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)

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