Thursday, April 17, 2014

1850s: 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 before one occurs again.  The period of time between may be random (cannot be predicted) or periodic (can be predicted). 

Salter believed asthma was more likely to be pure the younger the person is when he acquires it, so that asthmatics under the age of 15 have a great chance of outgrowing it, those between 20 and 40 a fair chance, and over 40 a rare chance. 

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

He answers 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)

Tuesday, April 15, 2014

1970-1985: No antihistamines for asthmatic boys

As I look back on my asthma past, which I've done a lot lately considering I'm writing a history of asthma, the thing that irritates me the most is that I wasn't allowed to take anything for my allergies.  I had severe allergies, and I was forced to sufferer through every one of them.

The reason this irritates me so much is there were antihistamines available since the 1950s, and there were even antihistamines in the bathroom cabinet at our house, yet I wasn't allowed to take them.  Now I don't know if it was my mom's fault or my doctors, but the reason my mom gave me was because the box states not to use if you have asthma as it "may cause wheezing."

I have severe allergies.  I'm allergic to a variety of molds, dust, fungus, and you name it.  Today I know that when my allergy symptoms are controlled, so controlled is my asthma.  The thing it when you're an adult it's easier to stay away from your allergens.  It's still no fun to avoid them, yet it's possible  

Kids, on the other hand, are under constant pressure of their siblings and friends to play on the ground, the dirt, the woods, etc.  Kids are closer to the ground, where allergens hang out.  Kids roll on the carpet.  Kids play in the basement.  Kids play in old, dusty, worn out forts.  Kids play hide and seek in bushes.  Kids are all over.  It's just what kids do.  

So you can see how it would be hard for a kid to avoid allergens.  As a kid who tried to be as normal as possible, I usually did whatever my brothers and friends wanted to do.  I paid little attention to my allergies, and I usually suffered as a result (although this changed as I got older).  And, when the sniffling and sneezing came about, I was forced to suffer.  When I got older I'd sometimes request a medicine for it.  Yet I was allowed none of it.  I was forced to suffer (My parents had empathy, they just weren't allowed to use antihistamines for me).  

I remember more than once playing with my brothers, and all of a sudden my eye would be swollen shut.  My mom would have me sit in my room, or on the couch, for hours with a hot, washcloth over my eye.  I remember this would happen often while on vacation. If my asthma acted up, that was an added dilemma.  Yet my allergies were something that there was nothing I was allowed except avoidance and warm wash cloths, and sitting like a moron on the couch while everyone else was having fun.  At school I got picked on.

Benadryl was a medicine in the bathroom medicine cabinet also that was marketed as a cure for allergies.  It was available as a prescription since 1946.  But I wasn't allowed to use it.  Perhaps the reason for this goes back to 1949, 21 years before I was born, when the Food and Drug Administration (FDA) cleared Neohetamine as the first antihistamine for sale over the counter without a prescription.  This medicine and a variety of others, including Benadryl, were advertised in magazines all over the U.S. as a remedy for allergies and colds that could be purchased without a prescription.  (1, page 227)

By 1950 there were over 21 over the counter antihistamine products, "packaged under one hundred different trade names in tablets, nasal sprays, eye drops, and creams."  (1, page 216-17) and they were advertised heavily, in what was called by many the "Cold War," according to historian Gregg Mittman.  Consumers started purchasing various antihistamine products believing that they were buying a cure for allergies and colds.  Mittman says that sales of antihistamines boomed.  

People were taking the medicine without reservation, and they were giving it to their kids.  Yet it didn't take long before parents realized antihistamines didn't cure hay fever, and had little effect on colds.  In fact, some were even noticing side effects, especially in children.  In the process of drying out the nasal passages and stopping the nasal drip, the medicine caused dehydration of the respiratory tract, especially if used in excess.  This caused wheezing, and possibly other asthma symptoms.

Mittman explains that "The initial attack on OTC antihistamine drugs came not from consumers or the FDA but from the AMA (American Medical Association)."  So while some were claiming antihistamines were the new miracle drug for colds, "Austin Smith, editor of the Journal of the AMA, declared that 'no one yet knows what harmful effects (antihistamines) may produce on the body in general, or on specific tissues, when taken over prolonged periods of time." (1, page 227)

Various groups started calling for the FDA to force manufacturers of the medicine to list potential side effects.  Mittan quotes the New England Journal of Medicine:  "This is the most striking example to date of the advertising methods of manufacturers and promoters who are steadily going over the heads of the medical profession in attempts essentially to force physicians through their trumped-up public demand to accept remedies before their usefulness has been adequately substantiated and ill effects determined." (2)

Mittman adds:  "While the FTC (Federal Trade Commission) deliberated over whether drug companies had violated federal trade laws, physicians stepped up their attack by alerting the public to the inherent dangers of antihistamines, particularly for children."  Voila.  That's what I was getting at.  I was a child, a direct recipient of this scare. As far as I know the scare may have saved lives, but it forced me to suffer (note: I may have suffered even with antihistamines, although, considering they help me today, I'm going to assume they'd help me back then).  (1, page 230)

Herman Bundesen, president of the Chicago Board of Health, warned that some children had died after "indiscriminate antihistamines use."  Likewise, "Children taking antihistamines for allergy or colds, advised Bundesen, needed to be placed under a physician's care.  Bundesen also advised caution and restraint in embracing antihistamines as the magical cure for children's allergies.  As much as parents might wish it, antihistamines did not eliminate the need for shots, special diets, or environmental control of the home.  The therapeutic effectiveness of antihistamines varied, Bundesen insisted, according to place -- in this case, the body of an individual child" (3)

A June 1950 compromise by the FTC allowed advertisers to continue advertising the products, although they could no longer say that they would "cure, prevent, abort, eliminate, stop, or shorten the duration of the common cold."  In other words, nothing changed.  There was nothing in the FTC decision regarding safety of the medicine. Advertisers, according to Mittman, were allowed to continue as they were already doing. (1, page 230)

The AMA was unhappy by the ruling.  However, an editor in Collier's was "cynical" the way I'm cynical regarding the medical industry (at times). The editorial suggested the AMA was merely hoping "to give the prescribing physician a monopoly on the first promising remedy that ever came along."

I think the same can be said of Ventolin of 2012.  Could you imagine how much business doctors would lose if Ventolin was available over the counter. Asthmatics with little money wouldn't be forced to pay for a doctor to get their hands on one, and they wouldn't have to pay $75 a pop, because the price would undoubtedly go down.  Patients, and parents, could decide how to treat asthma, as opposed to physicians.

I'm not petitioning for OTC Ventolin, I'm just making an example here.  Although, I think instead of scaring parents and doctors away from antihistamine use, the OTC should have provided doctors and parents with a warning such as:  "Use this medicine with caution for young asthmatics.  Consider the benefits with the risks, which are.... if you absolutely need to use this medicine, stop using it if your child appears to have an asthmatic attack as a result of taking the medicine."

Such a warning would have prevented abstaining use for asthmatic/ allergic children such as myself, patients who truly needed the medicine.

So in the 1950s and 1960s there was an ongoing battle:  doctors wanted allergy sufferers to see a doctor, and FTC and FDA wanted patients to be able to treat their own allergies, much like they treat their own colds.  (1, page 231)

To add to the scare, it must be added here that by that Mittman notes that by the mid 1950s it was observed that antihistamines did not do anything to stop an asthma attack, that was a job for bronchodilators.  (1, page 231) This must have been an added disincentive for doctors to prescribe antihistamines for young asthmatics.

Adults could do whatever was needed to get the medicine that allowed them to function in life.  Yet a child, as I was in the 1970s, had to rely on his physician and parents to not only observe the allergy and cold symptoms, but to do something about it.  I was basically at the whim of the warning on the box that warned against using on children and especially children with asthma. As a result I had to suffer despite the remedy in the medicine cabinet.

Instead of doing that, instead of scaring physicians from prescribing a medicine that might have taken the edge off the suffering of a boy with allergies and asthma, they should have warned physicians to weigh the possible advantages with possible side effects.  Physicians should have been warned to trial patients on the antihistamines, although monitor them closely.

Parents should not have been scared into not giving antihistamines to the one person in the household who would truly benefit from them.  Because, I can honestly say, while antihistamines don't take away all the symptoms of allergies, they sure do help.  Today I use Claratin every day, and it's a wonderful medicine.  Claritin is nice not only because it relieves and prevents allergy symptoms, it doesn't make you drowsy like Benadryl.

I also have to add here that when I was a patient at National Jewish Hospital/ National Asthma Center in Denver in 1985, my doctors there prescribed a daily dose of Drixoral.  Yet when I returned home my mom told me I didn't need it so she quit buying it for me. The irony is I probably needed the Drixorol more at home where the entire house was full of allergens, as compared to at the hospital where the only allergens was pollen and whatever other pollution was in the outside air (and only when I was outside, considering most windows were sealed).

So I suppose there was ignorance on both sides of the isle here.  Still, it frustrates me as I look back.  It frustrates me as I see myself suffering, and out of ignorance I wasn't treated. Although, as the old saying goes, do the best you can with the knowledge you know today, and as you learn better you do better.

My parents were also told to get rid of the dog.  My parents were also told to get rid of the plants.  My parents were told lots of things, and they didn't do much.  They did do some.  They replaced the wood heating vents in my room with steam heating vents.  Yet they still burned wood in the basement, and stored wood down there, because it was a cheaper way to heat the house.  Lord knows wood holds mold, and wood smoke triggers asthma by itself.

I empathize with my parents not doing much, however, because they were simply trying to live within their means  Plus neither of the had asthma or allergies, so even while they witnessed my suffering, they may not have fully understood it

I think of those years every time a young asthmatic passes through the ER when I'm working.  I treat patients with a heavy heart when they are in the ER because they can't afford Advair, which costs $220 a pop , or even Ventolin, which costs $73 a pop.  Lacking health insurance, lacking a good paying job, many of these asthmatic/ allergy sufferers have no option but to go to the ER when their asthma acts up.  They have to treat exacerbations as opposed to preventing symptoms. (Prices are in 2012 values)

References:
  1. Mittman, Gregg, "Breathing Space," 2007, New Haven and London, Yale University Press
  2. Mittman, op cit, page 229, quoted from: "MDs Hit Unlimited Antihistamine Use," Drug Trade News, 9 January, 1950, page 35
  3. Mittman, op cit, page 230, quoted from:  Herman Bundesen, "Dangers for Youngsters in Antihistamines," Ladies' Home Journal, June 1950, pages 192, 194

Thursday, April 10, 2014

1850s: Salter's prognosis for asthmatics

What is the prognosis for your asthma? What are the chances you will outgrow your asthma?  With everything else being coeteris paribus (equal), the answer to this question may depend on the following:

1.  Age of the patient:  Patients who develop asthma under the age of 40 are more likely to outgrow their asthma than those over the age of 40.  Barring organic injury, asthmatics under the age of 15 are most likely to "gradually 'grow out'" of their asthma.  Those over 40 have a "fair chance" of outgrowing it.  (1, page 168-9)

2.  Absence of organic disease:  You are most likely to outgrow your asthma if you do not have any pulmonary or circulatory organic changes, such as chronic bronchitis or heart failure. "If the heart and lungs are completely free of organic disease, recovery is possible." If an organic disease exists that causes bronchospasm or is the cause of the asthma, "recovery is impossible" (which is more likely to be the case in asthmatics over the age of 40).  If the "cause is incurable," so to "is its consequence." (1, page 170)

3.  Length of attacks:  Repeated attacks cause damage to the lungs by causing "permanent pulmonary congestion. At each attack the shutting off of air by the narrowed bronchules suspends the normal respiratory changes of the blood in the capillaries. This produces arrest in and ultimately engorgement of the whole pulmonary circulation, capillary and venous. Now this pulmonary congestion... becomes formidible and intractible in proportion to the length of time it has existed. If the atatck is short, and the speedy relaxation of the bronchial tubes quickly readmits a free supply of air, the vessels are at once relieved, the blood passes on, and the transcient congestion leaves no trace behind it." If the attacks last several days or weeks, "the capillaries and venules, long distended, never comletely recover themselves, their tone is lost, and pulmonary congestion, manifested by chronic dyspnoea and expiration, is permanent." The chronic pulmonary congestion occludes the bronchial tubes with mucus and becomes a permanent source of bronchial irritation (it becomes a permanent exciting cause of asthma). (1, page 170)

4.  Frequency of attacks:  "If the intervals are so short that the lungs have not time completely to recover from one attack before the occurance of another, the omen is very bad, because the mischief of each attack being engrafted on some portion of that of its predicessor, the organic derangement is accumulative, and the case one of progressive disorganization."

5.  Completeness of recovery:  If the patient recovers completely between attacks, then you can rest assured there is no permanent permanent organic changes to the pulmonary circulation. If dyspnea persists between attacks, you can rest assured that probably has been some organic changes.

6.  Persistence of exporation:  If the patient is chronically coughing and spitting up secretions from the lungs, this is a bad sign.  It generally means the patient probably has humoral asthma, which by all means is probably chronic bronchitis more so than asthma.  It is definitely chronic in nature and this type of asthma will not go away. 

8.  Direction disease is taking:  Are attacks becoming less intense or more severe? Are they more frequent or less frequent? Are they severe and more frequent, or milder and more distant? Since the loss of asthma is generally gradual, less frequent and milder attacks is a good indicator the asthma may someday disappear.

9.  Ability to detect exciting cause:  Asthma is easier to treat and cure when the exciting cause is known.  If the exciting cause is living in the country, then the remedy may be simply moving to the city.  If the cause is eating a large meal, the remedy and cure will be eating light meals.  If the exciting cause cannot be detected, or if there are many exciting causes, the "omen is bad."

Salter concludes by noting the following:  "If, then, an asthmatic were to present himself to me and seek my opinion as to his prospects... (after) carefully scrutinized the condition of his chest, put to him the following questions:
  • What is your age? (if not already ascertained)
  • How long do your attacks last?
  • How often do they occur? 
  • Do you lose all traces of shortness or difficulty of breathing between the attacks; or is the breathing always a little difficult?
  • Do you habitually cough and spit?
  • Does the disease appear gaining on you, or the reverse?
  • Is the exciting cause of the attacks clear; and can you undertake that it shall not recur? (1, page 172)
References:
  • Salter, Henry Hyde, "On Asthma: It's Pathology and Treatment," 1882, New York, William Wood and Company, pages 168-172  (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)

Tuesday, April 08, 2014

1930: Pneumostat, the first electric nebulizer

Pneumostat in use (2)
While a variety of steam inhalers were available in 1850, it was learned that the best way of getting medication to the lungs was not by steam but by mist.  Between the 1850s and 1930 there were a ton of inhaler and nebulizer devises made, but none were ideal.

The problem with these early mist producing inhalers is they required manpower to create the flow needed to create the mist.  As with other industries, the ability to control electricity changed everything.  Marketers soon started playing with the idea of creating an electric nebulizer.  

The first one to enter the market was produced by Weil in Frankfort.
It as a compact unit, meaning it was a combination compressor and nebulizer.  The comperssor created the electricity that created the flow to turn the solution of water and medicine to a mist. 

According to "Controlled Pulmonary Drug Delivery, it was a "110-120 volt machine was supplied in UK by Riddle to nebulize bronchovydrin (papaverine and eumydrine)."   (1, page 68)

Pneumostat (2)
Bronchovydrin also had adrenaline (epinephrine) and atropine in it.  It was a solution used to provide quick relief of an asthma attack.  I really had a hard time finding any other information on it, although it was used by lifelong asthmatic Harold Beck.

The electric nebulizer of the 1930s was epensive, so the physician may prefer to have the patient use a nebulizer where the flow is generated by hand power, like it was prior to the electric device.  One option would be the Adrenaline Inhaler or the Devilbiss No. 40 Glass Nebulizer.

Considering the bulkiness and cost of this machine, it was common for a pharmacist to own one, and for patients in need to visit that pharmacist. (3)

References:
  1. Smyth, Hugh D.C., "Controlled Pulmonary Drug Delivery," 
  2. Sanders, Mark, "Pneumostat," Inhalatorium.com, page 131, http://www.inhalatorium.com/page131.html
  3. Nickander, K, Mark Sanders, "The early evolution of nebulizers," MedicaMundi, 2010, 54/3, pages 47-53

Thursday, April 03, 2014

1850s: The stomach causes asthma

Due to the relationship between the stomach and lungs, "in no direction is asthma more accessible than through the stomach," or so surmised the infamous asthma expert Dr. Henry Hyde Salter.  And, therefore, one of the best ways of preventing asthma attacks is by eating small, healthy meals.  

The reason for this is "due to the close relationship between the stomach and lungs," writes Salter.  What you put into your stomach can and will trigger your asthma, and therefore, to prevent an attack, you must consider a proper eating regimen, and this is among the first things Dr. Salter would consider when taking you in as an asthma patient.  The remedy that worked was a remedy, and the preventative treatment was to eat less food on Sundays.  

For instance, Dr. Salter was requested at the home of a boy who presented with a case of asthma.  Upon questioning the boy and his family, Dr. Salter realized that the attacks occurred every Monday.  Then, upon further questioning, it was learned that Sundays was a day when the family participated in a great feast.  So it was wise of Dr. Salter to surmise the asthma was brought on through due to a full stomach.

So there are various ways asthma can be caused through the stomach. (1, page 135)

1.  Dyspepsia:  (Upset stomach; indigestion)  Asthmatics are generally dyspeptics. Rarely do you find an asthmatics with a perfectly strong, sound stomach.  "The stomach and lung symptoms are part of one morbid condition; the whole thing is deranged pneumogastric innervation, and the asthma of the pulmonary portion of it." (1, page 135)
  • Their stomachs are irritable, 
  • Their digestion capricious and irregular
  • Dietary restricted
2.  Errors in diet:  "To prevent asthma the most scrupulous care is necessary in all that relates to food," with any of the following bringing on an attack:
  • A debauch (self indulgence)
  • A late dinner
  • A heavy supper*
3.  After meals:  Asthma has a tendency to follow shortly after meals, and when an attack is on the asthmatic will feel obliged to starve as long as the attack is upon him.  Since the asthmatic will continue to have an appetite for food, this starvation only adds to the suffering.  (1, page 137)

4.  Gastric symptoms: 
  •  Flatulence
  •  Hiccough,
  •  Etc.  
By the observation that any of the above may cause asthma that Salter came up with his theory that "the taking of food (either by its mere presence in the stomach, or by the process or results of digestion) acts as an irritant to the morbidity irritable pulmonary nervous system. The affair is excito-motory; the food is the immediate or remote irritant, the nervous circuit involved is the pneumogastric, and perhaps in part the sympathetic; and, in obedience to the common law of reflex action, the potency of the stimulus is increased, or, in other words, the reflex nervous irritability is exalted, by the condition of sleep."

The remedy:  Basically, a diet should have consist of three qualities: it should be small in quantity, highly nourishing, and of easy digestion. 
  • Eat a healthy diet
  • Don't eat too late in the day, or too soon before sleep*
  • Do not eat food that is indigestible (should be plain and well cooked)
  • Foods should vary; do not give same foods over and over again
  • Foods should be nutritious (due to less food eaten in a day by asthmatis)
  • Avoid meat pies, beef steak, kidney pudding 
  • Avoid drinks containing carbolic acid (Bottled Scout, Scotch ale, etc.)
  • Avoid strong coffee with sugar (undigestible)
  • Avoid any unwholsome foods (as in all of the above)
  • Avoid eating too much (because it's indigestible, not because a full stomach presses up on diaphragm)
  • It is better to eat a large meal at breakfast, as opposed to a large meal at dinner time (this may be due to the fact the stomach has better digesting power in the morning.  As the day progresses, the digesting power becomes "exhausted by succeeding meals) (1, page 141)
  • Nights rest (restores digesting power of stomach)
The most important thing to remember regarding diet is this:  *let no food betaken after such time in the day as will allow digestion being completed and the stomach empty before going to bed

The following is Salter's recommended asthma diet:
For breakfast, a small basin, or breakfast-cup, of bread-and-milk, and besides this, an egg (two for a strong man with a good appetite), or a mutton-chop, or some cold chicken or game. As a drink, if any is required besides the bread-and-milk, I think tea is better.than coffee, cocoa better than tea, and milk-and-water better than either. For dinner (not before two or after four o'clock), let mutton be the staple meat, beef or lamb but rarely, pork or veal never. A little succulent vegetable and potato should be taken; and a little farinaceous pudding, or stewed fruit, or the fruit of a tart, should conclude the dinner. Only one helping of either meat or pudding. I believe, unless there is some special reason to the contrary, that water is the be3t accompaniment to an asthmatic's dinner. No cheese, no dessert. A great sufferer from hay asthma tells me that a little boiled fish and brandy-and-water have the least tendency to bring on his asthma of anything he can take; he can take this when a dinner of butchers' meat would be certain to be followed by difficult breathing. With regard to the brandy-and-water I will not speak positively of its advantages in hay asthma, but in ordinary asthma I do not like stimulus of any kind. With regard to the fish there can be no doubt that it is less of a diet, yields more readily and rapidly to digestion, than butchers' meat, and is, therefore, less provocative of any evil depending on prolonged and laborious digestive effort.' And here let me observe that butchers' meat is of all foods (with the exception of those particular articles of diet which are specially offensive to asthma, and to which I shall refer presently) that which is most apt to aggravate asthmatic dyspnoea, and it is because dinner is a meat meal that it is necessary to take it so early. From any occasional late meal that convenience, or circumstances, may force upon the asthmatic, butchers' meat should always be excluded.
Basically, based on this theory, Salter would question his patient as to his diet.  If you have an asthmatic, for instance, who eats butchers meat every day at 1 p.m. and who later has an asthma attack, then the solution may be eliminating the butchers meat.  If someone eats too late in the day, perhaps the solution is to eat earlier, eat less, or stay up later.

Now keep in mind here this is just a recommendation.  Salter was of the belief that what works for one asthmatic may not work for another, and that is why he was usually up to the idea of the patient experimenting to find what remedy -- or diet -- works best for him.

*A heavy supper causes a full and bloated stomach.  This will cause the stomach to press up against the diaphragm creating less room for the lungs to expand.  Some believe this causes asthma.  Salter believes this theory to be false, that a full stomach causes asthma because "the bulk of the food diminished digesting power by over-distending the stomach and so paralyzing its movements, and by being altogether in excess of the secreting powers of the gastric mucous membrane."  This in turn renders the food indigestible. If the mechanical theory were true the asthma would come on in direct proportion to the stomachs bulk, which is not true.  When eating healthy foods, such as arrow root, one can eat all he wants and this will not bring on a fit of asthma.  He may drink water all he wants, and this will not cause asthma. Another proof of Salter's theory is that asthma does not come on immediately after eating when the stomach is most full, but an hour or two later. Relief by an emetic is not mechanical, as it relieves asthma the moment nausea is felt, not upon vomiting. An emetic works even when the stomach is empty.(1, page 141)

References:
  • Salter, Henry Hyde, "On Asthma: It's Pathology and Treatment," 1882, New York, William Wood and Company, pages 168-9  (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)

Tuesday, April 01, 2014

1859: Lewin's Inhaler

Mathieu's Nephogene (from Lewin) (2)
There were many problems with the Nephogene (nebulizer) created by Mathieu.  The greatest concern was that the spray produced was so forceful most of the mist created pounded into the oral cavity and produced a cough, according to Jacob Cohen in his book "Inhalation: its therapeutics and practice."

This made it certain little of the spray made it to the lungs.  Of course Cohen makes sure to mention that this device was not first devised to deliver respiratory medicine, but to spray medicines on any part of the body.  

The person to fine tune the device to make it more appropriate for the inhalation of respiratory medications was Lewin of Berlin.  Cohen describes the device as such: (1, page 190)
Lewin, of Berlin, has constructed an apparatus with an ordinary suction pump (syringe) which forces the liquid into a reservoir, the air within which is thus compressed, and in its turn becomes a propelling force, driving the fluid, on the opening of a valve, out of a very fine aperture, whence it impinges on a convex button, and becomes thus broken into spray. This apparatus once set in action will continue to work for a considerable time without further pumping.

Lewin's glass nebulizer (1)
Yet another problem with inhalers prior to Lewin is that they were all mostly made of medal.  This meant that certain medicines couldn't be used if they interacted with metal.  Lewin aimed to correct this problem by using a "strong glass reservoir" instead of metal."  It's also graduated with markers so you know how much water to put into it.   (1, pages 194, 195)

It was covered by a "strong metal cap with three openings: one for the introduction of the liquid and the subsequent attachment of the condensing syringe; one affords exit to the capillary extremity of a slender tube which reaches to the bottom of the glass; and the third is covered by a spring safety-valve, through which the compressed air may escape after a certain pressure has been produced.  "  (see figure 19) (1, pages 194, 195)

To work it a "finger is placed upon the capillary extremity of the exit-tube until the air in the reservoir has been sufficiently compressed by a few strokes of the piston, when the finger is removed, and the fluid rushes out with great force and breaks upon a gilded metallic convex button secured in a glass drum, perforated to admit the stream, and attached by a support to the side of the instrument. The drum is not furnished with a waste-pipe, but is so inclined that the excess of fluid will flow over its edge into any convenient receptacle." (1, pages 194, 195)

So there were various advancements made by Lewin both to his nebulizer and to that of Mathieu's.   Yet his most significant contribution was the use of material that wouldn't react with medicine that might be used in it. Yet there were still flaws with it.

Either way, these nebulizers provided another option for physicians and patients, and were yet another step in the evolution of nebulizer therapy.  (1, pages 194, 195)

References:
  1. Cohen, Jacob Solis, "Inhalation in the treatment of disease: it's therapeutics and practice," 1876, Philadelphia, Lindsay and Blakiston, part II, "Inhalation of nebulized fluids, or sprays:  nebulized medicaments and the apparatus for their production," pages 184-212

Thursday, March 27, 2014

1850s: Salter's Asthma Remedies

If you suffered with asthma during the second half of the 19th century the chances were pretty good you tried, at one time or another, one or more remedy recommended by the famous asthma doctor: Dr. Henry Hyde Salter. 

Salter divided asthma remedies into two different types:
  • Treatment of the paroxysm (treatment of the symptoms that occur during an attack of asthma)
  • Treatment of the intervals of the paroxysm (the real treatment of the disease; preventing asthma)
As you approach your doctor for the first time with symptoms of asthma, he will, if he is following Salter's recommendations, follow a series of three steps:

1.  The very first thing he will do is question you to try to determine what was the exciting cause that set off your asthma.  Once the exciting cause is determined, his first suggestion will be to remove it.
  • Is the cause a cat? Remove the cat.
  • Is the cause a new feather pillow? Remove the pillow.
  • Is there a hay field nearby? Remove the patient from the area
  • Is there dust in the room? Smoke? Remove it
  • Is the air new, such as a visit to the country? Remove patient to some place that is agreeable
  • Is there ipecacuanha powder in the room? Remove it.
  • Is the cause an undigested meal? Give an emetic.
  • Is the cause a full rectum? Give an enema.
2.  Once that is done, you will want to position the patient into a "favorable position":
  • Get him out of bed
  • Bolster him up in an arm-chair
  • Place before him a table of convenient height, with a pillow on it, on which he may rest his elbows and throw himself forward.
Salter explains that "It is quite surprising, almost incredible, how much comfort this will give, and not only so, but how it will actually relieve the breathing and dispose the spasm to yield. Sometimes the patient's breath is so bad that he cannot sit; the same arrangements must then be made for him in a standing posture."

3.  If the above do not work, it is now time to try some "remedy by which we may hope to cut it short. In our choice of this we shall be very much influenced by our patient's former experience. Few asthmatics suffer long from their disease without having discovered what particular remedy is most efficacious in their case, and in this respect different cases of asthma vary so much, and display such a caprice, that I really know of no other guide except the patient's experience."

There are three classes of asthma remedies:
  • Depressants: Lower inervention, depressing nervous irritability, and enfeebling the contraction of the bronchial muscle, and weaken the hearts action (relax spasm of bronchial tube). The remedy should be given as soon as the attack occurs for best results:
    • Ipecacuanha: 20 grains of ipacacuanha powder.  Relief takes place before vomiting, so it's the depressent effects more so than the vomiting that relief the asthmatic fit. This is the most managable of the depressent remedies.  Ipecacuanha lauzenges also work well, especially for children.
    • Tobacco: for those not tolerant of it, faintness, nausea and vomiting often result.  It is this effect that can break a fit of asthma.  This is a good remedy for children (smoke until you puke). "It renders spasm impossible by knocking down nervous power. (doubtless by poisoning the nervous centers)." (1, page 115)  Usually 20 whiffs of a pipe or cigar will cause collapse.  Usually you will feel breathing relief before the vomiting, and you can stop at that time. Generally takes 20-30 minutes. Works well for hay asthma. To prevent asthma smoke a cigar during the hay fever season just before bed. However, for it to be a remedy it must not be a habit, because it's the poisonous effect that is the remedy.  This is the most speedy and effectual of the depressant remedies. For children, a couple puffs of a cigarette may do well. (1, page 99-104)
    • Tartar-emetic:  Another alternative to the above depressants.
  • Stimulants:  They dispel depressions in the mind and restores the will to a wonted activity.  It thus disfavors the of excito-motory action, and thereby relieves the fit of asthma.
    • Coffee: A most common and most reputed remedies. Most asthmatics have tried it as one time or another. It works because sleep favors asthma.  It causes "mental vivacity and activity, of acuteness of perception and energy of volition." This is a "referse of the abayance of will and perception which, in drowsiness or sleep, so favors the development of asthma. In sleep will and sence are suspended; after taking strong coffee they are not only active, but exalted." Dose should be one cup of very strong, hot coffee, with no milk or sugar, on an empty stomach.   (1, page 106-107)
    • Strong tea:  Works similar to coffee
    • Ammonia:  Works similar to coffee
    • Indian Hemp:  Works similar to coffee
    • Alcohol: Curative influence of violent emotion.  It works by creating a "new nervous condition other than asthma; it gives a "shock or shakeup of the nervous system."  It should be recommended only when all else fails, and used judiciously.  Side effects can be worse than asthma, such as habit and tolerance. The alcohol must not be taken as part of a diet, or taken every day; Brandy, whisky and gin work best because they are the most concentrated form; 
    • Mental excitement:  Allows you to forget asthma; set your mind on a different course
  • Sedatives:  Since asthma is the result of some nervous stimuli that causes nervous irritability that results in spasm of the air passages, sedatives often work as a nice remedy by allaying this "nervous irritability; destroying for that time the morbid sensitiveness of the pulmonary nervous system that constitutes so essential part of the disease." They ease the mind and east the spasm at the same time.  They work as both a treatment and preventative.  (1, page 114)
    • Tobacco:  For tobacco to cure as a sedative it merely produces the composing and tranquilizing condition with which smokers are so familiar.  It allays spasm by "temporarily effacing a morbid sensitiveness to certain stimuli, and inducing a normal indifference to and tolerance of them." When recommending this effect to the delicate and young the dose must be carefully measured. Note:  "Any one may experience the sedative effects of tobacco, and all smokers do habitually; but the production of its full depressant action is almost impossible in those who have long accustomed themselves to its use; in others, however, as in women and children, it is so easy that the difficulty is to prevent sedation from running into depression. It is for this reason that it is necessary, in administering tobacco as a sedative only, to the uninitiated, the delicate, or the young, to give the very mildest form, in carefully measured quantities, and to insist on its slow and deliberate exhibition.  Asthmatics are very commonly smokers, and many of them find in the habit an almost unfailing antidote to their disease. But in almost all the cases that I have met with, it is rather as a prophylactic that it is used— to secure immunity when under dangerous circumstances, or to meet the first threatenings of an attack—than as a veritable curative to cut short spasm."(1, page 115)
    • Chloroform: "One of the most valuable remedies for asthma that we possess; the inhalation of its vapor putting a stop to the asthmatic paroxysm more speedily and more certainly than even tobacco."  For the safety of the patient, an presence of a second person is necessary.  The medicine "dissipates the asthmatic spasm by relaxing muscular contraction... and acts through the general nervous system." In some the relief is produced without any insensibility whatever; and in some a very small dose is sufficient to give relief, the patient immediately passing into a tranquil sleep, which may continue for hours, and from which he will wake with the asthma gone, although the original dose was far short of enough to produce the true chloroform sleep. This remedy should be given as soon as the attack commences for best results. The dose is usually 2 drops of chloroform on a handkerchief.*  Side effects include: insomnia, deafness, apathy, tremulous of hands, an increase of the asthmatic tendency.  (1, page 115-117)  
    • Opium:  One of the less worthy asthma remedies, or what Salter refers to as "positively worthless." (1, page 115) It induces sleep, and sleep favors asthma.  Therefore, opium has a tendency to make the asthma worse.  It may work to help with bronchitis, but not asthma. (1, page 122-123)
    • Stramonium: (Datura Stramonium, thorn-apple)The powder of stramonium will be rolled into cigarettes or cigars, stuffed into pipes, or simply ignited on a place.  If you use a place, you may roll up a magazine to act as a funnel to better direct the smoke to your airway.  It was introduced in 1802 by General Gent from India, and was initially tried by all asthmatics.  However, due to the capriciousness of asthma it does not work as well as it was once thought for every asthmatic the same, and for the same asthmatic over time.  So, as with many newer remedies, "It's original reputation greatly exaggerated its merits, but that it has undoubted, though very unequal value, and will probably always maintain its place among the real remedies of asthma." Some asthmatics smoke it only to allay the fit, and smoke it daily even when the breathing is normal to fend off an attack. However, in most cases, it "mitigated rather than cured the spasm," giving only temporary relief.  Although it works different for different asthmatics. Likewise, the inhaling of smoke from Datura seeds is much more potent than inhaling smoke from other parts of the plant. Salter recommends smoking a mixture of both the leaves and seeds "as to administer by smoking a reliable preparation of an uniform strength." A direct inhalation of the smoke will allow much of the medicine to be directly applied as a topical to the lungs, and some small amount to be absorbed by the mouth and by swallowing saliva to the system.  Salter concludes that "I may say, in conclusion, with regard to this drug, that its great value in some cases would, in spite of its too frequent impotence, always induce me to give it a trial in cases in which it had not been tried; that I do not believe it is attended with any danger except from the most egregious overdosing."  He also recommends smoking a nightly pipe as opposed to waiting for the asthmatic paroxysm to occur.  (1, pages 123-6)
    • Lobelia: If it doesn't work you may try "sufficiently" larger doses. The Americans recommend "two drachms every two or three hours till some decided effect is manifested," and "it's effect is almost identical to tobacco-poisoning -- giddiness, faintness, sickness, cold sweat and complete muscular relaxation." Dr. Elliotson prefers to prescribe "frequent and gradually increased doses... ten minums every quarter or half hour, increasing each dose a minum till the disease yields, or the drugs tend to disagree with the patient." Side effect is vomiting, faintness and headache.  If these occur, the next time you use it never exceed above that point in dosing.  He warns that one must be careful, because some preparations are stronger than others.  Dr. Salter recommends to "give it in repeated doses every half hour, increasing the dose five minums each time, till some result is obtained."  By "some result" he means a side effect or cessation of the asthma.  The next time start with the dose that gave the desired effect.  (1, page 127)
    • Indian hemp:  (Cannabis Sativa) It is used by the natives in India as an anti-asthmatic and  has a great reputation.  It is a stimulant and a sedative.  In small stimulant doses has the "same effects as coffee, only in a marked degree." Due to its "hypnotic tendency" when given in high doses, Salter has the same objections to is as he does with opium.  
    • Ether: A very common asthma remedy written about by nearly all writers of the disease.  Some speak well of it, although many others say it does more harm than good.  (1, page 128)
  • Other Options:  When the above medicines do not work, the following have worked for some and may be worthy of a trial.
    • Inhalation of fumes of burning Nitre Paper: "This remedy consists in the inhalation of the fumes of burning nitrepaper—bibulous paper which has been dipped in a saturated solution of nitre (nitrate of potass), and dried. How or by whom it was discovered, or exactly when, I know not; but I find from the references made to it by different authors that it must have been in use for nearly twenty years, and its great value and efficacy are now beyond question, although for some time past it seems to have hybernated, and never to have attained a general notoriety." (1, page 129)  According to one referenced doctor, "the room becomes "almost instantly filled with a dense smoke" that is "always mitigating and sometimes completely relieving the spasmotic contractions of the air-tubes."  Such paper only works to relieve dyspnea from pure asthma, and in cases where both bronchitis and asthma are causing dyspnea, relief may only be partial as only one of the maladies is remedied.  "The paper must be moderately thick and very porous and loose in its texture (red blotting paper of moderate of moderate substance works best), so as to imbibe a sufficiency of the solution." Strammonium may be added to the solution for increased effect.  The goal is to produce "light, clear, white fumes," as opposed to black smoke. The nitre paper should then be stored in a dry place.  The best recipe is as follows, and is provided by one of Salter's patients: "Dissolve four ounces of saltpetre in half a pint of boiling water; pour the liquor into a small waiter, just wide enough to take the paper; then draw it through the liquor and dry it by the fire; cut it into pieces about four inches square, and burn one piece in the bedroom on retiring to rest at bedtime." (1, page 130-133)
    • Iodide of Potassium: It's a very common remedy that many physicians think highly of and recommend often for asthma.  "But I must say, that according to my own experience, it does not deserve so high a place as has been given it... in those which its success is complete are comparatively few." Although it does work in one case out of fine, and therefore "I should not think it right to omit its trial in any case in which it had not been fairly tried." (1, page 160) Dose should be "five grams of iodide of potassium and twenty minums of aromatic spirit of ammonium, in a wineglass of water, three times a day." How it works Salter does not know, but he suspects it may be most adventitious in asthma associated with gout.  
    • Inhalation of Powdered Alum:  Works better for chronic bronchitis than asthma.  (1, page 166)
    • Inhalation of nitre-hydrochloric acid vaporThe inhalation of nitrohydrochloric acid diluted with aqueous vapor.   Treatment:  "Nitro-hydrochloric acid, a teaspoonf ul in a quarter of a pint of water, to be raised to a temperature of 150°, and inhaled in an inhaler for a quarter of an hour three or four times a day." (1, page 166)
    • Inhalation of oxygen gas:  The theory here is that bronchospasm causes blocked air passages that stops oxygenation, thus this oxygen "suspended" in the lungs, resulting in "pulmonary congestion and a condition of partial asphyxia."  Supplemental oxygen would allow for the "blood to be "oxygenated and freely pass on, the vessels would unload themselves, congestion, the distress, and the effort would cease."  Of course the problem with this theory is asthmatics have trouble getting air in, an trouble getting carbolic acid out. Until the passages can be open an the carbolic air allowed to freely escape, the oxygen can be of little service. Salter believes that the main problem with asthma is not the want of oxygen, but the desire to exhale carbolic acid.  Because of this, the inhalation for the treatment of asthma does little good. Other doctors have come to a similar conclusion. (1, page 166-7)
    • Compressed air:  Inhaling oxygen by sitting in a compressed air chamber is still in the experimental stages.  Salter notes that some patients have benefit from this by it making breathing slightly easier, it probably would end an asthma attack.  Studies, however, are ongoing an Salter prefers to wait until making further judgement on it.  (1, page 167)
    • Galvanism:  It's passing galvanic shock through the chest. Salter warns against it:  " What idea could have originally suggested it I am at a loss to imagine, unless it were the paralysis theory of the disease—that asthma depended on loss of power of the bronchial muscle, or the muscles of the thoracic parietes. I have known it do great harm; I have known it bring on an attack in a patient at the time free from asthma, and I have known it aggravate existing spasm; but I have never known it do any good." (1, page 167): 
  • Other important remedies:
    • Dietetic:  That of which is determined by intake of food.  Basically, a diet should have consist of three qualities: it should be small in quantity, highly nourishing, and of easy digestion. 
      • Regiminal: Eating should be done only at certain times during the day, and meals should be small.  The food eaten should be regulated as to not eat any food that has in the past caused a fit of asthma, such as peanuts.  Very important:  food should not be taken too late in the day, as  sleep can play a major part in causing dyspepsia. Most important: "let no food be taken after such time in the day as will allow digestion being completed and the stomach empty before going to bed." (1, page 135-142)
      • Quality:  "Never eat foods that are generally indigestiblethe food should be plain, well cooked, and containing the proper proportion of animal and vegetable elements."
      • Variety:  Do not give the same food over and over again; foods should vary
      • Nutritious:  As much so as possible (important because some asthmatics eat as little as two meals in a day
      • Quantity:  Large meals cause a full stomach that makes it impossible for the body to digest it all, and this results in asthma (a myth is that it causes asthma because a full stomach presses up on the diaphragm.  It does press up on the diaphragm, but this does not contribute to asthma).
      • Avoid certain foods:  Mainly, avoid unwholesome foods as follows:
        • cheese (especially if old), 
        • Preserved food (sausage, potted meats, dried tongue, stuffing and seasoning)
        • Preserved fruits (ginger, candied orange peel, dried figs, raisins)
        • Meat pies, beef steak, kidney pudding 
        • Strong coffee with sugar (undigestible)
      • Breakfast:  Rarely does an asthmatic attack occur after breakfast, so if you are going to eat a large meal, this is the time to do it.  The asthmatic may eat all the food, at any quantity, that he craved for the days prior, during the morning hours. Although they should be of the "most nutritious materials."(1, page 141)
    • Locality: Locality may determine onset of asthma, so change in the type of air breathed may also be the remedy (getting away from offending air).    For some asthmatics the disease only shows itself in one location, in others it is only remedied in one location. It is not possible to predict what locality, or what air, will benefit one asthmatic as compared to another.  In fact, "the cure is often an inexplicable surprise." The asthma only stays at bay as long  as the person stays in said area, for as soon as he returns home the asthma will reappear.  The only rule Salter and his fellow physicians could think of was: "The air will probably cure which is the opposite of the air in which the patient is worse."
      • Urban Air:  Country asthmatics benefit by city air.  Any city air may benefit asthma, even that of which is densely populated, low lying, smoky, damp and dense.  This remedy is beneficial to the most asthmatics
      • Seaside:  City asthmatics benefit by visiting the seaside or country
      • Dry inland:  Moving away from damp, low lying areas with vegetable life, either seaside or dry inland
      • Dirty air:  The worse the air for the general health the better, as a rule, for asthma (such as smoky air of London)
    • Hygienic:
      • Exercise:  "I have seen several cases in which prolonged bodily exertion has been of great benefit, indeed, some in which it has been the best remedy to which the asthmatic could resort. This, at any rate, proves one thing—the compatibility of asthma with perfect organic health of lung; for if there were any structural defect in the organ—emphysema, bronchitis —or any heart-disease, it would be impossible to meet such extraordinary respiratory demands without embarrassment. It does not indeed show that asthma has never such organic disease for its cause, but it shows that asthma may exist without any organic basis, because it shows that in these cases such organic disease must clearly be absent.  This treatment is, of course, rather prophylactic than curative—it must be taken in the intervals of the attacks: but when so taken it seems to have a marvellous efficacy in keeping them off, and in giving to the asthmatic a lightness and freedom of respiration to which at other times he is a stranger.... it may act by the vigor and activity that it gives to the function of the skin... it may well that exercise, by increasing the amount of work done by the skin, throws less on the lungs, and gives that ease and freedom and sense of surplus power of breathing." Also, after prolonged fasting and exercise, the blood may be free of the poisons of certain foods that may travel through the lungs and cause "irritation of the pulmonary nervous system, and cause the bronchial tubes to spasm." (1, page 163-164)
      • Shower bath: "I think it is a law without an exception that nervous affections are less prone to occur in proportion to the general bodily vigor, and what, for want of a more definite term, we must call the tone of the nervous system. Anything, therefore, that corroborates and invigorates renders asthmatics less prone to their attacks. In this way the shock of the cold shower-bath, or sponge-bath, or sea-bathing, is often of great service to asthmatics. By raising the standard of the general health they also tend to prevent those humoral derangements which are often the exciting cause of asthma."
      • Tonics: "Of all tonics in asthma I think quinine the best, and next to quinine, iron. Whether the especial value of quinine depends at all on its antiperiodic power I cannot say, or whether the periodicity of asthma is one which quinine would not be likely to control. The tonic that I commonly order, and from which I think I have seen the best effect, is a combination of quinine, iron, and a mineral acid."
      • Avoidance of cold:  "Exposure of the external surface to cold is apt to induce asthma in two ways—immediately and directly, or remotely, through the intervention of bronchitis. Some asthmatics are at once conscious of an asthmatic tightening of their breathing if they venture out of doors with their chests imperfectly covered, or if their feet get damp and cold... But the most frequent way in which asthmatics suffer from cold is by its producing catarrhal bronchitis. In these cases the asthma is not immediate; it is accompanied by all the signs and symptoms of bronchitis, ftnd is proportionate to the intensity of the bronchitic affection, of which, indeed, it is but a complication, and without which cold never produces it..There is yet a third way in wliich cold generates asthma—by its direct application to the bronchial tubes by the inspiration of cold air. I have lately had under my care a lady of whose asthma this appears to be the one sole cause. Whenever she breathes cold air the wheezing immediately comeson, and no amount of warm clothing makes any difference. If a fire is kept up all night in her room she sleeps uninterruptedly till the morning, quite free from asthma, but if it goes out her dyspnoea shortly wakes her. A respirator is a perfect cure. I should mention that she has no symptoms of bronchitis...The practical rules that I draw from these facts are: That asthmatics should wear flannel nest their skins; that they should vary the amount of their clothing in proportion to the temperature ; that they should immediately change wet garments, avoid cold after perspiring, and take all other precautions for precluding catarrh."
      • Uniformity of life:  This is one of the best ways of controlling asthma. "It is, to establish a rigorous uniformity of life, to make one day the exact counterpart of another, and to avoid irregularities of every kind. Asthma often seems as if it were lying in ambush watching its opportunity, or on the lookout for some loophole through which to make its attack, and there is hardly any change of life or habit of which it will not, as it were, take advantage—change of air, change of sleeping apartment, alteration of meal hours."
      • Good nights rest:  Restores digesting power of the stomach.  
*Dr. Robert Bentley Todd (Salters mentor) warns that chloroform should never be self administered.  An attendant should administer the remedy "gradually and cautiously, and not in a full dose -- not to produce insensibility. A person should never give it to himself."

References:
  1. Salter, Henry Hyde, "On Asthma: It's Pathology and Treatment," 1882, New York, William Wood and Company, pages 97-168  (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)