The Nervous Theory Of Asthma: A Review

Earlier, I wrote that “Occupational Asthma” was “one of the oldest asthma subgroups.” I would like to make the case here that the oldest of oldest of oldest asthma subgroups is none other than “Nervous Asthma.” To help me make my case I thought a little history of nervous asthma would prove helpful. 

400 B.C. Hippocrates (400 B.C.) referred to asthma as epilepsy of the lungs. This is because he believed it was caused by phlegm draining down from the brain. He, therefore, believed asthma was caused by airway spasms similar to the body spasms of epilepsy. He also alluded to asthma as a nervous disorder when he said, "the asthmatic should guard himself against his own anger." 

1st Century. Galen (120-200 A.D.) is a physician who created theories about medicine that were well respected by physicians all the way up to the 19th century, and even into the 20th century. He performed one experiment (and probably on a stolen body) where he severed the spinal cord to produce asthma symptoms artificially. (1)

 
2nd Century.  Maimonides (1138-1204) said nervousness makes one prone to illness and may have been the first to describe how illness can contribute to diseases. He did describe asthma, but he did not link the two.

1550. Felix Platerus (1536-1614) observed asthma symptoms when nothing wrong could be seen with the lungs. He believed asthma was caused by an obstructed pulmonary artery, although he also believed it was caused fluid flowing down from the larger nerves from the brain.

17th century. Jean Baptiste van Helmont (1579-1644) was the first physician to focus on the idea that asthma was caused by airway spasms. However, he believed this was the result of nerve irritation due to stress. He thought this was the case because no scars were observed in the lungs of asthmatic patients. He gave examples of how stress could induce asthma. In one case he described how a woman developed it just by being exposed to flowers, and in a second case, he described how a man developed it and died just after being exposed to stress.

17th century.  Thomas Willis (1621-1675) also described asthma as having occurred despite any observable changes in the person. Paul Ammann (1634-1691) described in a book of law cases how asthmatics should be absolved from crimes because the fear that resulted could result in an asthmatic attack. This meant that all asthmatics must be kept out of stressful situations.

1850’s. Dr. Henry Hyde Salter published a series of articles that were eventually published in 1960 as “On Asthma: Its Pathology and Treatment.” In these articles, later published as chapters, he proved for the medical community that asthma was due to spasms of the air passages caused by irritation of nerves. Salter’s asthma theories are frequently cited in medical texts regarding asthma for the next 50 years. Those physicians who accepted Salter’s theories -- and this consisted of most physicians -- referred to Salter’s nervous theory as the “Nervous Theory of Asthma.”

1899. Dr. Henry Osler, the Father of Modern Medicine, referred to asthma as a "neurotic affection" in his medical texts, "The Principles And Practice Of Medicine." This book would be the main textbook used by medical students much of the next century, and so would have a significant impact on shaping the views of the medical profession.

1900. The discovery of epinephrine created a lot of buzz among the medical community, and it was trialed for a variety of diseases, including asthma. This worked to confirm an old theory, that asthma was due to airway spasms, and a new theory, that asthma was due to dilated blood vessels resulting in pulmonary congestion. These theories spawned from the fact that epinephrine both dilates airways and constricts blood vessels. So, for the first time in many years, the nervous theory becomes less significant among asthma physicians.

1910. This was the year that allergies were linked with asthma. This revelation would have no immediate impact on our history, but it will within the next 20 years. 

1920’s. German physicians became infatuated with psychosomatic medicine, and out of this infatuation grew an increasing interest in the idea that asthma was a psychosomatic disorder. Among these physicians was Dr. Franz Alexander, who will make a significant contribution to our history about 30 years later.

1930’s and 1940’s. Most American physicians continued to believe that asthma was triggered by emotions. However, their main emphasis now was attempting to control allergies. Also, as researchers started learning more about allergies, they realized that asthma symptoms were the result of an abnormal immune response to allergens. Spearheading the idea that allergies caused asthma was the germ theory of asthma. At this time it was believed that most diseases were caused by bacteria or some similar substance, so this theory sort of spearheaded the idea of allergies as a contributing cause of asthma. So, the nervous theory of asthma takes a back seat to this new thinking about asthma.

At the same time that was going on, German physicians, lead by Dr. Franz Alexander, were beginning to study the relationship between asthma and psychosomatic disorders like stress, anxiety, and depression. This sort of was a rebirth of the old theory of asthma as a nervous disorder. The main theme here was that strong emotions caused by an asthmatics separation, or threat of separation, from his mother were one of the main contributing causes of asthma. One treatment for this was psychological therapy. 

1951.  By now, Dr. Franz Alexander had migrated to the United States, and here he wrote a paper listing asthma as one of the seven psychosomatic disorders. This, in turn, re-established credibility of the nervous theory of asthma for physicians in the developed world. This was also the decade that corticosteroids were first used to reduce airway inflammation that was present during acute asthma attacks.

1957. The first metered dose inhalers enter the market. They were the Medihaler Epi and the Medihaler Iso. This was a great revelation for asthmatics as it gave them a lightweight, portable, and easy to use means for obtaining quick asthma relief.

1960s.   It was also discovered that corticosteroids come with side effects. So, by the end of the 1950's, steroids were soon reserved for only the severest asthma attacks that responded poorly to other treatments. However, researchers began a quest to see if they could develop an inhaled corticosteroid steroid to reduce the risks for systemic side effects. So, this was the decade where researchers started studying the benefits of inhaled corticosteroids on asthma.

1980’s.  By 1982 two inhaled corticosteroids were on the market. Studies showed they seemed to work very well for asthmatics. Research to learn how they worked lead to the discovery that asthma was an inflammatory disorder, where all asthmatics have some degree of underlying airway inflammation. It was now well accepted that asthma symptoms occurred due to exposure to asthma triggers, which may include strong emotions and stress, but also allergens, respiratory viruses, certain foods, exercise, etc. Researchers now understood that asthma was a respiratory disease consisting of chronic underlying airway inflammation and that this inflammation worsened when exposed to asthma triggers resulting in bronchospasm, increased mucus production, and asthma symptoms. This spearheaded the quest to understanding the exact genes, cells, and biological processes responsible for asthma. Rather than focusing on asthma as a nervous disorder, asthma was considered a disease associated with an overactive immune response to innocuous substances in the air inhaled. So, this new theory set aside any notions of asthma as a nervous disorder caused by stress, anxiety, and depression. That said, nervous disorders were still thought contribute to asthma by triggering it, maybe even making it worse, but it was no longer suspected to be the causative agent. 

1990’s. You might hear things like: “While stress and anxiety are no longer thought to cause asthma, both may act as asthma triggers.” I'm not sure who came up with this line, but I have heard it over and over by various asthma experts, often without citation. This may have acted as a relief, of sorts, for asthmatics, who were tired of hearing about asthma being all in their heads. However, it offered no advantage to the many asthmatics who continued to deal with both anxiety and asthma. 

2017. Modern evidence has brought upon a resurgence, of sorts, of the nervous theory of asthma. Studies seem to show that asthma might contribute to anxiety and depressive disorders, and that anxiety and depressive disorders might contribute to asthma. This new evidence comes with a modern twist, which includes the idea that not all asthma is nervous in origin. However, knowledge of a possible link should make physicians better armed to both diagnose and treat anxiety and depressive disorders in asthmatics in an effort to help them obtain ideal asthma control.http://asthmahistory.blogspot.com/2017/03/1950-alexander-defines-asthma-as-one-of.html

1899: Is asthma simply a "Nerve Storm?"

Nerve Storm: Seizure, as in seizure of the entire body (epilepsy), seizure of the muscles of a certain joint (gout) or seizure of the respiratory bronchi (asthma). The seizure is caused by some imbalance either internal (emotion) or external that triggers the abnormal response of the brain.

I've read about asthma being described this way in many older journals, yet Dr. Joe Shoemaker, in his 1899 book, "The Monthly Encyclopedia of Practical Medicine" (Philadelphia, Vol. XIII), uses this term with force.

He further describes asthma as:

• A disease essentially due to some nervous change (this was the accepted dogma of the time)
• Partial hereditary (so we still think this)
• It's occurrence is largely in "neurotic" subjects
• It's occurrence in families subject to migraine (hmmm, where does this come from?)
• Attacks are characteristic of asthma (dyspnea due to bronchospasm)
• Pt inclined to hold to a chair or bed railing firmly to help expiratory muscles of expiration
• And all this is caused by a "nervous storm"
• Triggered by some unknown cause
• The cause of who has such a "nervous change" also remains a mystery
• It's seen in children and some adults
• It's rare
• Sudden in onset
• Occurs between 2-4 a.m. (remember, this is based on his observations)
• Accessory and natural muscles of respiration are contracting vigorously
• Dusky face shows embarrassment to circulation and deficient oxygen in the blood
• Sweating skin shows muscular exertion
• Lungs enlarged during paroxysm
• Yet auscultation shows little to no air entering them
• No normal respiratory murmur, instead expiratory whistle is heard upon austultation
• Sonorous rhonchi often heard (which is what we now call a wheeze)
• Duration of attack is variable, yet is often over by morning
• Duration may last 24 hours or longer
• Attack ends with expulsion of mucus
• No continued cough or expectoration

This is all part of the nervous storm we call asthma. What do you think?

1878-1885: Asthma no longer a confused term

By introducing the art of percussion to his medical practice, Jean Corvisant realized that many cases of asthma were actually diseases of other organs.  When his student, Rene Laennec, introduced percussion with auscultation to his practice, he quickly observed that asthma was truly an abused term.

These are the two 19th century asthma experts we can thank for giving us the tools necessary for differentiating asthma from other diseases and diagnosing it as a disease.  In other words, prior to the 1820s anything that caused dyspnea was regarded as asthma, and after the 1820s asthma was more carefully diagnosed.

It is by these discoveries that asthma is divided into different categories, each of which ultimately became disease entities of their own:

• Cardiac Asthma: Dyspnea due to heart disease is now heart failure 
• Kidney Asthma: Dyspnea due to kidney disease, now known as kidney failure
• Bronchitic asthma: Dyspnea due to chronically inflamed air passages and excessive sputum production, now known as chronic bronchitis

William Pepper and Louis Star published a book in 1885 called "A System of Practical Medicine.  In the opening pages they explain the following: 

Ignorant to a great extent of pathological anatomy and unprovided with the improved methods of physical diagnosis which we now possess, they (previous asthma writers) described as asthma not only the dyspnoea due to cardiac and pulmonary diseases, but also that occasioned by affections of the pleura and greater vessels. Covering such an extensive range of territory, it was found necessary to subdivide the disease into a number of varieties, each author classifying them according to his conception of the cause, seat, and nature of the trouble. Some of these—e. g. a. dyspeptic-urn—still find a place in medical literature, but the vast majority of them, having ceased to be of any practical significance, have been discarded, and are now only interesting as examples of the crude and fanciful notions which prevailed in an age during which science rather retrograded than advanced. Of the writers of this period, Willis in the seventeenth century is especially worthy of notice as being the first to describe the nervous character of asthma. Without discarding the accepted forms of the disease, he mentions another variety, characterized by spasmodic action of the muscles of the chest, to which he gave the name asthma convulsivum. The improvement in physical diagnosis resulting from the brilliant discoveries of Auenbrugger (percussion) and Laennec (stethoscope) greatly curtailed the domain of asthma with the aid of auscultation (use of stethoscope to hear lung sounds) and percussion it was discovered that most of the cases hitherto regarded as asthma were only symptoms of some organic disease.  (1, page 184)

J.B. Berkart, in his 1878 book "On Asthma: It's pathology and treatment," wrote the following:

ALL early historical traces of the affection at present called asthma are lost. Although the disease is said to be mentioned in the Bible, and described by Hippocrates, Areteaus, Galen, and Celsus, there is not the least evidence that those remarks apply to the asthma of to-day. For in the former systems of medicine, all cases presenting the same conspicuous symptoms were, regardless of their anatomical differences, considered as of a kindred nature, and grouped into classes according to imaginary types. (2, page 12)

I know these quotes are almost trivial, yet I find it interesting because these physicians, in this era, were privy to the idea that they were taking part in the rapid evolution of the definition of the disease they were studying -- asthma. Or, more accurately, they were seeing the evolution of differential diagnosis of the various disease processes that often result in dyspnea.

In essence, Laennec's discovery sparks a leap through time.  Where 7,000 years of asthma suffering resulted in little progress in the way of asthma wisdom and treatment, the next 81 years -- part of which we are now observing -- provides for asthmatics more than all those 7,000 years combined. I think that Pepper and Star and Berkart and most other authors of pulmonary diseases in this era were well aware that this was happening.

And we learn that between 1816 and 1900 many different theories about what causes asthma are created, and every one of these theories has followers.  Each expert wrote his own definition of asthma based on his beliefs about the disease, and his own experiments and observations, and his own remedies based on these beliefs."

By the various proofs, by the various debates, that transpired during the 19th century about the disease we call asthma, and of other related diseases, it resulted in a significant fine tuning the definition of asthma.  Yet in the end, the two theories that won the day were:

1. Spasmotic theory of asthma (a.k.a. bronchospasm or convulsive): There was evidence to support it
2. Nervous theory of asthma (a.k.a. it's all in your head): There was no evidence to disprove it.

Or, more commonly, that these two theories of asthma were intertwined, such that some mysterious event or object (such as a certain food, a full stomach, laughter, strong emotion, excitement, dust, or cat) excites the nervous system, which in turn sends a message to the bronchial muscles to contract.

By the end of the 19th century the ground was set for an even bigger leap through time as far as asthmatics are concerned.  By 1899 adrenaline was isolated, and this sets off a wave of wisdom that greatly improves the lives of asthmatics. Yet for the time being (no pun intended), we find ourselves drifting from cozy doctor's 

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

1878: Thorowgood supports Salter's asthma theories

Dr. John Charles Thorowgood wrote a book called "Notes on Asthma" that went through a variety of editions.  Probably due to a wave of new evidence learned about the disease, the later editions were called "Asthma and Chronic Bronchitis, which sheds light for historians on the evidence clearly separating these two diseases.

Thorowgood's basic description of asthma is not far removed from the theories postulated by Dr. Henry Hyde Salter, that: (1, page 1-2)(2, page 16)

1. The main component of an asthma attack is spasms of the unstriped contractible fibres (bronchial muscles) that wrap around the bronchi that results in narrowing of these air passages
2. That the main cause of such spasming is due to a nervous disorder, as can be confirmed by autopsy when an asthmatic dies: no lung scarring can be found.  This lack of any evidence of disease clearly indicates asthma is nervous in origin.  There are two routes the nerves can cause asthma:
• Central Nervous System: Some exciting cause, probably emotional, triggers the asthmatic response, and causes narrowed air passages. 
• Reflex Action: Something stimulates the vagus nerve or pneumogastric nerve, such as overeating, forced expiration (coughing or laughing)

He also agrees with other physicians of his era, Salter included, when he writes the following: (1, page 2)(2, page 16)

During the intervals between his attacks the patient probably enjoys fair health, and, as a rule, lives to a good age; should he, however, be cut off prematurely by death, what do we find as the morbid anatomy to explain the wellmarked symptoms seen during life?

In other words, he believes that pure asthma is intermittent in nature, allows the patient to live a relatively normal life between attacks, and that asthma rarely causes death.  In the rare cases asthma does cause death, the asthma is not pure: it is associated with some type of morbid condition such as chronic bronchitis or heart failure.

He describes an attack this way: (1, page 2)(2, page 16)

He defines asthma as 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." 

He likewise agrees with Salter that while pure asthma may present with no structural changes, that after years of repeated and violent attacks, "cannot but lead to some alteration of tissue, and the microscope will probably show some granular or fatty degeneration in the air cells of the lungs, though to the naked eye appearances may be normal." (1, page 3)(2, page 17)

So in the rare event someone does die from asthma, it will be due to some form of organic changes that take place after years of asthma attacks.  Either that, or it was some organic change, such as occurs with chronic bronchitis and heart failure, caused the asthma and ultimately lead to that person's death.  (2, page 17-18)

These are things that both Salter and Thorowgood agree upon.

References:

1. Thorowgood, John C., "Notes on Asthma," 1878, 3rd edition, London, J & A Churchill
2. Thorowgood, John C., "Asthma and Chronic Bronchitis: A New Edition of Notes on Asthma and Bronchial Asthma," 1894, London, Bailliere, Tyndall, & Cox

1951: Alexander defines asthma as one of seven psychosomatic disorders

The idea of asthma as a nervous disorder is an age old concept that was postulated by various physicians over the years. This "nervous theory of asthma," or asthma nervosa, as it was so often called, gained momentum among leading physicians. This idea became deeply embedded in the minds of asthma physicians in the 1850s when a famous asthma doctor by the name of Dr. Henry Hyde Salter wrote on the subject.

The idea seemed to wane somewhat in favor of other theories at the turn of the 20th century, only to gradually begin its comeback in the 1930s after a famous German psychoanalyst by the name of Franz Alexander began talking about asthma as a psychosomatic disorder.

According to dictionary.com, psych is a Greek root for the mind and somatic means of the body or physical. Psychosomatic medicine, therefore, is the study of physical conditions that are thought to be caused by strong emotions of the mind, such as anxiety, stress, and depression.

In 1920, Hans Alexander (originally from Hungary) became the first student at the Berlin Psychoanalytic Institute, an organization whose goals were to train psychoanalysts, offer psychoanalytical treatment for those suffering from neurosis (manic depressive illness), and to conduct research on the subject. Their ultimate goal was to continue the great works of Dr. Sigmund Freud (1856-1939). (1, Alexander.)

As a quick side note, Sigmund Freud started the study of psychoanalysis around the turn of the 20th century. This involved a patient lying on a couch and talking freely about whatever comes to mind, while the therapist analyzes what the patient says. Freud was infatuated with sexual desires, and he believed males had an inert sexual desire for their mothers. Perhaps out of this is where Alexander derived some of his ideas about asthma.

Alexander and his psychoanalyst colleagues became infatuated with psychosomatic disorders. Among their works was to inspire an uptick in the idea that asthma was a nervous condition. It was here that the idea of asthma as a "suppressed cry for the mother" was born. 

This research was lead by Alexander, who "advanced the hypothesis that bronchial asthma might result, in part, from a threat of detachment from the mother." (1, Alexander)

Dr. Alexander, along with many of his colleagues, migrated to the United States. (1, Alexander) (3, page 771) He moved to Chicago where he set up a psychoanalytic workshop similar to what he left behind in Germany. His work here would inspired interest in psychosomatic medicine in the United States, including the of asthma as a psychological disorder. (1, Alexander.) 

By the 1930s and 40s, the idea that asthma was an allergic disorder was another theory that heavily influenced physicians at this time. While most physicians believed asthma was triggered by emotions, the majority of their efforts in the clinical setting were aimed at gaining control of allergies. (8, page ?)

The psychosomatic theory, combined with the allergic theory, was what ultimately lead the idea of parentectomy during the 1940s. This was an idea of abducting asthmatic children from their homes (with the permission of their doctors and parents) and placing them in asthma institutions, such as the one in Denver, Colorado. 

In 1950, Alexander would list what he considered to be the seven psychosomatic disorders: (2, page 771)

1. Psychosocial dwarfism (sometimes known as Grave's disease, hyperthyroidism)
2. Ulcerative colitis
3. Hypertension (high blood pressure)
4. Peptic ulcer
5. Dermatitis
6. Eczema
7. Asthma

Alexander essentially believed that, along with actual organic (of the body) processes, these disorders may also be caused, or exacerbated, by strong emotions such as anxiety and stress. (8, page 222-223)

He essentially noted that few people with these seven disorders (or very few asthmatics) received "psychoanalytic therapy." Because of this fact, he was unable to describe the benefits of this type of therapy on any of these disorders, including asthma. (6, page 222-223)

This psychosomatic view of asthma became well accepted among the medical profession. And, as we have observed throughout this history, once something becomes embedded in the mind's of physicians, it's difficult to extricate it out of their heads. It's just the way people are. It's just the way the medical profession is.

In 1968, Alexander linked the seven disorders with a personality conflict. For instance, asthma was a constant yearning for the mother or the fear of losing the mother. Wheezing was a sign that this person was having this conflict. The treatment was 

I think that Gregory K. Fritz describes it best. He said: 

I was a general psychiatry resident in 1974 and new to the psychiatric consultation service at a large public hospital. As I was preparing to do one of my first consultations, my attending, in an effort to be helpful, said, "You're in luck: An asthmatic patient. Asthma is a psychosomatic illness." He went on to describe the intrapsychic conflict that was said to be the psychological cause of asthma (a hostile/ dependent relationship between mother and child; the wheeze was a suppressed cry for nurturance.) I remember being both relieved and skeptical that such rote theory would make my job as a psychiatric consultant so simple."  (7, page xix)

Dr. Fritz said he went on to spent the next 30 years as an adolescent psychiatrist at various children's hospitals and as a researcher for pediatric illness. He explained how the next 30 years saw major advances in the relationship between the mind and the body. This would include asthma.

References:

1. Alexander,  Ilonka Venier, ""The Life And Times Of Hans Alexander: From Budapest To Alexander,"2015, Karnac, Great Britain
2. "Psychosomatic." Dictionary.com. http://www.dictionary.com/browse/somatic. accessed 3/19/17
3. Craighead, Edward W., Charles B. Nemeroff, editors, "The Concise Corsini Encyclopedia of Psychology and Behavioral Science," 3rd edition, 2004, Wiley, page 771
4. "Franz Alexander. Britannica.com, https://www.britannica.com/biography/Franz-Alexander#ref838920, accessed 3/19/17
5. Alexander, Franz, "Psychosomatic Medicine: It's Principles and Applications," 1951, Pediatrics, volume 8, issue 6, 
6. "Book Review. Psychosomatic Medicine: It's Principles and Applications," California Medicine, 1951, March, 74 (3): pages 222-223
7. Shaw, Richard J., David R. DeMaso, editors, "Textbook of Pediatric Psychosomatic Medicine," 2010, American Psychiatric Publishing, page xix
8. Jackson, Mark, "Health and Modern Home," 2007, Routledge

1870: Bert's experiments help anyone with respiratory ailments

Paul Bert (1833-1886)

"It can be said of Paul Bert as it has been of Vesalius, Harvey and Boyle, that the full significance of his work could not be fully appreciated until long after his death." (8, page v)

This was a quote from John F. Fulton, who wrote the forward to the 1843 edition of Paul Bert's book "Barometric Pressure."

Bert's experiments would have a broad and lasting impact on surgery, aviation, mountain climbing, deep sea excursions, mining, pressure breathing machines, and even the definition of asthma.

He was born in Auxerre, France, on October 17, 1833, attended school in Paris, and received his medical degree in 1863. (2)(8, page V)

Fulton said that while in Paris he was assistant to Dr. Claude Bernard in his laboratory. Fulton said "Bernard recognized his ingenious mind and predicted a brilliant future." (8, page VI)

Denis Jourdanet (1815-1892)

His thesis on grafting of animal tissue gained him public acclaim, and this helped him to quickly earn fame in the medical community. (2)(8, page VI)

Animal grafting, and later skin grafting, was "an operation consisting of the removal of a living part and transplanting it so that it shall continue to live on another part of the same individual or on another individual," said the authors of an 1888 biography of Dr. Bert in Popular Science Monthly.(2)(8, page V)

In 1865, the Academy of Sciences awarded him a prize in experimental physiology for his work on animal grafting and skin grafting.  This work was significant because it allowed physicians to perform plastic surgery on soldiers injured during the war of 1870.  (2)(5, page ?)(8, page V-VI)

In 1867 he was appointed to a chair in the Faculty of Sciences at Bordeaux where he taught zoology. Then he became Bernard's successor in December of 1869 when he was named Professor of Physiology at the Faculty of Sciences in Paris. (2)(8, page VI)(13, page 599)

In 1870 Bert became interested in respiratory disorders, such as asthma, chronic bronchitis, and emphysema.  He performed experiments to learn more about these diseases, and to find methods of helping people suffering from them.   (1, page 194)(8, page VII)

In 1854 Alton Wintrich performed experiments that seemed to disprove the spasmotic theory of asthma in favor of the diaphragmatic theory of asthma. For 16 years Wintrich gained many followers. But Bert aimed to prove him wrong.

In 1870 Bert attempted, with improved methods of scientific research compared to that used by Williams and Longet, to stimulate the vagi of dogs. As he expected, this indeed produced dyspnea. His experiment reaffirmed for the medical community the spasmotic theory of asthma. (10, page 10)(11, page 37)(12, pages 5-6)(13, page 16)(14, page 599)

According to W.H. Geddings in 1885, along with demonstrating that respiration could be "arrested by irritation of the pneumogastri (vagi)," it could also be arrested by irritation of the "laryngeal nerves or the Schneiderian membrane of the nose (membrane lining the maxillary sinus cavity)." (1, page 194)

In 1855, Ludwig Traube came to a similar conclusion.

Bert's experiment was important because it prevented physicians from spending what minimal time and money was dedicated to asthma form being wasted on areas that were already disproved.

Around this time, said Fulton, a friend of his, Dr. Denis Jourdanet, had just returned from an excursion to Mexico where he had spent time in the mountains at great heights and suffered mountain sickness. The two decided that Bert should dedicate his time performing experiments on the effects of pressure on plants, animals and humans. Jourdanet was a wealthy man, and he offered to provide any funds that Bert needed. (8, page VII)

Bert's first experiment was performed on April 15, 1874. He sent three balloon enthusiasts and equipment in a hot air balloon called Zenith. The mission was to collect data from the the upper atmosphere. Another goal, however, was to exceed 24,000 feet, which was the height accomplished by an English balloonist named Glaisher in 1862.

At 26,000 feet all of the men were unconscious. Upon the Zenith's return to the earth, two of the men had perished, and the third was insensible. Bert hypothesized the reason was due to lack of oxygen to the brain (2)(5, page 112)(8, page VII)

This was a set back for Bert in which none of the equipment, and obviously none of the men, were able to function at that height due to cold and rarified air. Most of the equipment was also damaged in the efforts made to get the balloon back down to earth, so no data could have been obtained anyway. (2)(5, page 112)(8, page VII)

While this was a set back, it did not keep him from marching forward. Instead of using humans to perform his studies from here on our, he did them in his laboratory using small animals. Only when perfected his experiments did he resort to using humans. (2)(5, page 112)(8, page VII)

The first order of business for Bert was to invent a device for measuring pressure and put together compression chambers. He used a smaller compression chamber for small animals, and a larger one for himself and his friends. (see figures)(2)(8, page VI)

In a laboratory experiment Bert placed a sparrow in the compression chamber made of pneumatic glass bells and exposed it to low pressures. When it started to suffer he administered oxygen, at which point the bird "at once became himself again." Upon this success, he performed the same experiment on himself, and he observed at higher pressures that his heart would beat faster and he'd have palpitations. At one point he wanted to write in his tablet, but could not. When he inhaled oxygen these symptoms went away. (7)

By these experiments he concluded that the lower the atmospheric pressure (as what would occur with high altitudes) results in oxygen tensions in the air and blood too low to support life. Instead of inhaling 21% oxygen which is present in normal room air, he was inhaling a lower percentage of oxygen.  (7)

High altitudes, or high atmospheric pressures, subject humans to the risk of suffocation or asphyxia. Early symptoms are increased heart rate,weakness, malaise, nausea, and vomiting. The colder the air the earlier these symptoms appear. For instance, the symptoms appear earlier in earlier in the Alps than in the Himalaya, Bert said. (7)

The remedy here would be "the respiration of an air sufficiently rich in oxygen to maintain the tension of that gas at its normal value." (2)

In another laboratory experiment Bert placed a sparrow in the compression chamber made of pneumatic glass bells and exposed it to high pressures (compression). He then decompressed the bird rapidly to atmospheric pressure, at which time the bird suddenly died. Upon inspection of the body he found air bubbles in the arteries and heart. The same effect resulted during similar experiments performed with rats and small dogs. (5, page 115)

Robert Boyl had observed bubbles in the eyes of a snake he placed in a compression tank he invented, although no further investigations were made at that time into the nature or cause of the bubbles. Bert, however, benefited from improved laboratory equipment. (5, page 116)

Bert concluded that higher atmospheric pressures (as what would occur as one travels deeper under water) result in increased oxygen tensions in the air and blood. The remedy here would be avoidance of too high a pressure (such as greater than 5-6 atmospheres), and gradual decompression back to atmospheric pressure (1 atmosphere). (2)

He observed that the effects of high pressures may kill not only humans and animals, but plants too.  (2)

While the significance of this work may not have been immediately known, the value of it was immediately recognized by the scientific community.  For this work the Academy of Sciences awarded him a prize of twenty thousand francs. (2)

His experiments would have an impact in many areas of science and medicine.

His conclusions about the effects of diminished pressure resulted in equipment, such as oxygen tanks and masks, that made aviation possible.  For this reason, he is often referred to as the father of aviation medicine.

Improved methods of storing and delivering oxygen was also thought to benefit people with respiratory disorders, and so research was eventually done in this regard, some of it by Bert himself.

His conclusions about the effects of increased pressure resulted in better knowledge of decompression sickness or bends. It occurs when a person moves from deep water (where the pressure is higher) to the surface (where the pressure is lower) too fast. This causes bubbles to escape into the blood and tissues, and can cause symptoms such as headache, joint pain, nose bleeding, vertigo, shortness of breath, nausea, vomiting, and sometimes death.

This is a small compression chamber made of a pneumatic glass jar.
Bert was able to use it to expose a sparrow to low pressures.
He reduced the pressure using a manometric tube,
observing at what point the bird started to suffer.
He used the India rubber bag to administer oxygen to the bird,
and "at once the bird becomes himself again," he wrote.
He concluded that at high altitudes, where the pressure was low,
: "it appears it is not the lowering of mechanical pressure
that produces the symptoms, but the low tension of oxygen
of the dilated air, which low tension prevents the oxygen from
entering the blood in sufficient quantity." (7)

So Bert became interested in helping people with breathing difficulties during the early 1870s. He said it was already known (such as by the works of Tavarie) that compressed air (higher pressure) helped people with anemia, chronic bronchitis, and emphysematous asthma. The result was easier breathing, and a lower heart rate. (7)(8 page VII)

Improved knowledge of the effects of high pressure on the human body resulted in Bert, and various other physicians, trying to invent machines that would adjust the pressure of inspired air to relieve the feeling of air hunger. Such machines would be experimented on patients of various lung disorders, including asthma.

In fact, in his 1877 article "Atmospheric pressure and life," Bert said:

The great influence that may be exerted upon living beings by atmospheric pressure is now questioned by none, and there is even a disposition to exaggerate its importance. If the barometric column rises or falls a few millimetres, nervous people affected with the asthma perceive phenomena, whether of a beneficial or of a noxious kind, which they do not hesitate to attribute to the weight or to the lightness of the atmosphere. But if this were the only cause of their sensations, then they should experience the same symptoms whenever they subject themselves to equal variations of pressure, as in passing from the level of the sea to a point only a few feet above it, or vice versa. (7)

In his 1878 book "Barometric Pressure," he published the results of his experiments on barometric pressure. He dedicated the book to his friend, and the man who funded the project, Dr. Jourdanet.

This is a compression chamber that allowed Bert to measure
the effects of barometric pressure on himself and others.
Inside was an Indian rubber bag so he could inhale oxygen.
Access points allowed him to take blood samples
to determine changes in blood oxygen tensions.
He exposed himself to decreased pressures.  Once he
started to feel symptoms he inhaled oxygen.  He wrote:
"But all these symptoms disappeared as by enchantment
so soon as I respired some of the oxygen in the bag;
returning, however, when I again breathed the air in
the cylinder."  (7) 

There would be many devices invented, and many failed experiments, over the next hundred years, before a truly effective, and mass producible, device would be invented to truly help patient's with respiratory disorders. Yet it was Bert's work that

He also performed work using anesthetics such as chloroform, and to administer it he devised an apparatus that allowed the patient to inhale an ideal percentage of the compound. (2)(3, page 427)

Along with being a successful physician and scientist, he was also a successful politician.

As he was performing his experiments on pressure,
he started to wonder how the world was created.
In regards to animals dying due to compression, he wrote:
"Thus it is the oxygen that is to blame.  Oxygen at too high
a tension destroys animal life.  Long I hesitated to characterize
as a poison the 'nursing father' of everything that lives, but there
was no help for it.  Oxygen, which gives us life, slays also,
when administered in too strong a dose.  I have had to study
thoroughly this paradoxal poison to determine the different
effects of varying doses, and its action upon our tissues. (7)

So after Williams, Longet and Bert all performed experiments to prove the spasmotic theory of asthma, you probably thought the subject was settled. Well, not quite. There still remained skeptics with credible arguments against it.

J.B. Berkart, in his 1878 book "On Asthma," explained that, during his work on asthma, Bert had a difficult time getting the air passages to contract until he realized that he had been over inflating the lungs.

Berkart said it was only when he provided less inflation that he was finally able to induce the air passages to...

"...contract... upon electrical irritation, applied either directly to it or to the pneumogastric nerve. But the contractions were so feeble and slow as to induce Bert to think that they had no active share in the mechanism of respiration. Moreover, the paralysis of the bronchial muscles, following the section of the vagus, did not appear to influence in that least the function of nutrition of the lungs. Thus the integrity of those muscles, not being indispensable to an efficient ventilation of the lungs, it seemed not unreasonable to conclude that their spasmodic contractions could hardly have the effect generally assigned to them." (4, page 42-43)(9,page 5)

Berkart said that Bert's experiments did not initially demonstrate contraction of the lungs because he over inflated them.

Berkart believed that Bert's experiments demonstrated proof that the air passages may constrict as Williams proved, but this did not occur in asthma because most asthmatics also present with emphysema, which is essentially over inflation of the lungs. (4, page 103)

Berkart's theory was respected among the medical community, although it did not have a long lasting influence.

In 1886 he was appointed governor-general of Tonquin, and soon thereafter his health started to fail. On a return to France during the year he gave a farewell speech at a meeting of the Academy of sciences, supposedly because he knew he was ill. He died of dysentry on November, 11, 1886. (2)

References:

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. "Sketch of Paul Bert," Popular Science Monthly," July, 1888, Volume 33, compliments of wikisource.org, http://en.wikisource.org/wiki/Popular_Science_Monthly/Volume_33/July_1888/Sketch_of_Paul_Bert, accessed 2/6/14
3. Waller, A., "Meeting of the society of Anaesthetists: Dosage in Anaesthetics," The Clinical Journal, April 6, 1898, pages 426-430, volume XI, October 27- April 20, 1898, Sixth Year, Edited by L. Eliot Creasy, 1898, London, The Medical Publishing Company
4. Berkart, J.B., "On Asthma: It's pathology and treatment," 1878, London, J. & A. Churchill
5. Phillips, John L., "The Bends," 1998, Yale University
6. Tissier,Paul Lewis Alexandre, edited by Solomon Solis Cohen, "Pneumotherapy: Including Aerotherapy and inhalation methods," volume X, 1903, Philadelphia, P. Blakiston's Sons and Co., pages 296-224.  If the profession of respiratory therapy existed in their era, we would be reading their books.  However, as it was, their books were written for the medical profession. All of the material from this post is from Tissier's book unless otherwise noted in the above paragraphs. Tissier page 72
7. Bert, Paul,  "Atmospheric pressure and life," Translated from the French by J. Fitzgerald, Popular Science Monthy, July, 1877, volume 11, http://en.wikisource.org/wiki/Popular_Science_Monthly/Volume_11/July_1877/Atmospheric_Pressure_and_Life, accessed 2/8/14
8. Fulton, John F., author of the Forward to Paul Bert's book "Barometric Pressure," 1843, Columbus, Ohio, The F. J. Heer Printing Company
9. Bert, Paul,  "Barometric Pressure," 1843, Columbus, Ohio, The F. J. Heer Printing Company
10. Dobell, Horace, "On Asthma: It's nature and treatment," 1886, London, Smith, Elder and Co
11. Brown, Orville Harry, "Asthma, presenting an exposition of nonpassive expiration theory," 1917, St. Louis, C.V. Mosby Company
12. Thorowgood, John Charles, "Notes on Asthma," 1878, 3rd edition, London, J and A Churchill
13. Thowowgood, John Charles, "The Lettsomian Lectures: delivered at the Medical Society of London, 1879, on bronchial asthma: it's causes, pathology and treatment," 1879, London, Bailliere, Tindall, and Cox
14. West, Samuel Hatch, "Diseases of the organs of respiration," volume II, 1902, London, Charles Griffin & Company, Limited 

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1860: Salter proved nervous theory of asthma

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

He said:

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

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

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

 Further reading:

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

Click here for more asthma history.

References:

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

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1860: Salter: Why do young people outgrow asthma?

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

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

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

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

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

He answered his own question:

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

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

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

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

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

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

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

References:

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

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1860: Dr. Salter, the famous asthma doctor

Figure 1 -- Dr. Henry Hyde Salter.

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

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

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

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

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

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

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

From a photograph of an asthmatic, whose disease

dated from whooping-cough at three months old.

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

Dr. Salter.) (6, page 115)

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Further reading:

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

Click here for more asthma history.

References:

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

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