Thursday, March 06, 2014

1850s: Dr. Salter's asthma signs and symptoms

A patient generally receives signs that an attack is oncoming, and these generally present themselves the night before the attack. Of interesting to note, these early signs may also be the cause and effect. That said, the following are signs of an impending attack according to Salter: (1, page 32-33, 37)
  1. Drowsiness and sleepiness: unable to keep head up or eyes open without doing anything that would account for the fatigue.  This is the most common precursory symptom of asthma
  2. Unusual mental acuity or buoyancy
  3. Opthalmia, or inflammation of the eyes; inflammation of conjunctiva; the exciting cause will also ultimately cause spasm of the air tubes. 
  4. Loss of appetite
  5. Flatulence
  6. Costiveness (a change in normal bowel habits)
  7. Uneasy sensation of the epigastrum
  8. Horizontal position of the body (which may explain nocturnal asthma)
  9. Itching under the chin (others can see it by his constantly itching under his chin)
  10. Headache
  11. Excitability
  12. Extremities get cold (during the heart of the attack)
  13. Temperature drops
  14. Sweats
  15. Wheezes
  16. Cyanosis
  17. He may have the appearance of a dying man
  18. Sonorous (coarse wheezes or rhonchi) and sibilant (musical wheezes)  rhonchi are heard on inhalation and exhalation
  19. Accessory muscle use; all muscles that increase the capacity of the chest are strained
Salter has an interesting explanation as to why asthma is so often nocturnal:  (1, page 33)
When a person lies down and goes to sleep, the recumbent position favors the afflux of blood to the right side of the heart, and therefore to the lungs; in addition to this, the position of the body places the muscles of respiration at a disadvantage, especially the diaphragm, against the under surface of which the recumbent position brings the contents of the abdomen to bear; to this may be added the diminished rate at which the vital changes go on during sleep; and lastly, the lowered sensibility of sleep which prevents the arrears into which the respiration may be getting from being at once appreciated.
He goes to bed feeling just fine, and he wakes up in a full fledged asthma attack. Salters continues: (1, page 34)
I know one asthmatic who often sits up half the night after taking a supper (breathing perfectly freely), because he knows that if he goes to sleep his asthmawill come on immediately ; but by thus sitting up till his supper is fairly digested, his stomach empty, and the source of irritation thus removed, he may go to sleep fearlessly and have a good night's rest .
In a sense, Salter explains, this is very similar to cardiac disease, where the patient is prone to orthopnea, which means the he must sit in order to prevent dyspnea; in order to breathe.

The following are signs of an attack, which generally occur after going to sleep: (1, pages 36-43)
  1. Profuse diuresis: hysterical urinne, which is an indicator of nervous cause of asthma
  2. Neuralgic pains: deep seated pains in nerves and joints
  3. He becomes distressed in his breathing
  4. He dreams of being in a circumstance that makes his breathing difficult
  5. Wheezing commences while sleeping, perhaps without disturbing the patient
  6. The wheezing wakes those in adjoining rooms
  7. He may wake and change his position
  8. Increasing difficulty breathing eventually awakens him
  9. He sits up in bed in a distressing, half conscious condition
  10. He gets temporary abatement
  11. Sleep overpowers him
  12. He falls asleep
  13. This cycle continues (the miserable fight between asthma and sleep)
  14. Breathing gets progressively worse to the point sleep is no longer possible
  15. Increasing dyspnea no longer allows the patient to forget himself for a moment
  16. He becomes wide awaye
  17. He sits up in bed
  18. Throws himself forward
  19. Plants his elbows on his knees; sits up on the edge of the bed with his fingers dug into the mattress; sits in a chair with his elbows on his lab, or sits in a chair and leans on a table, perhaps with the aid of a pillow on the table.
  20. His shoulders are raised to his ears
  21. With fixed head and elevated shoulders labors for his breath like a dying man
  22. If he moves at all it is with great difficulty, creeping by stages from one piece of furniture to another
  23. His back is rounded
  24. His gait stooping
  25. He grabs onto anything that aides his walk, and allows him to keep his shoulders high; this also helps to spare muscular effort in doing so
  26. His chest, back and shoulders are fixed; he peers around the room without moving his neck; only moing his eyes
  27. At every breath his chest is thrown back, his shoulders still more raised, and his mouth a little opened with a gasping movement
  28. His expression is anxious and distressed
  29. The eyes are wide open; sometimes strained, turgid and suffused. 
  30. His face is pallid
  31. He may be slightly cyanotic (blue tinge to his lips and fingers)
  32. Beads of perspiration stand on his forehead, or may run in drops down his face, which is attendant has  to wipe
  33. He is so engrossed in his suffering that he is unconscious of what is going on around him
  34. He becomes impatient
  35. He becomes intolerant of those who are trying in vane to help him
  36. He may have the appearance of a dying man
  37. The pulse becomes small, and yet smaller as the intensity of dyspnea increases, and may become excessively feeble and very difficult to feel
  38. The patient will present also with severe itching under the chin, which may be so bad he can't stop himself from itching at his chin.  Yet the scratching does not reliee it.  (I have done this to myself once, leaving scars under my skin as evidence for my friends to notice and tease me about)
  39. His breathing excessively tight
  40. His exhalations prolonged (with exhalation maybe 4-5 times longer than inspiration, and sometimes the air may not be completely expelled prior to the next inhalation.  This may contribute to the enlarged chest that often results from this)
  41. Exhalation is a violent, muscular effort (instead of being natural)
  42. His inhalations excessively difficult
  43. Thus, the respiratory rate is slow (perhaps only 9 in a minute, and this is a sign to the doctor that spasm of the air passages is evident, as if it were any other cause respirations would go up)
  44. In his strenuous efforts to fill his chest with air, his chest becomes permanently filled with it
  45. There is no rest after exhalation; inhalation starts immediately
  46. His chest becomes enlarged in every way
  47. The attack slowly comes to an end
  48. The chest comes down to its normal size
  49. The patient has a memory he'd rather forget, but never will
  50. Such an attack will last from a few minutes to several days.  
  51. In some the attack passes as soon as the patient grabs onto and leans on a piece of furniture, in some it ends when breakfasts is over, in some with one or more of the various asthma remedies, and in some it lasts all day until evening.  In some it gets gradually worse as evening comes on, and the second night is worse than the first."
  52. It usually ends coincidentally with a cough and the release of some sputum (which made Dr. Bree think this was the cause of asthma). 
The worse part was that there was little, even in the line of 19th century remedies, that would truly give him any relief.  So he may trudge his way to the window, and lean up on the windowsill, and gasp into the cool, night air.

His dad may take him for a ride in horse carriage, or he may grasp at one of the remedies he found useful in the past, such as inhaling burned powders of strammonium, smoking asthma cigarettes, drinking coffee or whiskey, smokes adnauseum , takes an emetic, or perhaps a simple massage of his shoulders.

Thankfully today we have rescue inhalers and nebulizers to allay and hopefully completely quell our symptoms.  Or, better yet, controller medicines to prevent them altogether.  And, if the asthma persists, emergency rooms replete with knowledgeable doctors, nurses and respiratory therapist with good medicine to help us.

References:
  1. Salter, Henry Hyde, "On Asthma: It's Pathology and Treatment," 1882, New York, William Wood and Company

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