a pioneer of medicine in Germany who, in 1855,

 wrote that a differential diagnosis of asthma didn't matter 

because anti-spasmotics were equally beneficial for both diseases.

  He believed asthma was a "spasm of the breathing organs"

 as opposed to accepting the spasmotic theory of asthma. 

(1, page 32)(5, page 32)(6)

The next in a series of experiments that confirmed the spasmotic and nervous theories of asthma were performed by Dr. John Reid and Dr. Joseph Bergson. Reid performed the experiments, and later, in 1851, Bergson used these to make his argument to disprove the paralytic theory of asthma, and prove asthma was only spasmotic and nervous.

M.H. Gill, in an 1850 edition of the Dublin Quarterly Journal of Medical Science, said Bergson was a physician from Hamburg, Germany, and that he wrote a prize essay based on experiments he performed with Amedee Lefevre. (3, page 373)

Figure 2 --Bergson, among other physicians, believed signals sent
 from the brainvia the vagus to the lungs caused an asthma attack.
 You can see by this diagram that the vagus feeds the various organs
 of the body, including the heart and lungs. Vagi is singular for vagus nerve.
 The vagus is responsible for all the things your body does without
you having to think about them, such as your heart beating, your mouth
 salivating, your eyes blinking, your lungs inhaling and exhaling, etc. 

Of course at the time the two prevailing theories regarding asthma were the spasmotic and nervous theories, although another theory that was gaining steam was the paralytic theory of asthma, which basically stated that paralysis of the muscles of respiration, the muscles that make you breathe, resulted in emphysema. 

The theory, therefore, postulated that emphysema was also a part of asthma. Berkart, therefore, believed Reid's experiments proved this paralytic theory wrong.  

Of this, J.B. Berkart, in his 1878 book "On Asthma," said: 

Bergson, however, denied the existence of a paralytic asthma, because, according to the experiments of John Reid, section of both vagi (figure 2) produces no dyspnoea so long as the animals are at rest and the supply of air unlimited—a fact duly confirmed by the later experiments of Rosenthal. Bergson, therefore, admitted only the spasmodic form of the disease, consisting in paroxysmal constrictions of the bronchi and air-vesicles, in consequence of a morbid irritability of the vagus. (1, page 28)

Ernest Schmiegelow, in his 1890 book, said:

It was especially after the publication of Bergson's prize work that a decided separation was made between the idiopathic nervous asthma, characterized by its periodical attacks, which are separated by perfectly free intervals, and the numerous forms of difficulty in breathing, which appear purely symptomatic in many different complaints of the chest. To Bergson the idiopathic nervous asthma is an independent neurosis of the organs of the chest, whose origin is a cramp or spasm which like all other neuroses can be caused by a central or peripheral irritation of the nervous centre. (2, page 4)

Gill said Bergson described asthma this way:

Having detailed a number of experiments from various sources, as the result of which our author considers himself justified in the conclusion that the asthmatic fit consists in a spasmodic contraction of the bronchial and pulmonary air-cells, caused by the action of the par vagum on the muscular fibres in these structures, so that he thinks it may properly be termed spasmus bronchialis, he divides it into two kinds: the first proceeding from the brain (cerebral asthma), and the second from the spinal marrow (spinal asthma). (3, page 377) 

In other words, he believed, as with other asthma experts of his era, that asthma was both nervous and spasmotic; that irritation of the nervous center by various stimuli triggered the muscular fibers that wrap around the lungs to spasm, thus causing the various symptoms of asthma.

Further reading:

1. 1851: Bergson describes typical asthma attack (2/23/16)

References:

1. Berkart, J.B., "On Asthma: It's Pathology and Treatment," 1878, London, J. & A. Churchill
2. Schmiegelow, Ernest, "Asthma, considered specially in relation to nasal disease," 1890, London, H. K. Lewis; he references the following source; Bergson, Das krampf. Asthma der Erwaohsenen, Nordhausen, 1850.
3. 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
4. Freudenthal, Wolff, "Bronchial Asthma," New York Medical Journal: A Weekly Review of Medicine, edited by Edward Swift Dunster, James Bradbridge Hunter, Frank Pierce Foster, Charles Euchariste de Medicis Sajous, Gregory Stragnell, Henry J. Klaunberg, Félix Martí-Ibáñez, volume CV, January-June, 1917 (Saturday, January 6, 1917), New York, A.R. Elliot Publishing, Co., pages 1-5
5. Brown, Orville Harry, "Asthma, presenting an exposition of nonpassive expiration theory," 1917, St. Louis, C.V. Mosby Company
6. Karl Friedrich Canstatt,  "Images from the history of medicine," nlm.nih.gov, http://ihm.nlm.nih.gov/luna/servlet/view/all/what/Portraits?os=18800&res=2&printerFriendly=1, the photo is in the public domain, accessed, 3/10/14

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1848: Rudolf von Kolliker strengthens convulsive theory of asthma

Rudolf Albert von Kolliker (1817-1905) (5, page 489)

In the 18th century William Cullen believed muscle was a continuation of a nerve, and he used this as his proof that asthma was a nervous disorder.  In 1848, a Swiss histologist by the name of Rudolf Albert von
Kolliker proved Cullen's claim to be wrong.

Kolliker was born on July 6, 1817, in Zurich, Switzerland  He began his secondary education at the University of Zurich in 1836, and then the University of Bonn in 1838.  He later studied at the University of Berlin where he became a pupil of two great physicians by the names of Friedrich Gustav Jakob Henle and Johannes Muller.  From these men he learned about the microscope and microscopic anatomy.  (1, page 422)(2, page 194)(3)(4)

Friedrich Gustav Jakob Henle (1809-1885) was
one of Johannes Muller's pupils, one of his prosectors,
and later one of von Kolliker's professors.
 He became the greatest histologist of his time,
and one of the greatest anatomists of all time.
 (5, pages 483-486)(6)

He received his medical degree from Heidelberg in 1842, and became Henle's prosector in 1843 (that means that he prepared a dissection for demonstration). This set him up nicely to become professor of anatomy and physiology at Zurich in 1844.  In 1847 he became professor of anatomy and physiologyat Wuzburg, where he was offered an opportunity to specialize in microscopic anatomy, and where he spent the rest of his active life. (1, page 422)(2, page 194)(3)(4)

He was among the first physicians to study the microscopic structures of the body, and he proved that cells did not just form on their own, only by existing cells.  He also was the first to isolate and observe minute cells called smooth muscle cells (unstriated muscle cells), and advanced scientific knowledge of nerve cells, nerve fibers, and red blood cells. (1, page 422) (2, page 194)(3)(4)

Johannes Muller (1801-1858) was one
of the first physicians to use the microscope
to study the microscopic structures
of the body.  (5, pages 475-478)

Upon further inspection, he discovered that smooth muscle cells lined the bronchiolar air passages all the way down to bronchioles as small as 0.18 milimeters in diameter. (2, page 194)

By his study of such minute structures of the human body he became one of the fathers of histology, or the study of tissues.

His research helped strengthen the convulsive or spasmotic theory of asthma in that he confirmed both the studies of Franz Daniel Reisseissen, who proved muscular fibers wrap around the air passages, and J.B. Williams, who proved these fibers constrict when stimulated.

He resisted all offers to take him away from the "quiet academic life of the Bavarian town, where he died on the 2nd of November 1905. (4)

References:

1. Daintith, John, editor, "Biographical encyclopedia of scientists." 2009, 3rd edition, Florida, CRC Press
2. Geddings, W.H., author of the chapter on "Bronchial Asthma," in the book  "A System of Practical Medicine," edited by William Pepper and Louis Star,Volume 3, 1885, Philadelphia, Lea Brothers and Co.
3. "Rudolf Albert von Kolliker," britannica.com, http://www.britannica.com/EBchecked/topic/321429/Rudolf-Albert-von-Kolliker, accessed 4/4/14
4. "Rudolf Albert von Kolliker," 1911 Encyclopedia Britannica, http://www.studylight.org/enc/bri/view.cgi?n=28434&search=span, accessed 4/4/14
5. Garrison, Fielding Hudson, "An introduction to the history of medicine," 3rd edition, 1821, Philadelphia and London, W.B. Saunders Company
6. "Friedrich Gustav Jacob Henle," britannica.com, http://www.britannica.com/EBchecked/topic/261245/Friedrich-Gustav-Jacob-Henle, accessed 4/4/14

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1840: Dr. Williams proves spasmotic theory of asthma

Charles J. B. Williams (1805-1889)

Healthcare workers may recognize the name Dr. Charles James Blasius Williams because he was the first person to use the terms "lub-dub" to describe the sounds emitted by the two chambers of the beating heart.  This is what history best remembers him for.

While this fact is definitely important to our history, what we are mostly interested in is the fact that Dr. Williams was the first person to effectively prove the spasmotic theory of asthma by discovering that the muscular fibers that wrap around the air passages may spasm under certain conditions.

According to his own memoirs, Williams was the youngest of nine siblings. His mother was the eldest daughter of a respected surgeon, whose name was also Williams. She died shortly before her son Charles started college at Edinburgh University in 1820.

Despite Williams proof that the certain stimuli may cause the air
passages of the lungs to spasm, some physicians continued to
argue this in no way proved this had anything to do with asthma.
Other physicians, however, believed this proved nervous asthma
caused spasms of the air passages.  The above picture shows
how far science expounded upon the experiments of Williams
in the years between the publication of his work in 1840 and
the publication of Dr. Henry Hyde Salter's 1860 book,
Asthma: It's Pathology and Treatment." The caption under
the picture read: "Diagram showing the four ways in which the bronchial tubes may be narrowed.
1. Bronchial catarrh. 2. Recent bronchitis. 3. Old bronchitis 4. Asthma.  (6, page 39)

His father was Rev. David Williams, who came from an eminent family of many teachers and scholars. Along with being a Reverend, his father was also a successful tutor, having "prepared several gentle men for the university, who have since attained distinction as scholars." He educated his son at home until he was accepted at Edinburgh University in 1820, where he began his pursuit to become a physician. (1, page 1, 6, 9)

Williams credited his father with exposing him to subjects he wouldn't have been exposed to had he attended the public schools, subjects which would help him in his later endeavors, such as "Geography, History, Biography, Natural History, and above all, Natural Science." (1, pages 2-3)

Williams would have learned about Franz Reisseissen, who discovered in 1808 that muscular fibers wrap around the air passages of the lungs.  He would have learned about Rene Laennec, who believed Reisseissen's evidence was proof enough of both the spasmotic and nervous theories of asthma.

J.B. Berkart, in his 1878 book "On Asthma: It's Pathology and Treatment," said: (2, page 17)

Laennec assumed that they, being muscles, were endowed with contractility, and therefore liable to spasm. Such a spasm, he thought, might probably have been the cause of that fatal dyspnoea; but whether this supposition were correct or not, the case itself seemed to indicate the existence of a nervous asthma. Yet, notwithstanding the negative results of physical diagnosis and post mortem examination, he had doubts on the subject. Hesitatingly he admitted spasmodic asthma, with this limitation, however, that it generally consisted of nervous and organic affections combined.(2 page 17-18)

He would have been well aware of the evidence in support of the nervous theory of asthma, that asthma is a neurosis of the respiratory organs, that came from the papers of Francis Ramadge in 1835, the essays of Joseph Bergson and Amedee Lefevre in in 1836, and the verification of this evidence by the experiments of Moritz Romberg in 1841.   (4, page 506)

Williams must have been aware of these studies, and believed this evidence was too overwhelming not to support the nervous theory of asthma.

Yet other physicians did not believe this was enough evidence to support any theory, especially Dr. William Budd, who performed experiments in 1840 that he believed disproved the spasmotic theory AND the nervous theory of asthma.

Yet our doctor Williams would have something to say about Dr. Budd's experiments.  Dr. Williams would prove them wrong, and he did it that same year: in 1840.

Dr. Berkart explained:

As the bronchial contractility was denied as often as asserted, Dr. C. J. B. Williams again took the question in order to settle the matter in dispute. He, indeed, succeeded in showing, by experiments conducted with all necessary precautions, that mechanical, as well as chemical and electrical stimuli do produce contraction of the air-tubes. Thus the theory of a bronchial spasm obtained the support of experimental physiology. And even those who until then wavered in their opinions as to the possibility of such a spasm saw now no reason for doubting, but readily accepted that doctrine.  (2, page 26)

Still, while Reisseissen discovered that muscular fibers wrap around the air passages, and while Williams proved that they may spasm under certain circumstances, this did not prove that they spasmed during an asthma attack. (3, pages 193-194)

Berkart said:

Yet one link was wanted to complete the chain of evidence in favour of a bronchial spasm. As yet nothing was known of the innervation of the bronchi. Irritation of the vagus had produced no effect upon their calibres, and Dr. Williams was therefore led to conclude that "the muscular fibres seem not to be excitable through the nerves of the lungs."(2, page 26)

This evidence would also come in 1840 by the experiments of Dr. Francois Achille Longet.  

Williams was among the physicians of his era to support that idea that the definition of asthma was too vague, including too many ailments that cause symptoms similar to asthma yet have nothing to do with the lungs.  He therefore wanted to simplify the definition. 

Berkart said:

Dr. Williams himself, assuming a plus and minus state of contractility, described two forms of asthma—the one spasmodic, the other paralytic. The former was supposed to be represented by the isolated attacks of dyspnoea which generally accompany emphysema; the latter by those which appear in connection with chronic pituitous catarrh. (2, page 26)

Wolff Freudenthal, in his 1917 article in A Weekly Review of Medicine titled "Bronchial Asthma, said:

In 1841, Doctor (J. B.) Williams, in Tweedie’s Dissertations of Diseases of the Organs of Respiration, describes two forms of asthma—a spasmodic and an atonic or paralytic form. He found “that defect of these properties (excessive contractibility of the bronchial tubes) would disorder the process of breathing, and is led to believe that there may perhaps be a nervous asthmaor dyspnea “from weakness or paralysis of the circular fibres, or of the. nerves which regulate their contractions.” (5, page 2)

Williams was correct that asthma needed to be redefined, yet his most impressive contribution to the history of asthma was his experiment proving that the muscular fibers that wrap around the lungs may contract when irritated by certain stimuli.

Surely his experiment didn't prove the spasmotic thoery of asthma, yet it made this theory look highly probable.  His experiment met with little opposition for the next 14 years (Wintrich, 1854), and would be noted by nearly every physician writing on the subject of asthma for the rest of the century.   

References:

1. Williams, Charles J. B., "Memoirs of Life and Work," 1884, London, Smith, Elder, & Co. 
2. Berkart, J.B., "On Asthma: It's Pathology and Treatment," 1878, London, J. & A. Churchill
3. Geddings, W.H., author of the chapter on "Bronchial Asthma," in the book  "A System of Practical Medicine," edited by William Pepper and Louis Star,Volume 3, 1885, Philadelphia, Lea Brothers and Co.
4. Whitaker, James Thomas, "The theory and practice of medicine," 1893, New York, William Wood and Company
5. Freudenthal, Wolff, "Bronchial Asthma," New York Medical Journal: A Weekly Review of Medicine, edited by Edward Swift Dunster, James Bradbridge Hunter, Frank Pierce Foster, Charles Euchariste de Medicis Sajous, Gregory Stragnell, Henry J. Klaunberg, Félix Martí-Ibáñez, volume CV, January-June, 1917 (Saturday, January 6, 1917), New York, A.R. Elliot Publishing, Co., pages 1-5
6. Salter, Henry Hyde, "Asthma: It's Pathology and Treatment," 1864, Philadelphia, Blanchard and Lea

Further reading:

1. Geddings, W.H., author of the chapter on "Bronchial Asthma," in the book  "A System of Practical Medicine," edited by William Pepper and Louis Star,Volume 3, 1885, Philadelphia, Lea Brothers and Co.
2. Biermer, Anton., "On Bronchial Asthma," in the book, " Clinical Lectures on Subjects Connected with Medicine Connected with Medicine, Surgery, and Obstetrics," by various German authors, 1866, London, New Sydenham Society,  pages 171-194
3. Williams, Charles James Blasius, Alexander Tweedie, William Wood Gerhard, "Tweedies dissertations of diseases of the organs of respiration," 1841, London, Lea and Blanchard

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1818: Erasmus Darwin: The father of psychosomatic medicine

Erasmus Darwin (1718-1802) 

The man who created the theory of evolution was not Charles Darwin, believe it or not, it was his grandfather, Erasmus Darwin. Surely Charles made the theory famous, yet it was Erasmus who first proposed the idea through his poetry. Inspired by his grandfather's work, Darwin took this theory to new heights, thus forcing many scientists to accept it as fact.  

Yet Erasmus was more than just another Enlightenment mind who postulated a new theory, he was also a famous physician who wrote quite a bit about our disease asthma, and for these contributions we must include him here in this history. 

As was the case with most educated people in the during the course of the 18th century, Darwin (Erasmus, that is) pursued many of the things he was interested in, including medicine, poetry, philosophy, botany, and, of course, nature.  He made quite an impression regardless of which path he followed.  At times he even shared his theories about the world through his impressive poetic voice. (1)(5)

Darwin (again, we're talking about Erasmus here), was born in 1731 in Nottingham shire, England, the son of a lawyer. He attended St. John's College, Cambridge (where he studied natural science, and the University of Edinburgh (where he studied medicine).  In 1756 he opened a "flourishing medical practice" in Lichfield, Stafford shire.  (5)

While perhaps best known as the father of Charles Darwin, and for his revolutionary ideas about the beginnings of mankind, his greatest interests through the course of the majority of his life were medicine and invention. It was not until later in his life that he became interested in botany. (4)

As a naturalist he came up with one of the first theories of evolution, which he shared with the world in his 1808 book "The Temple of Nature," which was subtitled (and originally titled) "The origin of society.  This book was a compilation of theories he devised about the origin of mankind. Unlike other books of it's nature, it was written in prose. (1)(5)

He published a variety of other books, although it's "Zoonomia, or the laws of organic life," which was published in 1818, that we are interested in.  It was in this book that he categorized diseases with their treatment, and among these diseases was our disease: asthma. So it is on this book that we will focus our attention.  (5)

In volume I of the two part series, he gave a basic description of asthma.  He said:

Another disease, the periods of which generally commence during our sleep, is the asthma. Whatever may be the remote cause of paroxysms of asthma, the immediate cause of the convulsive respiration, whether in the common asthma, or in what is termed the convulsive asthma, which are perhaps only different degrees of the same disease, must be owing to violent voluntary exertions to relieve pain, as in other convulsions; and the increase of irritability to internal stimuli, or of sensibility, during sleep must occasion them to commence at I his time. (3, page 163-164)

In volume II Darwin described two kinds of asthma, which were summed up nicely by Samuel Hatch West in his 1902 book "Diseases of the organs of the chest:" :

• Convulsive asthma: Having the same characters as all other cramps and epilepsies, and originating, like them, from nearly all distant parts of the body.  
• Humoral or hydropic asthma: Temporary anascara (swelling, congestion) of (blood in) the lung (2, page 599)

Darwin also noted the causes of these two types:  

• Convulsive asthma: The bodies effort to relieve pain in remote parts of the system. The most common cause is pain of the liver or biliary ducts. Another common cause is pain caused when children are gaining teeth (this pain in some is relieved by sobbing or sobbing and screaming; but in others a laborious respiration.  It may also be caused by worms, or by acidity of the stomachs of children, and by other painful situations in adults, in whom it is generally called nervous asthma. (1, page 291-292)
• Humoral or hydropic asthma: Torpor (slowing way down) of the blood flow through the pulmonary vessels, like that which occurs on going into the cold bath.  This causes congestion of the blood in the pulmonary vessels. (4, page 291)

Darwin said that it's often difficult to distinguish between these two types, although the vigilant physician should be able to distinguish between the two by observing key symptoms: 

• Convulsive asthma:  The absence of sweat on the head and breast. Convulsions of the limbs, as is common in epilepsy.  These are efforts of the body to relieve pain. These patients are also more likely to run to the cold air for relief, and are more subject to cold extremities, and experience the return of it more frequently after their first sleep, as compared patients with humoral asthma. It is distinguished from peripneumony and croup in that these conditions presents with a fever, and it is distinguished from hydrops thoracis in that convulsive asthma is intermittent and hydrops is continuous. Hydrops patients also sit upright, and the breath is colder, and when the pericardium (heart) is affected, the pulse is quick and unequal.  (4, page 291-292)
• Humoral or hydropic asthma:  Copious sweating of the head and breast, swollen legs, and other signs of anascara.  These are caused by sensitive exertions of the pulmonary vessels to relieve the pain occassioned by the anascaroius congestion in the air cells.  (4, page 291)

Darwin said both convulsive and humoral asthma are "more liable to return in hot weather; which may be occasioned by the less quantity of oxygen existing in a given quantity of warm air, than of cold, which can be taken into the lungs at one inspiration. They are both most liable to occur after the first sleep, which is therefore a general criterion of asthma." 

His remedies for convulsive and humoral asthma are noted as follows: 

Venesection once. A cathartic with calomel once. Opium. Asafaztida. Warm bath. If the cause can be detected, as in toothing or worms, it should be removed. As this species of asthma is so liable to recur during sleep, like epileptic fits... there was reason to believe, that the respiration of an atmosphere mixed with hydrogen, or any other innocuous air, which might dilute the oxygen, would be useful in preventing the paroxysms by decreasing the sensibility of the system. This, I am informed by Dr. Beddoes, has been used with decided success by Dr. Ferriar.  (2, page 292-293)

As noted by West: 

He mentions a case in which asthma disapeared with the development of gout, and another in which the attack followed the retrocession of an eruption on the face. (2, page 599)(4, page 292)

Darwin also mentions a third type of asthma, which was referred to by Dr. Francis Hopkins Ramadge, in his 1835 book "Asthma, its species and complications" as Darwin's asthma.  Ramadge said this was nothing more than some exciting cause affecting the nerves, and interfering with the natural functions of the heart. (6, page 18)

Darwin described this type of asthma as follows: 

• Asthma dolorificum or Angina pectoris:  The painful asthma was first described by Dr. Heberden in the Transactions of the College; its principal symptoms consist in a pain about the middle of the sternum, or rather lower, on every increase of pulmonary or muscular exertion, as in walking faster than usual, or going quick up a hill, or even up stairs; with great difliculty of breathing, so as to occasion the patient instantly to stop. A pain in the arms about the insertion of the tendon of the pectoral muscle generally attends, and a desire of resting by hanging on a door or branch of a tree by the arms is sometimes observed. (4, page 293)

Darwin described the following case of asthma dolorificum or Angina pectoris: 

Mr. W , an elderly gentleman, was seized with asthma during the hot part of last summer; he always waked from his first sleep with diflicult respiration, and pain in the middle of his sternum, and after about an hour was enabled to sleep again. As this had returned for about a fortnight, it appeared to me to be an asthma complicated with the disease, which Dr. Heberden has called angina pectoris. It was treated by venesection, a cathartic, and then by a grain of opium given at going to bed, with ether and tincture of opium when the pain or asthma recurred, and lastly with the bark, but was several days before it was perfectly subdued. (4, page 193)

So it appears the treatment of all three types of asthma is relatively the same. However, he described four patients...

"...all of whom I believed to labour under the angina pectoris in a great degree; which have all recovered, and have continued well three or four years, by the use, as Ibelieve, of issues on the inside of each thigh; which were at first large enough to contain two peas each, and afterwards but one. They took besides some slight antimonial medicine for a while, and were reduced to half the quantity or strength of their usual potation of fermented liquor." (4, page 194)

Yet while these four were able to survive, most patient's diagnosed with asthma dolorificum or angina pectoris are so inclined to an early death.

This led me to conceive, that in this painful asthma the diaphragm, as well as the other muscles of respiration, was thrown into convulsive action, and that the libres ofthis muscle not having proper antagonists, a painful fixed spasm of it, like that of the muscles in the calf of the leg in the cramp, might be the cause of death in the angina pectoris, which I have thence arranged under the name of painful asthma, and leave for further investigation. (4, pages 193-194)

He said the reason issues sometimes worked for angina pectoris, and also for humoral asthma, was...

...perhaps the absorption of a small quantity of areated purulent matter, stimulate the whole system into greater energy of action and thus prevent the torpor which is the beginning of so many diseases. (4, page 194-195)

In other words, the pain from the issues counteracts the causative pain (whatever it may be) and also absorbs some of the congested fluid in the vessels in order to allow the blood to flow more freely.

So the remedies for asthma dolorificum or angina pectoris are as follows:

Issues in the thighs. Five grains of rhubarb, and one sixth of a grain of emetic tartar every night for some months, with or without half a grain of opium. No stronger liquor than small beer or wine diluted with twice its quantity of water. Since I wrote the above I have seen two cases of hydrops thoracis attended with pain in the left arm, so as to be mistaken for asthma dolorificum, in which femoral issues, though applied early in the disease, had no effect.

He added the following about the cause of asthma dolorificum or angina pectoris: 

The remote cause seems to have arisen from ossifications of the coronary arteries, and the immediate cause of his death from fixed spasm of the heart. (4, page 294)

To his credit he did say that "other histories and dissections are still required to put this matter out of doubt." He likewise surmised that the fact asthma dolorificum causes both spasms of the diaphragm and the heart may indicate that "these may constitute two distinct diseases."  (4,page 294)

Another interesting thing about Darwin's book is best summed up by the authors of Britannica.com:

Darwin endorsed active intervention with drugs and mechanical apparatus; some historians trace modern psychosomatic (emotional, mental, nervous) therapeutic approaches to his insistence on integrating mind and body. (5)

It is because of this that he is often referred to as the father of psychosomatic medicine.

As with other physicians of his era, he likewise perceived asthma as a  nervous disorder. He said:

The insensibility of the lungs to cold is observable on going into frosty air from a warm room; the hands and face become painfully cold, but no such sensation is excited in the lungs; which is another argument in favour of the existence of a peculiar set of nerves for the purpose of perceiving the universal fluid (4, page 290) 

That's pretty much all we need to know about Erasmus Darwin for the purposes of our asthma history.

Note:  Since the telling of any history is best told through the words of the original authors, you may read specifically what Darwin wrote about asthma by checking out my post: 1818: Erasmus Darwin defines asthma. 

References: 

1. "Erasmus Darwin", ucmp.berkley.edu, "http://www.ucmp.berkeley.edu/history/Edarwin.html, accessed 2/11/14
2. West, Samuel Hatch, "Diseases of the organs of respiration," volume II, 1902, London, Charles Griffin & Company, Limited , page 599
3. Darwin, Erasmus, "Zoonomia, or the laws of organic life," volume I, 1818, Philadelphia, Published by Edward Earle
4. Darwin, Erasmus, "Zoonomia, or the laws of organic life," volume II, 1818, Philadelphia, Published by Edward Earle
5. "Erasmus Darwin (British Physician," encyclopedia.com, http://www.britannica.com/EBchecked/topic/151960/Erasmus-Darwin, accessd 2/12/14
6. 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

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1808: Reisseissen discovers smooth muscles along air passages

Samuel Thomas von Sommering (1755-1830)
was a German physician and anatomist who,
confirmed Reisseissen's discovery. (6, page 4)

Dr. Franz Daniel Reisseissen (1773-1828) was a German physician who studied the lungs, and proved that smooth muscles line the air passages. This was a significant discovery, and set the stage for later physicians to prove the spasmotic theory of asthma.

He performed experiments in 1808, and the results were published as essays in Berlin in 1822.  (1, pages 196-197)

W.H. Geddings, in the 1885 edition of A System of Practical Medicine, said Reisseissen discovered...

...smooth muscle fibres of the bronchial tubes. These fibres are found not only in the large and medium-sized bronchi, but even in those of the smallest calibre."(2, page 185, 193)

Emanuel Aufrecht (1844-1903)
attended school in Berlin
and was a student of Ludwig Traub
and Rudolf Virchow.
He graduated from medical school in 1866.
He became a physician at
 Magdeburg-Alstadt City Hospital in 1868,
and physician in chief of Internal Medicine
at Magdeburg in 1879.
He worked out the arrangement
of the bronchial muscle fibres. (7, page 163)
While chief of clinical medicine at Magdeburg,
he published a book with his colleagues in 1902
called "Diseases of the Bronchi, Lungs and Pleura."
(8, title page)

Gedding said the discovery was "The first step toward a truly scientific theory of the pathology of asthma."

Without his discovery, none of the discoveries that readily proved asthma was spasmotic would have been possible, including those of Charles J.B. William and Francois Longett.

Rene Laennec, in his 1819 book "Mediate Auscultation" said there were various theories as to the structure of the lungs prior to Reisseissen's discovery.  For instance, Laennec said: (3, page 154)

(Marcello) Malpighi conceived that the air cells (later to become known as alveoli) were formed by the inner membrane of the bronchi being divided, previously to their termination, into cells like those of a sponge. Helvetius fancied that he had ascertained by direct experiment, that the air cells were formed by a simple cellular tissue, disposed without any regular order, and derived from the cellular envelopes of the various vessels by which the lungs are traversed. (Albrecht von) Haller entertained almost the same opinion, which is, indeed, that of the greater number of anatomists. (3, page 154)

M. Varnier confirmed Reisseissen's experiments
that the bronchi may constrict when stimulated.
He believed "irritating fluids or fumes forced
into the lungs caused contraction therof."
There were also various other physicians
who confirmed Reisseissen's experiment,
including: Prochaska, Gotfried, Reinhold,
Treviranus, and Wedemeyer
(6, page 4)(7, page 27)

The speculation ended when, according to Laennec, Reisseissen...

...by means of a great many microscopical observations and mercurial injections, has ascertained that the bronchi, at their extremities, are subdivided into a multitude of small canals, terminated by cul-de-sac of globular form, grouped somewhat in the manner of terminal branchlets of cauliflower. (3, page 154)

John Forbes quoted Reisseissen as saying...

... that, although it appears difficult to follow the muscular fibres further, analogy leads us to admit their existence in the smaller branches, and perhaps even in the aircells. (4, page 186)

Dr. J.B. Berkart, in the 1878 edition of his book "On Asthma: It's Pathology and Treatment, said that while Reisseissen was aware of muscular fibres surrounding the large and small air passages, their function remained a mystery to him. (5, page 17)

The significance of these muscular fibres has still not been determined as of this writing, as I explained in my post "Asthma: The Appendix of the Lungs.

However, the significance of their impact on asthma lead to a massive search that would last for the duration of the 19th century. The hunt was on to learn more about them and what they did. This task was begun by Charles J.B. Williams and Francois Longett.  Yet the debate would continue on for the duration of the century.

References:

1. Addison, Thomas, J.M. Bourgery, and George Rainey, "On the air cells of the lungs," The Edinburgh Medical and Surgical Journal, volume 69, 1848, pages 192-214
2. Geddings, W.H., author of the chapter on "Bronchial Asthma," in the book  "A System of Practical Medicine," edited by William Pepper and Louis Star,Volume 3, 1885, Philadelphia, Lea Brothers and Co.
3. Laennec, Rene Theophile Hyacinthe, "A treaties on the diseases of the chest, and on mediate auscultation," translated by John Forbes, 1838, New York, Philadelphia, Samuel S. and William Wood, Thomas Cowperthwaite and Company
4. Forbes, John, ed., "The Cyclopaedia of practical medicine," 1833, volume 1, page 186
5. Berkart, J.B., "On Asthma: It's pathology and treatment," 1878, London, J. & A. Churchill
6. Shmiegelow, Ernst, "Asthma, considered specially in relation to nasal disease," 1890, London, H.K. Lewis
7. Brown, Orville Harry, "Asthma, presenting an exposition of nonpassive expiration theory," 1917, St. Louis, C.V. Mosby Company
8. Hoffman, Friedrich Albin, Ottomar Rosenbach, Emanuel Aufrecht, writers, John H. Musser, editor, Alfred Stengel, translator, "Diseases of the Bronchi, Lungs and Pleura," 1902, Philadelphia, New York and London,asthma history, COPD history, inhalation therapy history, medical history W.B. Saunders and Company. 

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