1851-1913: The history of asthma sputum

One of the components of the asthma attack is increased sputum production. Yet while most sputum has balled up microbes that tried to make it to the lungs, asthma sputum is usually sterile.  It's for this reason that asthma sputum is usually white.

I never really thought of it this way until I was recently perusing a book called, "Asthma and it's Radical Treatment," by Dr. James Adams. The book was written in 1913. Yet I believe the doctor was on to something when he wrote:

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

I think this makes sense because a normal, healthy person produces little sputum. So before the asthma attack, there wouldn't be much to cough up. It's only during the asthma attack that excess sputum is produced (except in a few hardluck asthmatics).

Asthmatics do have more goblet cells lining their respiratory tract than those without asthma. And during the attack, these goblet cells produce excess mucus. Due to the bronchospasm already occurring in the airways, this mucus becomes trapped inside the air passages.

Likewise, this mucus may further obstruct the airway. If the asthma attack is untreated long enough, mucus plugging may occur, and this may even further block entire passageways in the lungs. This results in less oxygen getting to the blood, increased dyspnea, and cyanosis (blue coloring of the skin).

Air is thus trapped in the lungs, so the asthmatic feels as though he cannot get air in. This makes sense considering there already is air trapped in the lungs. Expiration is prolonged and wheezy.

If the asthma attack is bad enough, there may be no wheeze. Yet as the asthma attack lets up (either by modern medicines or by pure luck) the muscles lining the air passages relax and this excess sputum is released. The patient experiences long coughing jags. At first the cough may be dry and non-productive.

When I was in this stage, my neck and chest would feel as though someone were down there with a feather tickling me. I would feel panicky and anxious. I would feel like this.

Charcot-Leyden Crystals

Yet then my breath would gradually come back (in my case this was usually due to theophylline intake, Ventolin or maybe even Susphrine), and relief would be the result. Yet there would be one fit of coughing, and then I'd start coughing up sputum.

As far back as 1913, Adams described asthma sputum this way:

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

Of course sometimes it might be these microbes that triggers the asthma attack. In this case it would be normal to find microbes in the sputum, but most of the time the sputum would be sterile.

The reason this is interesting is that the purpose of mucus production is to trap microbes and bring them up to the upper respiratory tract to be swallowed or expectorated.

Normally there should be little mucus or sputum production. The purpose of this response is to keep the lungs, particularly the periphery of the lungs, sterile. So unless there is an infection in the lungs, it only makes sense that sputum produced at the end of an acute asthma attack would be sterile also. This excess sputum was not produced to fight off an infection, it was produced to fight off some asthma trigger.

Other than bacteria and the virus, most asthma triggers are things that don't bother people without asthma, and, thus, are not infections. Therefore, in most cases, asthma sputum is sterile.
What should be present in the sputum of asthmatics is eosinophils. These are produced by the immune system during the allergic reaction.

Again, with asthma, the allergic reaction may be generated to attack some irritant that is generally considered safe, yet the immune system of the asthmatic is confused into thinking good things are bad and tries to get rid of them.

During this response, eosinophils are released, and this spearheads a reaction that results in increased inflammation. Mast cells that harbor leukotrienes and histammines and other mediators of inflammation are released into the blood stream, and it's these that cause inflammation of the eyes, nose, throat, and bronchioles.

J.B. Berkart, in his 1878 book "On Asthma: Its Pathology and Treatment," (page 31) wrote about Dr. Beau who worked with his pupil Crozant in 1851 to come up with his observation that asthma attacks end with a spit of sputum.  They believed asthma was caused by increased sputum and resolved when sputum breaks up with coughing fit.

Berkart explained that Beau basically believed asthma was a disease of chronic catarrh, which is essentially inflammation or swelling of the airways.  If we could jump into our time machine we could tell him he was right.  He believed this sputum was capable of obstructing the airway, and this is what caused the symptoms of dyspnea we refer to as asthma, "as well as the sonorous and sibilant rhonchi -- their 'rales vibrants." 

(Sonorous rhonchi is the sound of secretions moving through the air passages, and most medical experts now refer to this as rhonchi, and sibilant rhonchi is a constant high pitch of air moving through narrowed air passages in the lungs and we now refer to this as a wheeze).

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

Jean Martin Charcot (1825-93)

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

Leyden mistakenly believed the these crystals caused asthma.

In 1879 bacteriologist Paul Erlich discovered the eosinophil, and it was soon discovered that elevated levels of eosinophils (eosinophilia) was commonly found in asthmatics, according to Encyclopedia of Allergies (Myron Lipkowitz and Tova Navarra, 2001).

In 1882 Heinrich Curshmann observed other spirals in asthma sputum and believed they were associated with causing asthma, according to Emergency Medicine (Barry E. Brenner, Ed, 1998, page 10). He believed since Leyden's crystals didn't cause asthma, perhaps his crystals did.

Ernst Victor von Leyden (1832-1910)

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

Quite often doctors can now tell if someone is having an asthma attack if the level of eosinophils is increased in either the blood, sputum or both. This isn't always the case, yet if there's an allergic cause of the asthma attack, they most surely will be increased.

Heinrich Curshmann (1846-1910)

So the allergic reaction is a major reason for increased sputum, and eosinophils are often in it, but generally not bacteria or viruses.

This, coupled with bronchospasm, results in airway narrowing, air trapping, and the ensuing chest tightness, dyspnea, tickling feeling, and overall feeling of impending doom.

Adams observed eosinophils in his 1913 book, and also way back in 1878 in his book, "On Asthma: Its pathology and treatment," J.B. Berkart also noted eosinophils.

Hermann Sahli (1856-1933)

Likewise, Hermann Sahli, in his book "A treatise on diagnostic methods of examination," written in 1911, also described eosinophils in asthmatic sputum. Yet Sahli noted another author from 1891 who described eisinophils in asthmatic blood, and he concluded that these must be pathological with asthma. Yet he also noted neither the cause of the eosinophils nor their origin was known.

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

So now you know why asthma sputum is white, and the history of how the etiology of white asthma sputum came to be known by asthma experts worldwide.

(Check out the sputum lexicon)

Salter aimed to prove asthma was nervous

Sticking to Dr. Henry Hyde Salter's view "On Asthma," he made a gallant effort in his book to prove that asthma was all in your head. In fact, his theories were so powerful that doctors as late as the 1980s still studies asthma as a psychosomatic disorder.

Salter offered the following examples as proof asthma was started in the brain:

1. Many patients feel fine as soon as they enter the doctor's office
2. Mental emotion can bring on a paroxysm of asthma
3. Mental emotion can resolve a paroxysm of asthma
4. Remedies that relax the nervous system resolve asthma, such as tobacco, antispasmodics, sedatives, and nervous depressants. Examples include tobacco, alcohol, morphine, and especially chloroform.

Reference: 

1. Salter, Henry Hyde, "On Asthma: It's Pathology and Treatment," 1868, London

Here's how I keep track of my asthma

Here's another topic I was asked to discuss on my blog:  Share your best practices for keeping track of your asthma and how you use that information to guide conversations with your doctors.

I remember back in the 1980s when I had to take some medicine every three to four hours.  As a kid I found that this ultimately resulted in skipped doses and eventually life got busy and this resulted in me just saying, "Forget it."  Then I'd have no controller meds in my system and when exposed to my triggers I'd come crashing down and end up in an emergency room bed.

So then came along modern asthma controller medicines like Advair which only needs to be taken twice a day, and Singulair which only needs to be taken once a day.  These new medicines are exactly what I needed to get my asthma under control.

I don't think it's so much that these newer medicines are any better than older medicines, but it's just that they only need to be taken once or twice a day.  Thus, for the first time I was able to create an easy to follow daily ritual.  I get up and take my medicine, and then a take my medicine as I'm getting ready for bed. That's it.  No need for any further thought.  Even the laziest asthmatic can follow that plan.

So if I were to provide any wisdom regarding how to keep track of your medicines, I'd recommend that you don't be afraid to try these new medicines that only need to be taken once or twice a day.  Get into the habit of taking your medicines when you wake up and go to bed.

This will make all your life so much better because you'll kill two birds with one stone:  1) You'll have the medicine in your system and, 2) as a result, when exposed to your triggers your asthma attack will be less severe and easier to control, and it bay even be prevented altogether.

So the easiest way to keep track of your medicine is simply to keep it seldom and keep it simple.

Yet then theirs the problem of when your asthma does show it's ugly head.  Then what do you do?  Well, you'll have to use your Albuterol.  That's easy. Get instant relief.  You might want to work out a plan with your doctor, have it written down, open a drawer, pull out the paper, read it when you're in crisis, and then follow the algorithm.

Personally, I know I'll never do that.  It's not me.  So I basically treat the symptoms I feel.  That's me. That's how I do it.  If you're a person whose good at keeping papers and following written plans, then I think that's something you should try.  Yet if you're a normal person like me, common sense is the way to go.

If you have the ability to keep up an asthma diary, go for it.  I can think of no better way to keep track of your asthma, and what caused you to have a flare.  In retrospect I wish I had kept one through the years.

Monitor your symptoms, and then work with your doctor, or do your own research, and come up with a plan that will help you control and treat your asthma.  For tips on how to treat and control your asthma, click here.

While I have found a system that works for me, your job is to find a system that works for you.  You can create a plan that's unique like mine, or you can keep an asthma diary, or you can just do something.  The key is to find something and stick with it long term.

If you don't currently have a plan, I encourage you to do you own research.  If you have a plan, I encourage you to share what works for you in the comments below.

1850s: Asthma was thought to involve other organs

Asthma prior to the 1850s, and in many cases to the 1950s, was often considered to effect many organs, and not just the lungs. Consider the following:

• Lungs: Bronchospasm, emphysema (air trapping), fluid in the lungs


• Heart: Increased in size, weak pump, failure


• Nose: Crease on bridge of nose, nasal irritation


• Chest: Barrel chest, malformation of chest wall


• Spine: Curvature of the spine, hunchback


• Stomach: Eating too much made breathing difficult

Of course we know now that asthma does effect many systems of the body. For example, 70% of asthmatics have allergies, and this also results in nasal inflammation and irritation resulting in a crease due to constant rubbing.

We now know that too much food in the stomach causes the stomach to press up against the diaphragm making breathing difficult. Plus new studies show high fat food can cause an immune response where your body treats substances in fat as an allergen, and this causes increased inflammation in the lungs.

Chronic barrel chest and emphysema are not so much asthma but components of emphysema, a separate but equally distressing disease. An asthmatic can have a barrel chest, an asthmatic can have air trapping, yet it usually goes away once the exacerbation has diminished.

Of course it should be noted here that emphysema was not very understood and older references to emphysema generally refer to what we now call air trapping that causes a barrel chest.

Yet still, given limited wisdom, it's interesting to read how asthma experts of the past tried to link other organs as participating in the asthma patient's misery. One such expert I will introduce you to in a future post even linked asthma with rickets.

Asthma resolutions don't work for me

I was asked to participate in asthma awareness month by creating a list of three or five resolutions for how I will better manage my asthma in the next year, or how I will take action to help others with asthma.  I have decided I am unable to do this.

I suppose I could just ignore this topic altogether, yet it makes for a good talking point.  The reason I can't make a resolution to help me make my asthma better is not because my asthma is perfect, it's because I know I will never stick to it.  That's just me.  I know me.

We humans are creatures of habit.  My habit when I get up in the morning is to take my asthma controller medicines and then brush my teeth.  When I go to bed I take my asthma controller medicines and then I brush my teeth.  That's my habit.  That's my routine.  That's my life.

I can say that I will create a diary and do a peak flow daily to monitor my symptoms, but I know I won't stick to it.  I might do it a week or two, but I won't stick to it.  So making a resolution to make this change might be nice, and it might even result in better asthma control, yet I much prefer to simply monitor my symptoms.

It's what I've always done.  Besides, I know me.  I know my signs and symptoms of asthma.  I also know peak flows are made to get lost and never found.

I can make a blog post with five resolutions of how I will use my blogs to help other people, but isn't that something I already do?  Sure, I could do more, yet I'm not a social person so I know I won't make a public appearance any time soon.  Any communicating or teaching I do is right here in the faceless blogosphere.

Ten years ago this might have been different.  Ten years ago I didn't know me well.  Ten years ago I was still trying to be like my dad.  Yet now I know I'm not the outgoing, partying, cool, fun, social person that my dad is.  I'm me.  I'm an asthmatic, introvert, thinking, writing, blogging, educating, history loving, reading, fool.

I personally think that the best way to gain control of your asthma is to know yourself and be yourself.  Once you discover who you are, everything else -- including your asthma action plan -- will fall into place.

Resources: Management and Treatment, So You Have Asthma

For tips on how to better manage your asthma click here and then click here.

(May is Asthma Awareness month, and May 3 is asthma awareness day. For more information about asthma, check out the Centers for Disease Control and Prevention/ Asthma.)

10,000 B.C.: Asthma caused by too much phlegm?

Were disease theories formed during the Neolithic Revolution about 10,000 B.C.?

Asthma-like symptoms were described in ancient societies in Egypt, China, Korea, India, Greece and Rome, and while various terms were used to describe respiratory ailments, most societies believed in one way or another that disease was caused by an imbalance of bodily humors. 

There are different descriptions of the humoral cause of disease.  For instance, the Chinese describe it as an imbalance of yin or yang causing an obstruction of sorts to the flow of human life, or qi.  The Ancient Greeks believed it was an imbalance of the four bodily humors:  blood, phlegm, yellow phlegm and black bile.

The cause of such an imbalance was believed to be caused by stressful living conditions, poor living conditions, and improper diet.  Remedies for disease were believed to be incantations, drinks or inhalents of various herbal concoctions, or anything to return the humors back to normal. 

Yet whatever way you look at it, the similarities of the cause of disease by different civilizations is stunning.  It almost makes one think such a theory was proposed before mankind split up into six different regions during the neolithic revolution or agricultural revolution nearly 10,000 years before the birth of Christ.  Either that or there was more communication between Ancient Eastern and Western societies than historians are aware of.

Asthma, or asthma-like symptoms were believed to be caused by too much phlegm that causes a ceizure or epilepsy of the lungs resulting in various respiratory symptoms such as foaming at the mouth, cough, dyspnea (short of breath), and wheezes.  These symptoms would be the result of anything that causes dyspnea, including exertion from running or battle.  The remedy for asthma, as with any disease, was as simple as improving diet and getting plenty of sleep and exercise. 

While the definition of asthma matured through the years, it wasn't until the mid 19th century that the myth of humoral cause of disease left the medical profession.  In this sense, the humoral cause of disease was such a simple description of disease it was easy to believe, and this dogmatic theory lasted perhaps 11,850 years if not longer. 

Even the great asthma expert of the second half of the 19th century, Dr. Henry Hyde Salter, didn't completely reject the humoral theory.  Although he was the first to successfully sway from this mindset. And even then it took a lot of convincing to finally change the minds of dogmatic physicians and an ignorant society.  It took science, and a lot of hard work by a few physicians struck by asthma.

Click here for more asthma history.

It's time to grade your asthma action plan

So I guess if I were to review my asthma action plan and grade myself on how well I adhered to my doctor's recommendations, I'd have to give myself a A+. The main reason is that I've been able to keep my asthma under control without the need for any unscheduled doctor visits since 1997.

My Asthma Action Plan is a bit unique, and perhaps even simpler, than the ones recommended by most asthma experts. Mine does not involve my doctor, and generally incorporates vigilance and common sense.

Myplan pretty much consists of the following:

• Take my asthma controller medicines daily


• Avoid my asthma triggers as best I can
• Monitor my asthma symptoms
• Play it by ear

I have to do it this way because I know me. I know I will never keep a diary. I know I won't do a peak flow on a regular basis, and even if I do I won't remember my personal best anyway. That's me. I know me. I know how I function. And catering your asthma action plan to YOU is what it's all about.

It's about controlling your asthma so YOU can live a normal life. What I wrote above is what I do to maintain control of my asthma based on what I know about myself. And for the most part, it's worked like a charm for 14 years.

I can do better, as we all can do better. Yet one of the main problems I encounter is I like to live a normal life, and I like to, well, clean my basement for example. And I know that most people, myself included, become rapt in certain project they enjoy and want to work until they get the job done.

Yet as an asthmatic I cannot do that. I know If I get rapt, and I don't pay attention to the early warning signs of asthma, and I just keep on a working on cleaning my basement, I will have trouble breathing for the next couple weeks. It will be a major set back. The job will never get done.

So I have learned that a better method, even though it is hard for me to do, is to limit myself to 30 minutes on any given day involved in any project in my basement. Once thirty minutes is up I have to be done. I have to quit at the 30 minute mark. My wife too has to understand that projects entrusted to me might take a while.

You see, if you have asthma you have to make adjustments in your life. You have to do what you need to do to live a normal life the way you see it.

I ask you, my readers, to review your asthma action plans and grade yourself on how well you're doing. What's that? You don't have an asthma action plan? Well it's time you invent one.

You ideally should work with your doctor, and I have done that in the past. Yet as an adult perhaps you'll find you're better at doing one on my own. After all, YOU know yourself better than anyone.

Do you give yourself an A grade? Keep up the good work. Do you give yourself a B? A C? Perhaps you guys should refocus on self-management and consider identifying a “personal champion” for encouragement and support.

Any F’s? Perhaps you should wisit their doctor to reassess your asthma action plan and determine whether alternate treatment options would be better for controlling YOUR asthma. And don't feel bad if you grade yourself an F, because we all start out there -- I did too.

As you learn about yourself, and your illness, you'll learn, perhaps, how to adjust your asthma action plan to your personality.

To learn how to create an asthma action plan click here.

Download Printable Action Plan by clicking here

(May is Asthma Awareness month, and May 3 is asthma awareness day. For more information about asthma, check out the Centers for Disease Control and Prevention/ Asthma.)

Asthma triggers from 1850-1950

Dr. Henry Hyde Salter believed asthma was essentially a nervous disorder that resulted in narrowing of the air passages in the lungs as a result of some internal or external stimulant triggering the disease.

The stimulant excites the nervous system, and a signal is sent to the lungs that results in spasming of the bronchial muscles that line the bronchial passages of the lungs. This in essence would be your asthma attack.

The following are what he listed as possible asthma triggers:

• Hayfields
• Dust
• Emotions
• Exhaustion (being too tired)
• Humoral (imbalance of fluids of the boody)
• Fear
• Stress
• Excitation (too happy or to upset or too sad, laughter)
• Excitation of other organs, particularly the stomach

External stimuli are less of a factor than internal stimuli. One of the most obvious factors that triggers an asthma episode is emotions such as fear, stress and excitation. In one case, he describes how asthma effected the parenting of one mother.

He writes, "I was told that when the asthmatic was a little boy he found in his disease a convenient immunity from correction. 'Don't scold me,' he would say, if he had incurred his father's displeasure. 'Or I shall have the asthma,' and so he would; his fears were as correct as they were convenient."

The stomach can trigger an asthma attack as well, yet not directly, he writes. Irritation of the stomach, such as it being too full or filled with an asthma irritant such as something that had bad humors in it, will trigger the mind to send a message to the lungs to cause bronchoconstriction.

Click here for more asthma history.