Monday, June 13, 2011

1818: Rostan claims asthma is cardiac, not nervous

Leon Louis Rostan (1790-1866) 
Writing as early as 1818 Professor Leon Louis Rostan (1790-1866) said that he did not believe in nervous asthma. In fact, he went as far to conclude in his writings that asthma was not even so much asthma but was nothing more than cardiac asthma.

Mr. Rostan was the son of a wealthy family and received a good educat

A brief biography of Mr. Rostan was given by Harris L. Coulter.  He wrote:
He studied at Paris and graduated in 1812.  By 1814 he became (Philippe) Pinel's deputy at the Salpetriere where for eight months he administered a 2000-bed ward for Napoleon's army returning from Russia.  Four years later he was appointed physician at the same hospital where for the next fifteen years he gave heavily attended courses in "organicism."  A Zurich student noted in 1831 that Rostan's clinic was the most enlightening of all, being the only one given at the sickbed. (6, page 526)(also see 7)
As with many other physicians who studied asthma, he himself had the disease, suffering at one time a severe attack.  Perhaps this is what enticed him to study asthma during his tenure at Salpetriere.  (7)

After studying asthma in elderly women for many years at Salpetriere, and then performing autopsies on them once they passed away, he determined that what they actually had was heart disease, or what he called cardiac asthma. He published the results of his findings in a paper called "Is the asthma of old people a nervous affection?"  (3 pages 56-57)(5, pages 152-153)

The following are a couple examples of what he found (3, page 57):
  • 61 years old idiot who suffered from periodic paroxysms of great oppression of breathing... a large aneurism of the left ventricle of the heart, and ossification of the parts surrounding the bronchiae, were the appearances observed after death.  3, page 57)
  • A 74 year old woman, who had been asthmatic for 18 years: upon opening the body, he found an active aneurism of the left ventricle, with ossification of the aorta.  (3, page 57)
According to George Gregory, in his "Treaties on the theory and practice of physic, Rostan noted possible causes of asthma were "morbid alteration in the organs of respiration and circulation, producing an accumulation of blood in the lungs."  Examples include: (4, page 214)
  • Thickening of the left ventricle of the heart
  • Enlargement of the left ventricle
  • Ossification (hardening) of the valves of the left ventricle
  • Ossification of the valves of the aorta
  • Thickening of the parieties of the aorta
  • Adhesions between the lungs and the pleura
  • Effusions of serum into the cavity of the chest
  • The bronchia inflamed and filled with mucus
  • The lungs converted to a substance resembling liver (4, page 214)
J.B. Berkart, in his book "On Asthma: It's pathology and Treatment," said Rostan always found some pathological explanation for dyspnea.  He said:
Rostan,  more especially, urged that in the numerous instances of it which had come under his notice he had always found pathological changes sufficient to account for the dyspnoea; and saw, therefore, no reason to assign this to a derangement of the nervous system. He appears, however, to have employed the term asthma in a manner too vague to give weight to his objections. So that the demonstration of the symptomatic nature of the disease in his own cases does not necessarily apply to all others. (1, page 22)
While some of the patients at Hospice de la Salpetriere were diagnosed with asthma, Rostan said "he never saw a case of purely nervous asthma." That all the cases that "commenced as nervous affections" were discovered to have some form of organic disease.  (3, page 57)

Armand Trousseau, in a 1858 lecture at Hotel Dieu, said the following of Rostan:
If my honorable colleague, Prof. Rostan, admits to-day the existence of purely nervous asthma, he has not always admitted it. There was a time when he did not believe in this peculiar neurosis of the respiratory organs, and he regarded it as being symptomatic of affections of the heart.  Influenced by the recollection of the laborious investigations which he had made on this subject in the case of the asthma of old men, while he was a physician of the Salpetriere, M. Rostan recognized no difference between asthma and dyspnoea. (2, page 517)
Trousseau, however, said he disagreed with Dr. Rostan.  He said:
To him, these two words (dyspnea and asthma) were synonymous; to me, this is far from being the case. Asthma is, in my eyes, a special, complete malady; it is a manifestation, a particular form of a general condition, having very different local expressions, manifesting itself sometimes by attacks of dyspnoea, of oppressed breathing, constituting asthma, but able, also, to exhibit itself in attacks of articular gout, or gout in a more diffused form, in attacks of gravel, or rheumatism... It is not the difficulty of breathing which constitutes asthma; for it would be necessary in this case to call by this name the dyspnoea which is symptomatic of diseases of the heart, or great vessels, the violent distress which goes to the verge of suffocation in patients suffering from oedema of the glottis, or children taken with croup. Now there is no one who would not shun such a confusion. Between dyspnoea and asthma the difference is immense. If asthmabe a dyspnoea of special form and character, every attack of dyspnoea is not asthma. (2, page 517)
Other physicians, however, agreed with Rostan that asthma was not nervous, including Beau, Crozant, Budd, and Louis.  (1, 30-31,

Berkart said Beau and his pupil Crozant, instead of believing asthma was nervous or spasmotic, thought it was a disease of "chronic bronchial catarrh, accompanied with very viscid secretion.  Such sputa, they maintain, are capable of obstructing the bronchi, and of thus producing the dyspnoeal attacks, as well as the sonorous sibilant rhonchi -- their 'rales vibrants' (sound of mucus moving through narrowed air passages).  With the displacement of the mucous plug into a 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, in their opinion, due partly to an idiosyncrasy of the patient, partly to exciting causes, which greatly vary in different individuals.  ."  (1, page 30-32) (8, page 52)

However, Berkart said Beau's opinion was not well supported, mainly because the nervous theory of asthma "was so well rooted to be readily abandoned upon the mere denial of its foundation. Beau omitted to offer and proof that a bronchial spasm was impossible or improbable" (1, page 31)

Of Budd, Berkart said he believed asthma was a tonic spasm of the diagram or glottis  (1, page 34-35)  Of Louis, Berkart said he believed "emphysema was a disease of gradual and insidious development, it therefore seemed to them highly probable that the asthmatic paroxysm were merely its precursory symptom."  (1, page 32)

Rostan's theory arose from the fact he studied older men and women with dyspnea, and determined the cause was not asthma but heart failure (cardiac asthma).   So most of Rostan's cases probably weren't even asthma to start with, but cases of heart failure.

Regardless of the views of Rostan, Beau, Constant, Budd and Louis, the nervous theory of asthma won the era.  It would remain a main asthma theory until it was disproved in the 1950s.

References:
  1. Berkart, J.B., "On asthma: its pathology and treatment," 1878, London, J. & A. Churchill
  2. Trousseau, Armand, "Lectures on Asthma: Lecture III, Examination of the opinions of the profession of this disease," delivered at Hotel Dieu and translated from the Gazette de Hospiaux on Sept. 16th, 1858, for the Boston Medical and Surgical Journal, published in the Medical and Surgical Journal, 1859, edited by W.W. Morton, page 517
  3. "Historical sketch of the progress of medical science, from January to July, inclusive, 1819," The London Medical and Physical Journal, Volume XLII, no. 245, July 1819, J. Souter, pages 56-57
  4. Gregory, George, S. Colhoun, "Treaties on the theory and practice of physic, with notes and additions adapted to the practice of physic in the University of Maryland, ," volume 2, 1826, Philadelphia, J.H. Cunningham
  5. Wood, John, "On some effects of inflammation of the membranous lining of the larynx; with suggestions relative to the operation of bronchotomy and incidental remarks on spasm and wounds of the throat," pages 138-157,  Volume XVII, London, 1832, Published by the Royal Medical Chirurgical Society of London,
  6. Coulter, Harris L., "Divided history of the schism in medical thought," volume II, 1977, Berkeley, California, North Atlantic Books
  7. Rostan, Leon Louis, "encyclopedia.com, http://www.encyclopedia.com/doc/1G2-2830903744.html, accessed 12/30/13
  8. Fox, Wilson, writer, Sidney Coupland, editor,"A treaties on the diseases of the lungs and pleura," London, 1891, J. & A. Churchill

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